Tag Archives: Heroin Addiction

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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?

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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.

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Thank you for coming back to my blog site.  In case you have missed any of the previous eight blogs on the Ten Reasons for the Current Heroin Epidemic, please do scroll down to check them out.  Today we will be discussing how Mental Health Treatment or actually the lack thereof has contributed to the overall increase in illicit drug and alcohol use, and opiate/heroin dependency.

Mental Health Parity Picture

 

It is well documented that patients with mental illness are still greatly underserved, and despite some positive movement to increase treatment funding and access, the drastic cuts from the distant and recent past have not been eliminated.  NAMI, the National Alliance on Mental Illness, released the report State Mental Health Cuts: A National Crisis which documented the drastic cuts implemented by states between 2009 and 2011 for spending for children and adults living with serious mental illness. These cuts led to significant reductions in community and hospital based mental health services, with a direct effect also on access to psychiatric medications and crisis services. The Medicaid funding issue is a complex analysis, but there is no question that too many patients are left without viable treatment options.  In an article by the Pew Charitable Trusts, Some States Retreat on Mental Health Funding, Medicaid expansion “may also have persuaded some states to pull back funding for community mental health centers and other mental health initiatives, including school and substance abuse programs.”

The lack of access is not limited to the Medicaid insured population, as many commercial insurers also do not cover mental health services in parity with medical and surgical illnesses. In addition to private insurance companies not abiding by parity laws, the federal and state governments, who are responsible for overseeing compliance, apparently are not doing a good job,  Despite Laws, Mental Health Coverage Often Falls Short.  It was also reported that “NAMI found that patients seeking mental health services from private insurers were denied coverage at a rate double that of those seeking medical services … [and] patients encountered more barriers in getting psychiatric and substance use medications.”

Enough with the statistics! How does this lead to the heroin epidemic?  Simply stated, patients with mental illness are no different than patients with a wide variety of complaints – they all want to feel better.  However, when there are roadblocks related to funding and access to treatment and medication for psychiatric illnesses, patients look elsewhere to feel better.  It is a well-known phenomenon that patients who cannot access care are more likely to self-medicate. So it should not surprise us that patients with depression, anxiety, bipolar illness and other psychiatric health issues reach for drugs that make them feel better: alcohol, stimulants such as cocaine, and opioids such as OxyContin or heroin are commonly used.

When I started this blog series, I promised that I would not only assign blame for the Heroin Epidemic, but also offer solutions.  So here is another solution:  Federal and State Governments must enforce parity laws and we must increase access and funding for mental illness. As they say in the Midas commercial, “You can pay now or you can pay later, but you are going to pay.”  Inadequate mental health treatment can lead to substance use, crime, dysfunctional family dynamics and an overall increase in financial costs to society.

Bad things can happen when mental illness goes untreated, and especially when drug use compounds the situation.  In Addiction On Trial  this is illustrated by Aunt Betty’s conversation with Jimmy’s father:

Adam continued, “Jimmy’s in jail. He was arrested for possession of drugs. But now they are trying to pin a murder on him, but there’s no proof, and well, it’s really a case of mistaken identity.” Adam tried to ground his runaway emotions, but with a trembling tone he blurted out what he so desperately wanted to believe. “Jimmy had nothing to do with it!”

Adam’s anxious moment gave Betty the opening she needed. “Adam, how can I help? And don’t lie to me. We both know that just because Jimmy may not have intended to do anything bad, well, you know what I am saying. When people are high on drugs, accidents happen and sometimes it looks like it wasn’t an accident.”

And during the trial, Venla Hujanen, the Finnish born District Attorney, also focuses on drugs and mental illness while cross examining Dr. Saul Tolson:

Dr. Tolson spoke softly while nodding affirmatively. The District Attorney proceeded, “So Dr. Tolson, it sounds like you do agree that if a person is addicted to drugs—even though he may have been ‘clean’ for a while, and even though when not using drugs he is able to process things better—if he returns to drug use and again becomes ‘high,’ his anger can resurface, poor choices can be made, and bad things can happen.”

 

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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.

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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!