Author Blog

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As you may recall, my last blog listed 10 reasons for the current heroin epidemic. Over the next weeks, I will be addressing who and what to blame for this epidemic and the changing demographics of today’s heroin user, which has migrated outside of our major cities to suburban and rural America. But before we engage a detailed explanation of who/what to blame, to better understand the complexity of the issue, let’s review the biological, psychological and sociological aspects of addiction.

beer bottle

Biological:
To understand the biological aspect of the disease of addiction, let’s look at it from the viewpoint of genetic predisposition. Years ago, Scandinavian studies demonstrated that your biological parents are the predominant factor whether you would develop the disease of addiction. The study followed identical (monozygotic) twins who were adopted into different families. The results demonstrated that the children most likely to develop addictive behavior were those from birth parents with the disease of addiction. Although environmental factors were also shown to be important, the predominant factor on whether determining who would develop the disease of addiction was most highly correlated with parents and genetic predisposition.

Metabolism is another example of a biological component that influences addiction. There is a segment of the Japanese population that rarely drinks alcohol and they also commonly lack an enzyme called alcohol dehydrogenase. In most of us, alcohol dehydrogenase is the predominant substance that breaks down alcohol in to metabolites, which are then excreted by the body. A small amount of alcohol is metabolized by an alternative pathway. However, if one lacks the enzyme alcohol dehydrogenase, the majority of alcohol is metabolized by the alternative pathway. The alternative pathway produces a toxic metabolite which can make one extremely ill.

The symptoms and effects of the toxic metabolite can range from mild nausea and dizziness to losing consciousness from low blood pressure, seizures, heart attacks or other significant consequences. Individuals who lack the enzyme alcohol dehydrogenase typically avoid these unpleasant effects by not drinking alcohol. In fact, the medication called disulfiram (Antabuse) is prescribed to some patients who wish to stop drinking. Antabuse blocks the enzyme alcohol dehydrogenase forcing alcohol to be metabolized by the alternative pathway, thus producing toxic byproducts. This type of aversion therapy using medication and recommended counseling can be effective albeit it does carry a risk if patients are not compliant.

Psychological:
Many substance users consume alcohol or drugs in order to eliminate or minimize feelings, fears, or symptoms. Unfortunately, medical services are not easily obtainable for many people suffering from mental health related illnesses, and they may self-medicate with alcohol or illicit drugs. In addition, people commonly fear the effects of withdrawal and this psychological response continues to drive addictive behavior. There seems to be a relationship between anxiety disorders and alcohol; depression and cocaine or other stimulants; bipolar illness and opiates; and ADHD and marijuana. Treating of underlying mental illness is an important component to curb inappropriate substance use. There have been reports that as many as 50% of patients with substance use disorders have underlying mental illness.

Sociological:
Where we live and how we live makes a difference in our choices. If we live in an environment where there is no alcohol or drugs then we are unlikely develop a substance use disorder, even if we have genetic predisposition or underlying mental illness. If we reside where drugs and alcohol are readily available and dependency is developed and then we wish to stop using, it is more difficult to refrain if we return each and every day to this same neighborhood with the same sociological cues. This is a major factor why Vietnam war veterans who became addicted to heroin abroad tended to do much better in recovery when they returned home, having left sociological cues behind in Vietnam; and why it is more difficult for a drug user to change his/her habits if living with another user of alcohol or drugs.

I wonder what role Mr. Bomer had in his son’s drug and alcohol use. It must have been difficult for Travis to grow up in a household with a father suffering from alcohol addiction. Yes, I am referring to the same Travis, who became dependent on heroin, and despite his addiction, saved a crewmate’s life on the high seas.

Kathy used this interlude to permanently separate the two men. “Frank, dear, why don’t you walk over to the Holiday Inn and get us checked in.” Kathy never confronted Frank about his unpredictable temper, which got worse if he either went too long without a drink or drank too much. It was a fine line between his drinking enough to eliminate the irritability of alcohol withdrawal and not drinking so much that he became belligerently drunk. “It’ll only take you about half an hour and then you’ll be back and we’ll be able to see Travis.”

Kathy knew that Frank would not be able to tolerate the overall situation, and in her heart knew her husband was an alcoholic who needed his beers and shots of whiskey throughout the day. Even if Kathy had been able to face the reality of her husband’s incapacity, this was hardly the time to confront it. All her energies were focused on protecting and supporting her son.

Hope you enjoyed this week’s segment, and next week we will discuss the difference between Tolerance, Dependence and Addiction; and explain why Aunt Tillie may be dependent on opiates but not addicted!

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There are ten reasons that I can think of why we have a heroin/opiate epidemic, but before I go into all the reasons, let’s first get a few points established.

A. The disease of addiction has three components:

1.Biological
2.Psychological
3.Sociological

B. There are three related terms that are essential to understand:

1.Tolerance
2.Dependency
3.Addiction

C. And there are ten reasons of who or what to blame for the heroin/opiate epidemic raging through our cities, suburbs and rural America:

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

Over the next weeks in a series of blogs, I will explain each of the issues in the three categories. Then we will have a template of understanding to further engage in conversation of how best to approach the heroin/opiate epidemic. I hope you will stay tuned. And as we go along, if you want to put some real faces on this scourge to society, I hope you’ll read about Jimmy, the heroin addict from away who is accused of murdering Annette; and Travis, the hard working fisherman who is able to head out to sea by trading his heroin for oxycontin (“Oxys”); and when called to duty to save another shipmate’s life, he does not fail!

“He would meticulously safeguard his supply of Oxys until out at sea, where it was nearly impossible to snort lines on the Margaret Two without being discovered … Because Oxys can last up to twelve hours, Travis could perform his job at a very acceptable level and in a relatively normalized state of mind and body … Tuned into the first signs of early withdrawal symptoms, he always carried a pink Oxy in his pocket … Before heading topside each morning, Travis secured his dependability for the hard work ahead by making certain his concentration was not distracted by physical discomfort. While brushing his teeth in the confines of the head, he slipped a yellow Oxy into his mouth just before taking the last swig of water.”

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I am overwhelmed and appreciative of the many inquiries I have been receiving, so much so, I am compelled to give answers to the questions, “What is taking you so long and when will the next Shawn Marks Thriller be finished?”  I am humbled by the interest in the sequel to Addiction on Trial, which is entitled, Lost to Addiction.  But as we all know, once editors and publishers get hold of the manuscript, who knows what the title will be☺.

But that won’t affect the story line and for those of you who want a taste of the coming action, and without giving away anything to the readers who have not yet finished the first adventure of Shawn Marks, that egotistical but likable big shot Boston attorney, let me give you a peek through the window.  The opening chapter of Lost to Addiction has Shawn Marks sitting at dinner with District Attorney Venla Hujanen at the French restaurant overlooking Somes Sound.  Just as the conversation is about to fall into the crevasse of legal entanglements, with each struggling to ignore personal attraction and maintain appropriate professional etiquette between two adversarial attorneys, Marks get a phone call from shipping magnate George Kreening.  You remember Mr. Kreening – he’s the one who allowed Marks to stay on his yacht in West Haven Harbor while defending Jimmy, the heroin addict from away, who was accused of murdering Annette.  Apparently, Kreening’s son has found himself in a bit of trouble, to say the least – a dead roommate is never a good thing.

Okay, sorry I got sidetracked, but I am as anxious to get the sequel finished as you are to read it.  And yes, that bombshell reporter Sally Jenkin may even return, along with the likes of Hanny!  But I have some good reasons for the delay.  As you know, I wrote Addiction on Trial to entertain while also educating about what addiction really is; to enthrall while sending a message of societal discrimination toward drug addicts; and to weave intrigue and suspense culminating in a riveting murder trial while relying on medical and legal truths.  I am pleased to say, that I have accomplished my goals, and more so than I ever imagined.  As a result I am being pulled me away from finishing the sequel.  But if I sound like I am complaining, au contraire.

And if you think that the relentless New England blizzards this winter would allow me to nestle up next to a fire, while writing voraciously, I think these photos show a different perspective ☺

Steven Kassels

Snow 18

But on a more serious note, my worlds of doctor and author have both collided and merged.  As you may know, there is an opiate (Heroin, OxyContin, etc.) epidemic raging across our country, most notably along the east coast.  Our politicians are not responding in concert, as you may have read in my previous Blogs & Op-eds.  My medical administrative responsibilities have increased significantly with the surge in demand for treatment, and the requests for my participation in educational and legislative matters have grown as well.  This week, I will be in on the road for three days.  First, I will have a meeting at a medical school to discuss how to incorporate Addiction on Trial into the general education of students; to help them understand at their embryonic stages of becoming doctors that addiction is the precursor to many diseases and societal ills.  The following day I will be on the MBPN/NPR Radio Call-In Show along with a patient to discuss my book and more importantly the legislative budget proposals to cut certain funding for addiction treatment in Maine.  From there I will travel to meet with students in Psychology courses at a local college to review the characters of my book and to discuss potential treatment strategies, as if the characters  were real, which they are, at least in my mind, and based on thirty years of Addiction Medicine experiences.  In May, I have been invited to speak to medical school deans and curriculum advisors at a meeting of the Coalition of Physician Education in Substance Use Disorders – “COPE”.  I also appreciate the interest by book clubs and groups to meet with me in person and by Skype, and these interactions are always engaging and fun; so please let me know if you want to schedule an event.

But none of this would be possible without the tremendous support I have received from all of you who have read, enjoyed and embraced the messages of Addiction on Trial.  It may take me a little longer than we all want to get the sequel on to bookshelves, but in the interim, I hope that I do not lose your passion for more of Shawn Marks, as he takes us on another adventure of murder and intrigue, passion and denial, and the “what-ifs” of life.  A special thanks to all the readers who have written Amazon Reviews and my utmost appreciation for your spreading the word.

Please feel free to post comments and let me know what characters you definitely want back in the sequel, as it is not too late!  And be sure to let me know what actor should play Shawn Marks in the movie ☺

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History repeats itself, unless we learn from prior experiences.  This is true in many aspects of life, and unfortunately it takes a toll on all of us in terms of individual and community well-being and longevity of life. This is evident not only in the wars that are fought around the world, but in our approach to medical care.  Knee jerk reactions have no place in medical decision making, and especially not by politicians who choose to ignore the data of scientifically proven treatments.  This is why I felt compelled to speak out about the recent legislative proposal in Maine to limit treatment options for opiate (Heroin & OxyContin) addiction.

This is also why I wrote the book, Addiction on Trial – to demystify and destigmatize the disease of addiction, but through the back door to reach a wider group of readers.  The book is written in a “novel” approach, as a murder mystery/legal thriller based on medical and legal truths – which will entertain, enthrall and educate; and I am appreciative of the 4.9 star Amazon rating. I hope you will enjoy both my Op-ed below as well as my page turning thriller, Addiction on Trial.

Thank you and please spread the word that repeating historical mistakes with politically motivated knee jerk reactions needs to end!

Sun Journal

Steven Kassels: Drug addiction is a medical issue, not a political issue

By Steven Kassels

Lewiston Sun Journal: Published on Sunday, Feb 8, 2015 at 12:12 am

We, as a society, have arbitrarily differentiated between acceptable and unacceptable drug addictions. Why else would our politicians enter into medical decision making?

After 50 years of accepted science, we know that the cost of not treating opiate addiction is up to 12 times greater than the cost of the treatment itself (National Institute of Health). Likewise, the benefits of having multiple medications available to treat various illnesses (patients respond differently to treatment regimens) have been well documented.

So why do some politicians want to insert themselves into the medical world and make arbitrary decisions about which medications to pay for when it comes to the disease of addiction, particularly when the political decisions fly in the face of medical science?

For those who want to believe addiction has no biological, psychological or sociological components (like the disease of diabetes), surely you will agree that abusing substances can cause disease. It is commonly accepted that Vice President Dick Cheney smoked way too many cigarettes (nicotine addiction) and Hall of Fame baseball player Mickey Mantle drank way too much beer (alcohol addiction). To one we gave a mechanical heart, followed by a heart transplant, and to the other we gave a new liver. They had “acceptable” addictions.

But how about the Vietnam veteran who came home addicted to heroin? Or young men and women who become addicted to painkillers after suffering some type of accident? Are there really “good addictions” and “bad addictions”? Is there really a difference between addictions?

If the differences are so great, why does the medication naltrexone decrease cravings in alcoholics and also block the effects of heroin? Are the addictions really all that different?

Why does methadone treatment still carry such stigma? And why are some politicians in Maine considering defunding it? Is that based in science or bias?

If we look back in history, it was President Richard Nixon who stated in 1971, “ ... methadone is a useful tool in the work of rehabilitating heroin addicts, and that tool ought to be available to those who must do this work” (Special Message to the Congress on Drug Abuse Prevention and Control). And in 1999, Mayor Rudy Giuliani — a mayor as tough on crime as any modern politician — initially recommended ending methadone treatment in New York, but upon review of the scientific data, he reversed his decision (Mayor Relents on Plan to End Methadone Use). Science won out.

By contrast, have you ever heard of politicians trying to prohibit coverage for other medications, such as Valium, because they have addictive qualities and thereby limiting doctors’ ability to treat certain illnesses? Have our politicians ever decided that people who smoke cigarettes should not get blood pressure medications because the condition is self-inflicted, chronic and might last years or decades?

Why do we have a heroin and opiate epidemic? We can blame doctors; we can blame pharmaceutical companies; and we can even blame our elected officials who decided to go to war in Afghanistan (U.S.’s $7 Billion War on Drugs Helped Grow Afghanistan’s Heroin) — but blame gets us nowhere.

Our focus should be a doubling of effort to limit the demand for drugs, and the way we limit the demand is through treatment. Incarceration, which is the failed and more expensive approach proposed by some politicians in Maine, just leads to a revolving door.

Some Maine politicians are also trying to claim that treatment with the medication Suboxone — which is a costly prescription medicine often provided through doctors’ offices, is superior to its less-costly relative Methadone — which is provided through heavily regulated clinics that are required to offer counseling and screening services to patients.

But, this is another political approach to a medical issue, and is short on science. Suboxone not only has a ceiling effect that makes it ineffective for many patients, it also has no mandatory requirement for patient counseling that is essential to effective addiction treatment.

We must remember that not all patients are the same, and every patient does not respond the same. Suboxone works for some and methadone is better for others. Should our politicians enter into the practice of medicine by defunding methadone, which is considered the gold standard for opiate addiction treatment?

Much has been made of government not getting involved between a doctor and a patient. I find the current proposal to defund methadone just that.

We cannot let decisions be based on fear, bias or a lack of understanding scientific studies. NIMBY does not work. Opiate addicts live in our communities and in our families, and they work in our businesses.

Politicians should not practice medicine, and they should not defund methadone. Treatment with this scientifically proven medication is fiscally responsible, and cutting it will put patients back on the street, increase crime, jeopardize public health and raise our taxes.

That is bad medicine for Maine.

Steven Kassels, MD, has been board certified in emergency medicine and addiction medicine. He serves as medical director of Community Substance Abuse Centers in Lewiston and Portland, and is the author of “Addiction on Trial — Tragedy in Downeast Maine.”

http://m.sunjournal.com/news/columns-analysis/2015/02/08/steven-kassels-drug-addiction-medical-issue-not-political-issue/1650811

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As we all know, the holiday season brings joy to some and anxiety to others.  It is therefore not unexpected that at this time of year there is an increased feeling of loneliness for those who are alone, a heightened sense of hopelessness for those who have depression and an increased challenge by the temptations of the season for those who are faced with the disease of addiction. “Tis' the season to be jolly.  Fa la la la la, la la la la.”  Really?  So during a time when we are faced with the senseless deaths of fellow citizens for minor crimes and the rising up of voices, which reminds us of the disparity that existed between the discriminatory penalties imposed for crack cocaine versus powder cocaine, I thought I would share a few stories.

As a physician who has spent many holidays working in Emergency Departments treating those who come to the hospital for care as a place of last resort, it is clear that we as a society need not only to open our hearts and our wallets but our minds to ameliorate the suffering.  It is time to embrace mental health and substance use/abuse as illnesses no different than diabetes, high blood pressure or heart disease.  But until we are willing to accept that our neighbors, co-workers, friends and family members are equally affected by this illness, community resistance to establishing local treatment centers for addictive diseases will persist.

Treatment does make a difference, but it is not a one size fits all, as illustrated by two patients who live inside of me, especially at this time of year.  Both patients were in their mid-seventies when I met them as a young physician several decades ago.

I will refer to the first patient as “Joy”, as that is what she truly was.  Joy had been coming to see me for alcohol dependency for a few years, and she was able to remain abstinent from drinking except for the time between Thanksgiving and New Year’s - the time when families gather to eat, drink and be merry.  Joy needed some help to stay sober, a little more encouragement from her family and maybe a different approach than just an increase in her counseling visits during the holiday season.  Otherwise the pattern of this delightful and spunky woman “falling off the wagon” during the holiday season, resulting in this joyful person becoming joyless, was bound to continue.

So one day she asked me about the medication called Antabuse, which forces alcohol to be metabolized by an alternate pathway.  If one drinks while on Antabuse the alternative metabolism creates toxic byproducts that can make one very ill, resulting in low blood pressure, fainting, nausea, vomiting and even passing out - too dangerous to risk in an elderly woman with other medical illnesses.  But she insisted she wanted to try it.  So I prescribed an extremely low dose (really a sub-therapeutic dose) and was pleased that she never questioned why I had her break the tablets into multiple small pieces. Yes, I lied, or maybe just exaggerated, about the potentially catastrophic consequences if she took even the smallest sip of alcohol.  I think she knew I was fibbing a tad, but she never asked. “Now remember, you need to also stay away from the rum cake,” I would tell her with a smile.

So off Joy would go with her prescription for a sub-therapeutic dose of medication to last her from Thanksgiving to New Year's; and she lived on without ever again taking another drink!

The second patient I will refer to as “Happy” because that is just what he was - an extremely warm and positive man who also struggled to stay sober over the holidays. As a younger man, he was able to just say, “No” when offered a drink at his family’s multiple holiday events.  He came from a “large family of partiers” as he would refer to his relatives; who never believed anyone could have a problem from just a few highballs.  So despite Uncle Happy’s persistent refusals to drink, they never gave up hope!  At the prior year’s Christmas Eve event, he succumbed to the pressure of constantly be handed a drink.

When I saw him shortly thereafter, he had gone on a three week “bender” and needed hospitalization for dehydration.  Over the ensuing ten months, he always kept his medical appointments and remained sober, but had lost some of his happiness, replaced by guilt and embarrassment.  Just as he was starting to let go of these negative feelings, the holiday season was again upon us.  What to do?  “How about you make sure the first thing you do is make yourself a drink as soon as you walk in the door.  Put some tonic water and ice in a glass and be sure to add either a lemon or a lime.  Or maybe grab a martini glass, fill it with water and drop in a few olives.  That way everyone will see you have a drink and your empty hands won’t be empty.”  A big smile came across his face, as he responded, “And I could even take a sip if I wanted to.”

So during this holiday season I hope everyone can find Joy and be Happy just like my two special patients.  “Tis' the season to be jolly.  Fa la la la la, la la la la.”  As a special holiday gift to bring some additional pleasure, my book Addiction on Trial, is now on sale through January 8th and the ebook is just 99 cents!  And a special thanks to the many folks and organizations that have been supportive of my literary endeavors over this past year.

Happy Holidays and Healthy New Year 🙂