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.
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.
Many thanks to Channel 2 WLBZ Portland for allowing me to explain some of the issues regarding the current Heroin/Opioid Epidemic - and don't think for a minute that it is only affecting Maine. In fact, it has become a worldwide issue, so maybe we should more appropriately be refer to it as a Heroin/Opioid Pandemic.
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
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
“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
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
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
1991 Study: Effectiveness of Methadone Maintenance
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!
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
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.
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?
Why did I write a medical murder mystery/legal thriller. Easy answer: to become a famous author and to have my book become a blockbuster Hollywood movie! Really? – NO - Not really. But I did write Addiction On Trial to educate through the back door – to reach the areas of our brains that typically we do not want to access after a long day at work. My goal was to reach an audience of readers who yearn to escape into a page turning novel; readers who understandably do not want to pick up a scientific book about addiction at the beach or in front of a crackling fire. So why am I questioning if a Murder Mystery can be Literary Fiction?
When the Coalition on Physician Education in Substance Use Disorders (“COPE”) asked me to read excerpts from my novel to thirty-five medical school curriculum deans and then the Philadelphia College of Osteopathic Medicine chose to use my book in its curriculum to decrease bias among medical students and other allied health care professionals toward addictive illnesses, I started to ask the question, Can a Murder Mystery Be Literary Fiction?
Literary Fiction is a term generally used for fictional works that hold literary merit - novels that offer social commentary, political criticism, or focus on the individual to explore some part of the human condition. Other definitions state that Literary Fiction does not emphasize plot as much as commercial fiction, but focuses on the "inner story" of the characters who emotionally drive the plot to capture the reader’s interest.
So, who kills Annette – is it Jimmy?
Can a heroin addict be capable of saving another’s life on the high seas?
Should the physician father of the accused murderer and heroin addict blame himself?
Is addiction a disease?
Should society pay to treat an “addict”?
What does it feel like to be a heroin addict in jail?
Do addicts have a silent code to protect one another?
These are just some of the questions posed in Addiction On Trial and the answers are imbedded within subliminal social commentary and political criticism, and through the characters who emotionally drive the plot.
I hope you will give it a try and let me know if you think I am full of malarkey 🙂
