Tag Archives: opiate addiction

Heroin Powder

After 10 weeks we are finally finished with blaming, but what a way to end – let’s blame our politicians and our other public officials.  Why? -  Because if all our public officials showed the leadership and courage of Vermont Governor Shumlin, we would have another solution to curb the heroin epidemic.  As I stated in an Op-Ed in the Boston Globe:

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.

We need our politicians and public officials to stand up for what is right and bring forward the real facts about addiction. I explained this further in another Op-ed submitted to the Boston Globe:

We must cut back on the demand to stand a chance of limiting the financial damage.  And to our politicians, I know this is a politically hot issue, but lives and dollars are at stake and it is time to lead the charge to educate through scientific fact and not out of fear.  I commend Governor Shumlin of Vermont for spending his entire state of the state address on this essential economic issue and his call to attack the epidemic on the demand side (treatment); recognizing that putting more people in jail may make us feel good on the short term, but does not solve the problem.  Governor LePage of Maine addressed the issue of drug addiction as an economic issue as well, but he unfortunately spoke not of increased funding for treatment and access to care, but only of expanded law enforcement and judicial response.

As the death of Philip Seymour Hoffman’s has again  reinforced, drug addiction, including heroin abuse, is an equal opportunity disease affecting all socioeconomic strata; and knows no boundaries.  This is not a problem of the welfare state or the poor or less fortunate.  It is NOT NIMBY!!  The disease is present in our impoverished neighborhoods as well as our wealthy suburban communities and in our resort towns and backwoods … Establishing treatment centers for addiction in one’s own locale should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center; both of which are illnesses that may be related to the disease of addiction.  NIMBY no longer works!

America Heroin Problem

We can make great strides to solve the scourge of heroin addiction, but we need to stop blaming and put words into action.  As I have discussed over the past ten weeks, there is plenty of blame to go around!

Addiction On Trial exposes many of the reasons why we have a heroin epidemic; Police Chief, François Bergeron, understood the political and emotional realities of heroin addiction.  The story may be fiction, but it is based on medical, legal and political truths.  IT IS TIME TO STOP BLAMING AND TIME TO START IMPLEMENTING SOLUTIONS!  Thank you for continued interest in my blog site and I hope that Chief Bergeron’s insights will make a difference (Chapter 15):

Although Chief Bergeron had witnessed first-hand the increasing influx of drugs into not only his community but into all of Downeast Maine, Annette's death and the likelihood it was drug connected posed challenges never before encountered. Although the chief understood that drug addiction was a complicated topic and a burgeoning problem, this view was not shared by most, many of whom even refused to believe that Downeast Maine had a significant drug issue despite the fact that a methadone treatment center about two hours away had recently opened to treat the epidemic of heroin and Oxycontin addiction in the region. There had been a prolonged battle within the ranks of city government and among the citizens who irrationally opposed the siting of the treatment center, delaying its opening for years. Eventually, there was some acknowledgment that Downeast Maine, no different than innumerable regions and communities up and down the east coast, had a heroin and Oxycontin problem, but it was greatly minimized. The clinic was finally approved after much rancor, but treatment was initially limited to one hundred patients. Since no one ever wants to believe its municipality has a significant drug problem, it was decided that opening up one hundred outpatient slots would more than satisfy the need and help to quell the escalating controversy. The clinic filled all its patient slots within a month and droves of needy patients were placed on waiting lists.

This struggle to establish treatment centers was not unique. There were similar controversial and heated discussions in many cities and towns … Lawsuits between municipalities against well-intentioned medical providers were not unusual. Paradoxically, at about the same time, a New England Governor’s Council Forum had convened … Presentations by illustrious speakers demonstrated the extent of the epidemic …What Bergeron remembers most from the conference was the statement by a prominent elected official that “these are telling times when elementary and middle school children are offered a bag of 70-80 percent pure heroin for the price of a double scoop ice cream cone.”  The forum’s mantra was interdiction, education, and treatment. This battle cry was good in theory, but in practice it was a different story at the local level. NIMBY—“Not In My Back Yard”—was the rallying cry of most municipalities. No town would admit to having a significant drug issue; it was always the next town over that had the problem. The rationale was based on the fear that if a drug addiction center was established in one’s own town, which of course did not have a problem to begin with, all the addicts from the neighboring townships would spread the scourge as they migrated for treatment, thereby creating a drug problem that never before existed. Despite the documented epidemic of drug abuse across the nation, hardly any individual town, if you spoke to the locals, had much of a problem.

Chief Bergeron understood the apprehension of the townsfolk, that a drug treatment center in West Haven Harbor would label the town as a drug haven. The tourists would be frightened and stay away, the local economy would falter, and everyone would suffer. As a result, many in need of treatment never got it. Chief Bergeron’s concern for the lack of treatment options was now a secondary issue. He recognized that the townsfolk's anger directed at an addict from away was irrational, especially before all the facts were known, but he also understood their desire for retribution for Annette's murder.

Author : Meghan
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war on drugs photo

 

Welcome back to my addiction blog and I hope that as we discuss the final four reasons for the heroin epidemic, you will remember that there are solutions within reach.  The issue of Supply & Demand directly relates to both the problem and the solution.  Let me explain further.

supply demand 1

 

Heroin production and distribution seems to be an unending saga; especially after the consequences of the War in Afghanistan.  No matter how many drug lords and kingpins we kill or arrest, there is always someone willing to fill the void.  Money and power is the “addiction” that attracts people to the illicit drug world.  Interdiction and attempting to close our borders to drugs is a losing battle; and increasing tax payers’ burden by growing law enforcement and judicial budgets has been unsuccessful.  Yes, we can arrest and incarcerate all the current drug pushers, big and small, and we can continue to burn the fields of the countries that produce opium; but the profits of this organized industry of drug production and distribution is so great that there is a continuously replenishable supply of people who want to be the next kingpin or the next local drug pusher.

Let’s look at this from a different perspective, using an economic analysis.  If we cannot limit the supply, then we must look at the demand side of the equation.  If there is decreasing demand, there will be decreasing profits and therefore decreasing production.  I am not saying that we should abandon attempts to bring to justice those who are poisoning our communities with a constant flow of illicit drugs.  What I am saying is we should attack the demand side of this problem with greater vigor.  We spend $400 Billion Dollars annually dealing with the consequences of addiction.  This should be incentive enough to advocate for more preventive programs and more treatment centers to decrease demand.

As I stated earlier in this blog series of the Ten Reasons for the Heroin Epidemic, there is plenty of blame to go around.  We must focus on the solutions.  The last blog dealt with NIMBY, which is interconnected with the Supply and Demand issue discussed today.  Moving forward, over the next several weeks, we will address three more interrelated reasons and pose other solutions.  I hope you will stay tuned for Reasons 8 - Physician Training & Biases; 9 - Mental Health Treatment and 10 - Public Officials.

Please enjoy the following excerpt from Addiction On Trial that gives insight into Jimmy’s inner struggles and I hope to see you next week.

What the defense team did not appreciate was the inappropriate loyalty one drug addict feels for another and the risks they will personally take to protect a drug-dependent comrade. As time went on, Jimmy would become more forthcoming, but a degree of brotherly protection persisted…

Jimmy struggled with this dilemma as it ripped away at his core, tossing and turning night after night in the confines of his cell until he felt soulless. He wished he could have just one session with his therapist. He dreamed, mumbling aloud as he conjured up Saul Tolson’s response.

“Saul, I just can’t tell on Travis…. His life is ruined. And then if I rat him out as the one who bought the heroin and the cocaine for Annette and me . . . I can’t do it! Just because he offered me the drugs, I didn’t have to use them. I knew better, or I should’ve.  Damn it, if I could trade my life and bring back Annette and make Travis whole again, I’d do it. Why won’t they believe me?...

“Jimmy, I don’t think it’s that simple. And I think what you are saying is that you feel like you really let yourself down.”

Jimmy tossed in his hard cot, with sweat dripping off his body. “Oh, Saul, if I had a belt, I’d hang myself. I’ll never rat on Travis! Even if I did, who would believe me? I just can’t go on.” Jimmy let out a scream, “I want to die!”

“Hey keep the noise down. Just because you killed someone doesn’t mean you need to wake us all up. It’s three o’clock in the morning. If you want to die, then just go do it and shut up!”

Jimmy did not respond to the incarcerated voice a few cells away, but now fully awakened, Jimmy just laid there, crying softly to himself.

Author : Meghan
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NIMBY – Not In My Back Yard is the rallying cry heard from many politicians and citizens when asked if there is a drug problem in their neighborhood or if they would welcome a drug treatment facility.  “Sure, maybe we have a problem, but it’s not that bad” or “it’s really worse in the next neighborhood over”, or “the next town over” or “the next state over.”  Baloney – it’s in all of our yards and is as prevalent as the ragweed that grows in all of our lawns!  It does not matter if we live in the city, suburbia, the Northeast Kingdom of Vermont, Downeast Maine or in the farmlands of America – it is truly everywhere!

To truly understand the magnitude of this problem we need to examine the economic impact of addiction to society.  There have been reports that when one considers the cost of drug use related to law enforcement, crime, judicial costs, incarceration, emergency room visits, hospitalizations, lost worker productivity, and workers compensation; not to mention the deterioration of societal priorities or the overall risk to the public in terms of spread of disease (Hepatitis C & HIV) or secondary health and safety consequences such as domestic abuse or childhood asthma … the overall national annual cost exceeds 400 Billion Dollars.  Moreover, as an example, to treat one heroin addict in an outpatient medication based treatment center with admission and yearly annual exams, laboratory screening for HIV and Hepatitis C, group and/or individual counseling on a regular basis, and frequent random drug testing, the cost for this patient is approximately $3,000 - $5,000 per year.  Halfway houses can cost $20,000 or more per year and incarceration of this patient costs upwards of $50,000 per year.  And even if one wants to ignore the scientific evidence that treating a heroin or “Oxy” opiate addict with a replacement medication such as methadone or buprenorphine is not simply trading one addiction for another, one cannot deny the documented fact that patients who enter into this type of treatment have an approximate tenfold decrease in criminal activity.

State legislators, our local politicians and our neighbors need to look critically at the facts and not adopt a NIMBY approach to drug addiction that is ruining lives and stealing our tax dollars by inadequately treating and preventing this epidemic from expanding.  Heroin deaths are rising each year and one of the fastest segments of society developing dependency on opiates and heroin are suburban women in their 20’s and 30’s.  The disease of addiction is in all of our back yards!

Drug addiction, including heroin abuse, is an equal opportunity disease affecting all socioeconomic strata; and knows no boundaries.  This is not a problem of the welfare state or the poor or less fortunate.  It is NOT NIMBY!!  The disease is present in our impoverished neighborhoods as well as our wealthy suburban communities and in our resort towns and rural areas.  Establishing treatment centers for addiction in one’s own locale should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center; both of which are illnesses that may be related to the disease of addiction.  NIMBY no longer works!

Please enjoy this week’s excerpt from Addiction on Trial.  Police Chief François Bergeron is keenly aware that disease of addiction is all around us!

The Chief was perturbed that Annette’s death and some of the circumstances were leaked within minutes, not hours. He had already received calls from the local TV stations. Bergeron did not welcome the added pressure created by the dramatic news reports of a murder with blood splattered all over the deceased’s car and the primary suspect from away in jail for heroin and cocaine possession…

Although Chief Bergeron had witnessed first-hand the increasing influx of drugs into not only his community but into all of Downeast Maine, Annette's death and the likelihood it was drug connected posed challenges never before encountered. Although the chief understood that drug addiction was a complicated topic and a burgeoning problem, this view was not shared by most, many of whom even refused to believe that Downeast Maine had a significant drug issue despite the fact that a methadone treatment center about two hours away had recently opened to treat the epidemic of heroin and Oxycontin addiction in the region. There had been a prolonged battle within the ranks of city government and among the citizens who irrationally opposed the siting of the treatment center, delaying its opening for years. Eventually, there was some acknowledgment that Downeast Maine, no different than innumerable regions and communities up and down the east coast, had a heroin and Oxycontin problem, but it was greatly minimized. The clinic was finally approved after much rancor, but treatment was initially limited to one hundred patients. Since no one ever wants to believe its municipality has a significant drug problem, it was decided that opening up one hundred outpatient slots would more than satisfy the need and help to quell the escalating controversy. The clinic filled all its patient slots within a month and droves of needy patients were placed on waiting lists.

This struggle to establish treatment centers was not unique. There were similar controversial and heated discussions in many cities and towns throughout New England. Lawsuits between municipalities against well-intentioned medical providers were not unusual. Paradoxically, at about the same time, a New England Governor’s Council Forum had convened at the old City Hall near the waterfront at Faneuil Hall in Boston. Presentations by illustrious speakers demonstrated the extent of the epidemic. New England had a significantly higher heroin use rate than the rest of the country. Portland, Maine, and the Massachusetts cities of Boston and New Bedford were primary ports used for smuggling. Chief Bergeron had attended this forum as a member of Maine’s Drug Task Force Committee. What Bergeron remembers most from the conference was the statement by a prominent elected official that “these are telling times when elementary and middle school children are offered a bag of 70-80 percent pure heroin for the price of a double scoop ice cream cone.”  The forum’s mantra was interdiction, education, and treatment. This battle cry was good in theory, but in practice it was a different story at the local level. NIMBY—“Not In My Back Yard”—was the rallying cry of most municipalities. No town would admit to having a significant drug issue; it was always the next town over that had the problem. The rationale was based on the fear that if a drug addiction center was established in one’s own town, which of course did not have a problem to begin with, all the addicts from the neighboring townships would spread the scourge as they migrated for treatment, thereby creating a drug problem that never before existed. Despite the documented epidemic of drug abuse across the nation, hardly any individual town, if you spoke to the locals, had much of a problem.

Chief Bergeron understood the apprehension of the townsfolk, that a drug treatment center in West Haven Harbor would label the town as a drug haven. The tourists would be frightened and stay away, the local economy would falter, and everyone would suffer. As a result, many in need of treatment never got it. Chief Bergeron’s concern for the lack of treatment options was now a secondary issue. He recognized that the townsfolk's anger directed at an addict from away was irrational, especially before all the facts were known, but he also understood their desire for retribution for Annette's murder.

Author : Meghan
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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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