Tag Archives: Heroin

I am honored to have Geoff Kane, MD, MPH as a guest blogger this week.

I have known Geoff for many years and he is not only an extremely competent physician, but also possesses the highest degree of compassion for patients and the utmost commitment to assisting those afflicted with the disease of addiction. Dr. Kane is the Chief of Addiction Services at the Brattleboro Retreat in Brattleboro, VT.  He is board Certified in Addiction Medicine and Internal Medicine, a Fellow of the American Society of Addiction Medicine, and Chairs the Medical-Scientific Committee of the National Council on Alcoholism and Drug Dependence.

If you want to learn more about Dr. Kane, please visit: geoffkane.com

Thank you Geoff for permitting me to post your insightful and thought provoking blog, which was also posted by the National Council on Alcoholism and Drug Dependence, Inc. (“NCADD”).

Curbing Addiction Is Everybody’s Business

By Geoff Kane, MD, MPH

Addiction statistics are scary.  For example, excessive alcohol causes an estimated 88,000 deaths per year in the United States.  Deaths from cigarette smoke exceed 480,000 per year.  In 2013, about 100 Americans per day died from drug overdoses.  The annual cost to this country of addiction and other substance abuse—including healthcare, crime, and lost productivity—is over $600 billion.

Such damage ought to prompt interventions that are swift and sure, but that is not the case.  Not only have severe social and economic consequences of addiction been with us for a long time; some measures are getting worse.

Conflicts of interest impede the prevention and treatment of addiction by inhibiting individuals throughout society from adopting alternative actions that would reduce the toll of addiction.  If we attribute all responsibility for addiction to addicted persons themselves, we are like a naïve family member who says, “It’s your problem.  Take care of it.”

People in all walks of life contribute to the proliferation of addiction—whether they realize it or not.  The clearest conflict of interest, however, may indeed lie within the individual with addiction.  More addictive substance will surely forestall withdrawal and ease emotional and physical distress, and perhaps cause pleasure as well.  In the “logic” of addiction, competing priorities such as family, career, and citizenship are eclipsed by the drive to obtain more substance.

Yet others’ conflicts are also part of the problem.  Such as well-intentioned family members who long for loved ones to get sober but later undermine their loved ones’ sobriety when abstinence reconfigures the distribution of power in the household.  Or well-intentioned addiction treatment professionals and mutual-help members who are so attached to specific treatment approaches that they fail to engage newcomers who don’t align with them.  Or well-intentioned community members who only support addiction treatment centers located someplace else, making treatment less accessible in their own neighborhoods.

Conflicts of interest often involve money.  Do some doctors prescribe controlled substances too freely?  Could some addiction treatment facilities provide less than rigorous care so that patients will return?  Are some health insurance companies more invested in restricting access to care than providing it?  Are some managed care reviewers rewarded when they deny coverage instead of certify it?

In order to be used, addictive substances must first be available.  Use increases when these substances are easily obtained, which promotes new addiction along with recidivism among the abstinent.  The business interests of large segments of the pharmaceutical, alcoholic beverage, tobacco, and legal marijuana industries are in conflict with the health interests of the public.  Might the business interests that boost substance availability also influence decisions of government and other policymakers?

Besides availability, belief that the risk of harm is low or otherwise acceptable is a second condition to be met before many individuals will initiate use of addictive substances.  Numerous people who subsequently developed addiction were given a false sense of security from well-intentioned peers, family members, healthcare providers, and the media including advertisers, reporters, and editors.

Respectful, nurturing interpersonal relationships in families and throughout society reduce the vulnerability of young people to addiction and make recovery more attainable for those seeking a way out.  Yet people continue to depersonalize one another, reacting to stereotypes rather than appreciating individual human beings.

Addiction statistics are not likely to improve until we all identify and accept our own unavoidable share of responsibility for curbing the problem.  Individuals seeking recovery are responsible for accepting support and changing elements of their lifestyle.  Communities—meaning everyone, including law enforcement, business, government, healthcare providers, third party payers, and the media—are responsible for reducing the availability of addictive substances and permissive attitudes toward their use; making individualized addiction treatment accessible; reducing barriers to transportation, employment, and housing; and replacing stigma with respect.

A collective desire to be part of the solution may not be sufficient to make a difference.  Healthy change proceeds more reliably when individuals are held accountable.  For example, recovery from addiction often requires that family, professionals, and recovering peers keep tabs on those entering and maintaining recovery and impose consequences if they get off track.  Likewise, we may all better meet our responsibilities if we gently but firmly hold one another accountable to act on addiction in ways that address the overall picture rather than just our own narrow point of view.

Geoff Kane Steven Kassels Addiction on Trial

To think about:  Will manufacturers and distributors of illegal addictive substances ever support the common good?  Is accountability under the law the only possible incentive for them to change?

Author : skassels
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Addiction Prescription Treatment
Welcome back to my Blog Site and I apologize for deviating from my planned sequential discussions of the “Ten Reasons for the Heroin Epidemic” but I really do have good reasons. I felt obligated to respond to the readers inquiring why an Emergency Medicine & Addiction Doctor became a novelist (“Why I Wrote a Mystery Thriller” – May 6, 2015) and the need to acknowledge my appreciation to my readers (“Heartfelt Thanks for 100 Reviews” - May 20, 2015). And yes, thrown in the mix was my exuberance to report on my trip to the American Society of Addiction Medicine meeting in Austin, TX to make sure folks got a look at the wonderful work being done by advocates such as Patrick Kennedy & The Kennedy Foundation, Gary Mendell and Shatterproof, and so many others (“ASAM Recap: Great People Doing Important Work” - April 29, 2015). In addition, in early May I was invited to discuss my book and to give a presentation to thirty-five medical school representatives gathering at a regional meeting in North Carolina on behalf of the Coalition for Physician Education in Substance Use Disorders (“COPE”). What an incredible group of physicians dedicated to the advancement of knowledge of addictive diseases. But more on this another day – let’s get back to the “Ten Reasons for the Heroin Epidemic”.

As you may recall, past Blogs discussed:

The disease of addiction has three components: Biological, Psychological and Sociological;

The three related terms that are essential to understand the disease of addiction: Tolerance, Dependency and Addiction; and

The ten reasons of who or what to blame for the heroin/opiate epidemic:

  1. Injudicious Prescribing by MD’s
  2. Patient Expectations
  3. Internet Sale of Pain Pills
  4. Oxycontin Reconstitution
  5. War in Afghanistan
  6. NIMBY
  7. Supply & Demand - “War on Drugs
  8. Physician Training & Biases
  9. Mental Health Treatment
  10. Public Officials

Today, I will discuss the first reason, injudicious prescribing practices by physicians. When I was a medical student some decades ago, we were taught to very carefully prescribe opiates, such as Morphine, Demerol, Percocet and other pain medications typically referred to as “narcotics”. Well, it came to pass that we as physicians were under-medicating patients for relief of pain. In fact, it has been shown that for severe pain, if the patient waits for the pain to recur to high levels before taking their next dose of medication that in fact it may take more medication to again relieve the pain.

Then physicians were educated to more appropriately prescribe pain medications. However, due to factors related to patient expectations, “Big Pharm” the increasing number of pain pills available and the need for additional physician education, many physicians have inadvertently been over-prescribing pain medications in dose amounts, frequency of administration and length of treatment. The pendulum has swung too far in the other direction.

Long term use of opiates in most cases of non-cancer pain has not been shown to be advisable, which is understandable due to the terms tolerance, dependency and addiction discussed in an earlier blog. However, for intractable pain, exceptions may need to be made. Fortunately, many states now have continuing medical education requirements that obligate physicians to take courses in appropriate opiate prescribing as a prerequisite to renewing their medical licenses.

So, yes we can blame the doctors for the increase in opiate/heroin addiction, but as we explore the other nine reasons, it will be clear that this is not just a physician prescribing issue – there is plenty of blame to go around. And let’s not forget that biological, psychological and sociological aspects are major contributing factors to the disease of addiction!

I hope you will stay tuned for the next episode of why we have an opiate/heroin epidemic - Patient Expectations. Until then, I hope you enjoy the following snippet from Addiction On Trial.

“Dr. Tolson understood in a very philosophical manner that Jimmy’s illness, the disease of addiction, was composed of biological, psychological, and social elements. He would give lectures on a regular basis to fellow drug counselors, local school committees, police, and to anyone who would listen.

‘Everyone in this room already has an opinion of what an addict is. Usually we use the word addict in a special way—cocaine addict, heroin addict, but rarely do we hear the words alcohol addict or nicotine addict. No one would refer to Vice President Cheney as an addict, despite the fact that we know that nicotine contributes to heart disease. And Mickey Mantle remains a hero despite needing a liver transplant because of liver cancer, complicated by cirrhosis from his years of drinking. I am hopeful that each of you can put aside any bias, any preconceived notions that you bring here today. For thirty minutes I ask that you be like that athlete who has never rowed before and put aside your current opinion of addiction. Give me your cleansed minds for just a brief time. At the end of my presentation you may accept, reject, or modify anything I say, but please start now with a clean slate. Before I begin, I want everyone to join me and tightly close your eyes. For just sixty seconds let us each listen to our own breathing and contemplate nothing.’

Not everyone followed Dr. Tolson’s request, some dumping him into the category of one of those earthy crunchy granola type liberals—precisely the type of labeling he was trying to combat, which is why he would wear a sport coat and tie to the lectures. He would wait a full sixty seconds before saying ‘Now, slowly open your eyes and without verbally responding, I want you each to ask yourself if the last sixty seconds were spent only listening to your breathing while repressing all thoughts. If you were not successful in completely voiding your mind, you now know the struggles of addiction. It is not just mind over matter. I will do my best to further explain the complexities of addiction.’”

Author : skassels
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Steven Kassels Book Signing Addiction on TrialOver the past several weeks I have received several emails from readers and others inquiring about my background and why I decided to write Addiction on Trial. I want to use this week’s blog to explain why I wrote a novel, albeit based on medical and legal truths, and to share my background. So, bear with me as I babble along!

I am a physician who is the youngest son of a physician. My father came to the United States at a very young age, worked his way through college and medical school and chose to practice medicine in two offices attached to our home in Everett, Massachusetts. My mother was the bookkeeper, secretary, cook, laundry service and most importantly, my Mom. When the home phone rang (which was also the office phone) we all answered it the same, “Doctor Kassels office; may I help you.” Not infrequently, patients would come to the front door on holidays and weekends with “specimens”. These were the same patients that would make holiday gifts for my brother and me. I can still hear my Dad, “Put that bag with the bottle in it on the counter in my little office and then wash your hands – and wash them thoroughly – did you hear me Stevie?” I heard my Dad then and I still hear him now.

Why did I write Addiction on Trial: Tragedy in Downeast Maine? Simple answer: I wanted to.

Through my years of practice in Emergency Medicine and Addiction Medicine I have had the privilege to treat patients from all walks of life. From a medical perspective, it is very clear that we have differences but we are more similar than not – we all need hearts to pump in order to sustain our organs and to perfuse our brains. When we are sick, we all benefit from compassion and care. Society should not differentiate between diseases! But who wants to read another scientific book about addiction? Not me! That's why I wrote Addiction on Trial as a mystery thriller to both entertain and educate through the depiction of the realistic struggles of addiction. I hope you enjoy reading Addiction on Trial as much as I enjoyed writing it.

Author : skassels
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September is National Recovery month, which is now in its 25th year!  "National Recovery Month is a national observance that educates Americans on the fact that addiction treatment and mental health services can enable those with a mental and/or substance use disorder to live a healthy and rewarding life. The observance’s main focus is to laud the gains made by those in recovery from these conditions, just as we would those who are managing other health conditions such as hypertension, diabetes, asthma, and heart disease.”

Recovery Month spreads the positive message that behavioral health is essential to overall health, prevention works, treatment is effective, and people can and do recover.  This year’s theme, ‘Join the Voices for Recovery: Speak Up, Reach Out,’ encourages people to openly speak up about mental and substance use disorders and the reality of recovery, and promotes ways individuals can use to recognize behavioral health issues and reach out for help.”

So this month, I wish to again focus my blog on further destigmatizing and demystifying the disease of addiction. This illness has no socio-economic barriers and two recent articles definitely reinforce this.  It is time to abandon any and all preconceived stereotypical notions we might have!  Give it up!  We are all affected, regardless of skin color, race, religion, education or employment status.

Please check out these two articles and be sure to let me know what you think!  Vermont Quits War on Drugs and Whites Account for Rise in Heroin Deaths

I hope you will consider reading my book “Addiction on Trial” and remember that its subtitle could just as easily read “Tragedy Anywhere USA”.  Please also consider checking out a previous blog: We Need More Doctors Like Saul Tolson to better understand the biological, psychological and sociological components of addiction.  And just imagine what it must be like to be the parent who gets a call that your son is A Heroin Addict in Jail

September is Recovery Month – Spread the word!!!

Author : skassels
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"The Scourge of Heroin Addiction"  

Op-ed published by the Boston Globe April 1, 2014  http://b.globe.com/1kAzt54

Governor Deval Patrick has appropriately declared the opioid addiction epidemic as a public health emergency.  The governor's directives will save lives and help to put some brakes on this run away scourge to society.  But questions remain and more issues need to be  addressed. 

For example, why is medication management for the treatment of heroin/opioid addiction scorned by so many? In a recent Boston Globe article, "Heroin Epidemic Exposes Deficiencies In Care System" (http://b.globe.com/1iNFmzo), Ms. Jacobs, Director of Substance Abuse Services for the Commonwealth of Massachusetts, acknowledged, "medications are not used as much as they could be for opiate addictions because of stigmas attached to them, she said."  We watch endless commercials about how to treat illnesses such as urinary incontinence or erectile dysfunction but public service announcements addressing the heroin/opioid epidemic and the proven benefits of outpatient cost effective medication management have been relatively sparse.  The governor's directives, which include public health advisories to educate the public about opioid addiction treatment options, will hopefully demystify common misperceptions, such as crime increases when there is a treatment center in one's community. In fact, there is a 50% to 80% reduction in crime by heroin addicts when in treatment. (http://bit.ly/OVVRfh ;  http://1.usa.gov/1dtb42B)

We read about the blame for the heroin epidemic, but rarely do we address a complex underlying issue – that we as Americans want instant results and we want total pain relief after an injury or procedure.  Injudicious prescribing of pain medications undeniably contributes to the problem, and holding doctors accountable is essential; but this is not the only reason we have an unabated heroin epidemic. Other factors include: the war in Afghanistan, which directly led to a surge in heroin production; the reconstitution of oxycontin pills, so they could not as easily be used to "shoot up" or "snort", resulting in more persons turning to heroin as a drug of choice; the increased availability of opiates through the internet; inadequate mental health treatment services resulting in some patients "self-medicating"; and the lack of addiction treatment facilities due to a common community approach of NIMBY (Not In My Back Yard) along with the stigma associated with seeking treatment for the disease of addiction.  Despite the arrest of kingpins and drug pushers, big and small, we still have a supply and demand problem. The supply of heroin has increased and cost is down to as little as $4/bag. As fast as we take drug pushers off the streets, they are replaced by others - there is too much money involved.  Governor Patrick is right to focus on the demand side of the issue.

If outpatient treatment is not more widely accepted and available, inappropriate hospitalizations and incarcerations of patients will continue.  It is time for our locally elected officials to openly support establishing treatment centers in their communities?  We all know heroin addicts, albeit we may not know who they are. They could be any one of a number of patients I have treated: your plumber; the mailman; your kid's college professor; the IRS agent who audited your tax return; the person selling flowers at the corner; the principal of an elementary school (http://bit.ly/1m6XMbL); someone who works in a mayor's office (http://bo.st/1hbtN20); or a neighbor; or a family member.

A recent study has shown that less than 20% of individuals needing addiction treatment actually received treatment (http://1.usa.gov/1hYRzvX)..  Another study found that only 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment and that "most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge" (http://bit.ly/1o2l3Ax). Are we willing to accept as status quo the present system of  unnecessarily hospitalizing or incarcerating patients?  We are wasting tax dollars: it costs up to $50,000 or more per year to incarcerate (http://bit.ly/1iBKSlg ; http://nyti.ms/NW5dGQ) and approximately $5,000 per year for outpatient treatment (http://bit.ly/1rCh3G6). “There are things besides beds that are effective in this system,” Jacobs said. “More people should see this treatment as a viable option.”  (http://b.globe.com/1iNFmzo)

There should be just as many public service announcements about addiction as there are Viagra and Cialis commercials. In addition, expansion of addiction treatment services in jails would help to mitigate much of the revolving door phenomenon. Furthermore, we should demand that our medical schools and hospitals improve addiction training of our physicians. While there is plenty of blame to go around, let's focus on the solutions. The scourge of addiction is in all of our yards.  The solution is to decrease the demand with bold public initiatives and a change in attitude.  It is both the humanitarian and fiscally responsible thing to do.

Steven Kassels, MD has been Board Certified in Addiction Medicine and Emergency Medicine.  He currently serves as Medical Director of Community Substance Abuse Centers and has authored the book, “Addiction on Trial: Tragedy in Downeast Maine”.  

Author : skassels
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