Tag Archives: Addiction Treatment

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We have heard a lot lately about “alternative facts” and “fake news” but I have not heard any mutterings about these misgivings as it relates to the current opioid epidemic. But then again, despite the number of deaths being claimed every day by fentanyl and heroin and in contrast to the sound bites heard during the presidential primaries, no one is talking facts about addiction. For that matter, politicians are barely  even talking about addiction! We are talking a lot about the murders caused by immigrants, and there is no one doubting that immigrants do murder people, but so do native born Americans, and at a much higher rate than first generation immigrants. So, yes, we need to be concerned why second generation immigrants commit crime at rates much higher than their forefather immigrants and at a rate similar to native-born Americans; but if we are really serious about saving lives, let’s also talk about that which claims more lives than gun crime or automobile accidents – the disease of addiction. Let's not get caught up in the fake news that building a great wall or cutting Medicaid funding and trashing the Affordable Care Act will stop the influx of drugs or assist those afflicted with the disease of addiction.  I hope you will read on.

So what are the facts:

Drug overdoses now kill more Americans than guns

Overall, overdose deaths rose 11 percent last year, to 52,404. By comparison, the number of people who died in car crashes was 37,757, an increase of 12 percent. Gun deaths, including homicides and suicides, totaled 36,252, up 7 percent.

More than 50,000 Americans died from drug overdoses last year — the most ever.

The disastrous tally has been pushed to new heights by soaring abuse of heroin and prescription painkillers, a class of drugs known as opioids.

Heroin deaths rose 23 percent in one year, to 12,989, slightly higher than the number of gun homicides, according to government data released Thursday.

Deaths from synthetic opioids, including illicit fentanyl, rose 73 percent to 9,580

Overdose deaths rise by more than 100 percent in some states, CDC report says

According to data from the Centers for Disease Control and Prevention, 30 states saw increases in overdose deaths resulting from the abuse of heroin and prescription painkillers, a class of drugs known as opioids. New Hampshire saw a 191 percent increase while North Dakota, Massachusetts, Connecticut and Maine had death rates jump by over 100 percent.

Louisville, Kentucky reports record spike of 52 overdoses in 32 hours

“What we’re seeing in the streets right now is fentanyl mixed with heroin, as opposed to heroin mixed with fentanyl.”

“Everything happens for a reason, and I’m thankful it did happen, because I have a new look-out on life,” said Nathan Johnson, who said a recent overdose has him ready to stay clean.  “They threw me in the shower, they did 18 minutes of CPR before the cops got there. Nothing was working, so the cop came in and he had to use two Narcans. It brought me back to life,” said Johnson. He can now use naloxone — or Narcan— on others. Kentucky’s ‘Good Samaritan’ law protects people who are administering the drug in an effort to keep someone alive.

“We’re often accused of being enablers, and we are. We are enablers. We enable people to live” said Read.

Drugs are the leading cause of accidental death in this country. Fatal overdoses surpassed shooting deaths and fatal traffic accidents years ago.

Drugs Kill

Heroin-related deaths increased 439% from 1999 to 2014. As of 2014, heroin-related deaths had more than tripled in five years and quintupled in 10 years.

 

Opioid Addiction – ASAM - 2016 Facts & Figures

Adolescents (12 to 17 years old)

  • In 2015, 276,000 adolescents were current non-medical users of pain reliever, with 122,000 having an addiction to prescription pain relievers.
  • In 2015, an estimated 21,000 adolescents had used heroin in the past year, and an estimated 5,000 were current heroin users. Additionally, an estimated 6,000 adolescents had heroin a heroin use disorder in 2014

 Women

  • Heroin overdose deaths among women have tripled in the last few years.

 Trump leaves out context in claim about immigrants and crime

Overall, there are about 16,000 murders and 10,000 drunk driving deaths a year (the drunk driver is the person killed more than 60 percent of the time)

About 11.1 million unauthorized immigrants accounted for about 3.5% of the total national population in 2014, according to Pew Research Center. Certainly some undocumented immigrants do commit violent crimes

While Trump’s discourse suggests waves of immigrants equals violence, scholars say studies don’t substantiate that message.

Research on immigrants and crime finds that immigrants are not more likely than U.S.-born individuals to take part in crime, said Christopher P. Salas-Wright, an assistant professor at Boston University’s School of Social Work.

"Again and again, we see evidence that they are not," Salas-Wright said. "In fact, it’s the opposite."

Studies show that for the most part, people who migrate are a self-selecting group who want to better their lives, provide for their families back in their home countries and who don’t want to risk getting in trouble with the law, said Kubrin, the criminology professor at University of California, Irvine.

The American Immigration Council, a pro-immigrant nonprofit, analyzed data from the Census’ 2010 American Community Survey and found that about 1.6 percent of immigrant males between 18 and 39 years old were incarcerated, compared to 3.3 percent of the native-born population in that same age group. (The Census does not specify legal status.)

Justice Quarterly - An Examination of First and Second Generation Immigrant Offending Trajectories

Results suggest that the myth remains; trajectory analyses reveal that immigrants are no more crime-prone than the native-born. Foreign-born individuals exhibit remarkably low levels of involvement in crime across their life course. Moreover, it appears that by the second generation, immigrants have simply caught up to their native-born counterparts in respect to their offending. Implications of the findings for theory and future research are discussed.

Crime rises among second-generation immigrants as they assimilate 

Immigrants

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For the first time in U.S. history, the Surgeon General has sent letters to each and every physician warning them about the Opioid Epidemic.

Dr. Vivek Murthy is not only asking for changes in prescription practices, but also "asking clinicians to help us change how our country thinks about addiction."

For a more in-depth analysis of the role physicians play in this health crisis, please read my blog post, "Heroin Epidemic Reason #1: Blame the Doctors".

As evidenced by the Surgeon General's warning, we must all take steps to change how the country thinks about the disease of addiction.

To that end, I am donating all my author proceeds from my novel, Addiction on Trial, to addiction treatment centers, homeless shelters and academic endeavors that support the destigmatizing of addiction.

I hope you will consider buying a copy for yourself or to give it as a gift to anyone interested in changing hearts and minds about the disease of addiction.

Please also visit my Facebook page or Twitter account to learn which organizations have been identified as the beneficiaries of this ongoing fundraising campaign.

If you would like to recommend any additional organizations that would benefit from an author-proceeds fundraising campaign, or awareness-building social media posts, please send information to me through my Contact Page.

Below, please read about how Dr. Vivek has taken unprecedented steps by sending an official Surgeon General's warning to all doctors about opioids, which he calls 'the health crisis of our generation'.

Photo Surg GenI have included below a copy of the personal letter I received. I look forward to assisting the Surgeon General in his mission to destigmatize the disease of addiction!  Remember - "It Takes a Village" and "A Thousand Points of Light".

Surgeon General's Warning

I welcome your comments, questions and insights by either clicking "Leave a Reply" below, or by answering any of my Polls about the Heroin Epidemic!

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I commend Martha Bebinger and NPR for bringing forward the latest information re: implantable buprenorphine to treat patients who are opioid dependent/addicted.  The implant system has four controlled release buprenorphine rods that are placed under the skin and the effect can last up to six months. The FDA is expected to make a decision about this treatment approach within a few days.

Titan-Implant-e1449685245240

However, just as there is no one antibiotic to treat all bacterial pneumonias, or one way to treat every person who has diabetes or depression, there also needs to be multiple approaches to treat addictive illnesses.  What commonly gets overlooked is the underlying hallmark triad of addiction with its biological, psychological and sociological components.  Medication may be an essential aspect of treatment for some, but addressing the behavioral/psycho-social aspects through counseling cannot be ignored or minimized. In fact, it is through the behavioral treatment approach that patients better understand the nature of the issues and cues that contribute to drug seeking patterns.

When treating a patient with oral buprenorphine (Suboxone), the patient receives a maximum of a thirty day prescription. In between the monthly medical visits and sometimes concurrently with the doctor visits, the patient may engage in group and/or individual counseling sessions.  So just as we as a society want quick fixes for many things, we need also to be careful how we look at new treatments.  The issue of wanting our pain totally relieved has contributed to the over prescribing of pain medication.  Immediate gratification is always enticing, but not necessarily the best approach.  Surely, implantable buprenorphine has great promise, especially if it is reasonably priced.  While some patients may need the daily structure provided at a methadone treatment center or be better served by methadone if their tolerance is exceptionally high; other patients may be better served by a prescription for oral buprenorphine and monthly or weekly medical visits; and yet others may be better served by implantable buprenorphine; but all patients will be best served by incorporating a structured behavioral component into the treatment plan.

Implantable buprenorphine is not a cure-all for opioid addiction but it will be a welcome addition for physicians to have at their disposal.

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Welcome back to my blog. I appreciate your continued interest and I look forward to your comments.  I have been quite busy lately and as a result I have not posted anything new for a month. One of the projects I have been involved with recently is related to a legislative meeting in Augusta, Maine.

I had the privilege to give testimony to the Maine Health and Human Services Committee this week pertaining to a bill sponsored by Senator David Woodsome (R-York).

I was extremely encouraged by the wide support the bill received. As you may know, Governor LePage (R), has emphasized increasing funds for law enforcement but not for treatment. We cannot arrest our way out of the heroin epidemic!

Here is the bill and Senator Woodsome’s comments, followed by my testimony.  My testimony was coordinated with others, as we each had limited time to present.  Collectively, however, we discussed all the important aspects.

LD 1473, “Resolve, To Increase Access to Opiate Addiction Treatment in Maine”

“Opioid addiction is a public health crisis in Maine. We need to approach the issue on all fronts, and that includes providing access to effective treatment.  I have heard from many constituents in the Sanford area about those who have suffered because of the local methadone clinic that shuttered – we can make a difference in our addiction crisis and in people’s lives by funding treatment and clinics that are doing this work right.”

Testimony of Steven J. Kassels, MD

Medical Director, Community Substance Abuse Centers

January 28, 2016

Senator Brakey, Representative Gattine, and members of the Health and Human Services Committees, my name is Steven Kassels. I have been Board Certified in Addiction Medicine and Emergency Medicine. I have practiced medicine for approximately forty years and I currently serve as the Medical Director of Community Substance Abuse Centers which provides Methadone and Suboxone as part of comprehensive treatment programs for Opioid Use Disorders.  I am here today to speak in support of LD 1473. I sincerely appreciate the opportunity to discuss the opioid epidemic with you.

Unfortunately, the disease of addiction continues to be a misunderstood illness and carries with it a significant amount of stigma, which is especially true of opiate dependency/addiction.   When I give lectures and I ask folks to raise their hands if they know a heroin addict, very few hands are raised.  But how can that be when we all acknowledge that we are in the midst of a heroin/opioid epidemic?  I have treated college professors, school teachers, IRS agents, nurses, carpenters, electricians, politicians, homeless people and possibly your neighbors. We all know heroin/opioid addicts – we just may not know who they are.  The stigma of the disease forces individuals to hide and to not seek treatment. This is a significant contributing factor why only one in seven people with the disease of addiction are in treatment. Today the highest increase of heroin users is comprised of white suburban men and women in their twenties and thirties. But why should this surprise us. In the early 1900’s the average opioid user was a middle aged, middle class, housewife and mother who typically was addicted to the opioid drug Laudanum.

Heroin Addiction

CDC MMWR July 11, 2014

fig 1

It is essential that we stop characterizing addictions into two categories:  “Good” Addictions and “Bad” Addictions.  Addiction is addiction, and whether we have dependency to alcohol or to heroin, the mechanism of action in the brain is similar.  Both stimulate the reward center by eliciting their effects on the same area of the brain.  In fact, the medication Naltrexone (“Vivitrol”; “Trexan”) decreases cravings for alcohol and also blocks the effects of heroin.  Alcohol, heroin and cocaine all exhibit their effects by stimulating the pleasure center in the brain, the same center that gets stimulated when we eat a nice meal, go for a jog, watch a good movie or enjoy intimacy.   With all of these activities our internal  opioids, called endorphins, get secreted and stimulate the brain’s pleasure center. In fact, during child birth, increased secretion of endorphins are thought to help to diminish pain.

When a person uses opioids for a long period of time, there are changes in both the production of endorphins and its effect on the brain’s receptors.  There are documented structural and functional changes that take place in the brain.

Brain Scan:  Normal & Addicted Brain

Maine Health and Human Services Committee Steven Kassels Addiction on Trial

“Drug addiction is a brain disease that can be treated.”

Nora D. Volkow, M.D., Director, National Institute on Drug Abuse

The question of whether these changes are reversible is dependent on the severity of the disease, no different than diabetes.  With improved diet, weight loss and exercise, the pancreas of some patients will be able to produce sufficient amounts of insulin to no longer need insulin injections, while others will need insulin replacement therapy for life.  Insulin replacement therapy in diabetes or steroid replacement therapy in the disease of the adrenal gland called Addison’s Disease is no different than endorphine replacement therapy.  Treating patients with methadone or buprenorphine (“Suboxone”) is not replacing one drug with another; it is the use of a medication to replace what the body can no longer produce or use effectively.

The changes in the brain in opioid addiction can be profound and can lead to a vicious cycle of severe withdrawal symptoms leading to drug seeking behavior and drug use to alleviate the symptoms, only to have the withdrawal symptoms return, leading to repetitive behavior.  In the case of heroin, withdrawal symptoms start to return within 4-8 hours.

Opioid Withdrawal

fig 3

Opioid replacement medications interrupt this vicious cycle and decrease and eventually eliminate the cravings and drug seeking behavior.  However, depending on the severity of the changes in the brain, some patients may need medication for prolonged periods.  However, as in all chronic illnesses, success rates are not determined by “curing” the patient; but by limiting relapse rates and allowing the patient to resume a normal life.  Furthermore, the relapse rates for a patient with addiction is not significantly different than those with other chronic illnesses.

Relapse Rates: Addiction & Other Chronic Illnesses

fig 4

We do not arbitrarily limit type or duration of treatment for other chronic illnesses, so why should we for addiction?  The key to success in treating opioid addiction is to eliminate withdrawal symptoms so the person can focus on a life free of drug seeking behavior, reestablish relationships and contribute to society.  Maine statistics support this approach as do studies as far back as 1991.

Information from Maine 2015 Treatment Data System

fig 5a fig 5 b fig 5 c

1991 Study: Effectiveness of Methadone Maintenance

fig 6a

The misunderstanding that the addict can be cured needs further explanation.  We must understand that although it is a person’s choice to use a drug or to drink alcohol, it is not their choice to become dependent/addicted.  Once addicted, similar to other chronic illnesses, there is no cure.  When a person chooses to eat a poor diet, not exercise and becomes obese there is a greater likelihood they will develop diabetes.  This is because the pancreas, the organ that makes insulin, has become injured.  This change can be irreversible requiring the need for us to replace what the patient can no longer make, so we prescribe insulin. When President Kennedy developed Addison’s Disease as a result of his adrenal gland no longer being able to produce steroids, he received replacement therapy.  The end organ that is diseased in opioid dependency/addiction is the brain. But this should not surprise us.  The end organs in alcoholism is the brain and the liver.  Nicotine’s end organ is the heart and lungs.  Why is this relevant?  Because when the opioid addict’s disease progresses from continued use, there are changes in the brain, which may become irreversible.  However, “drug addiction is a brain disease that can be treated.”

Opioid replacement medications eliminate withdrawal symptoms and “normalize” brain activity. Methadone and Suboxone in therapeutic doses do not make addicts “high” and in fact block the effects of heroin and other opioids.  But the essential key to success is regular counseling to ensure the patient gets the psychological and social support to integrate back into society in a productive manner.  Replacement medication alone is not comprehensive treatment; counseling is essential and reestablishing the reimbursement rate to prior levels is necessary to be able to provide the necessary counseling to the patients.  We must remember, that many of us live with chronic illnesses, but with appropriate treatment and support, there is a much greater likelihood of living a productive life. As a physician, I consider that to be success!

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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?