Tag Archives: Heroin

"The Scourge of Heroin Addiction"  

Op-ed published by the Boston Globe April 1, 2014  http://b.globe.com/1kAzt54

Governor Deval Patrick has appropriately declared the opioid addiction epidemic as a public health emergency.  The governor's directives will save lives and help to put some brakes on this run away scourge to society.  But questions remain and more issues need to be  addressed. 

For example, why is medication management for the treatment of heroin/opioid addiction scorned by so many? In a recent Boston Globe article, "Heroin Epidemic Exposes Deficiencies In Care System" (http://b.globe.com/1iNFmzo), Ms. Jacobs, Director of Substance Abuse Services for the Commonwealth of Massachusetts, acknowledged, "medications are not used as much as they could be for opiate addictions because of stigmas attached to them, she said."  We watch endless commercials about how to treat illnesses such as urinary incontinence or erectile dysfunction but public service announcements addressing the heroin/opioid epidemic and the proven benefits of outpatient cost effective medication management have been relatively sparse.  The governor's directives, which include public health advisories to educate the public about opioid addiction treatment options, will hopefully demystify common misperceptions, such as crime increases when there is a treatment center in one's community. In fact, there is a 50% to 80% reduction in crime by heroin addicts when in treatment. (http://bit.ly/OVVRfh ;  http://1.usa.gov/1dtb42B)

We read about the blame for the heroin epidemic, but rarely do we address a complex underlying issue – that we as Americans want instant results and we want total pain relief after an injury or procedure.  Injudicious prescribing of pain medications undeniably contributes to the problem, and holding doctors accountable is essential; but this is not the only reason we have an unabated heroin epidemic. Other factors include: the war in Afghanistan, which directly led to a surge in heroin production; the reconstitution of oxycontin pills, so they could not as easily be used to "shoot up" or "snort", resulting in more persons turning to heroin as a drug of choice; the increased availability of opiates through the internet; inadequate mental health treatment services resulting in some patients "self-medicating"; and the lack of addiction treatment facilities due to a common community approach of NIMBY (Not In My Back Yard) along with the stigma associated with seeking treatment for the disease of addiction.  Despite the arrest of kingpins and drug pushers, big and small, we still have a supply and demand problem. The supply of heroin has increased and cost is down to as little as $4/bag. As fast as we take drug pushers off the streets, they are replaced by others - there is too much money involved.  Governor Patrick is right to focus on the demand side of the issue.

If outpatient treatment is not more widely accepted and available, inappropriate hospitalizations and incarcerations of patients will continue.  It is time for our locally elected officials to openly support establishing treatment centers in their communities?  We all know heroin addicts, albeit we may not know who they are. They could be any one of a number of patients I have treated: your plumber; the mailman; your kid's college professor; the IRS agent who audited your tax return; the person selling flowers at the corner; the principal of an elementary school (http://bit.ly/1m6XMbL); someone who works in a mayor's office (http://bo.st/1hbtN20); or a neighbor; or a family member.

A recent study has shown that less than 20% of individuals needing addiction treatment actually received treatment (http://1.usa.gov/1hYRzvX)..  Another study found that only 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment and that "most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge" (http://bit.ly/1o2l3Ax). Are we willing to accept as status quo the present system of  unnecessarily hospitalizing or incarcerating patients?  We are wasting tax dollars: it costs up to $50,000 or more per year to incarcerate (http://bit.ly/1iBKSlg ; http://nyti.ms/NW5dGQ) and approximately $5,000 per year for outpatient treatment (http://bit.ly/1rCh3G6). “There are things besides beds that are effective in this system,” Jacobs said. “More people should see this treatment as a viable option.”  (http://b.globe.com/1iNFmzo)

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.

Steven Kassels, MD has been Board Certified in Addiction Medicine and Emergency Medicine.  He currently serves as Medical Director of Community Substance Abuse Centers and has authored the book, “Addiction on Trial: Tragedy in Downeast Maine”.  

I hope you enjoy meeting Dr. Saul Tolson.  At the time of this therapeutic session, Jimmy had been "clean" from heroin for thirty-four months.  This would be one of his final sessions with Dr. Tolson before moving from Kansas City to Downeast Maine, where Jimmy would be accused of murder.  Read on and experience the life of an addict, who struggles with his past demons; and meet Saul Tolson, the compassionate and insightful therapist, and listen to one of his passionate lectures on the disease of addiction.

Addiction on Trial: Tragedy in Downeast Maine; Chapter 13.

It was the end of March when Jimmy finalized his plans to return to West Haven Harbor. His last three sessions with his Kansas City therapist, Dr. Saul Tolson, were dedicated entirely to the courageous steps and the inherent risks of changing his habitat and job. They reviewed the triggers to drug use and the need for continued awareness that drug addiction is a chronic disease, a lifelong challenge.

Jimmy had heard all of this before but no longer exhibited a defensive response to the message. He was full of optimism. After more than twenty years of drug abuse and addiction, three years at an alternative high school focused on building self-esteem, multiple rehab experiences, and a near death experience, he felt he finally understood the pressures and cues that had guided, or misguided, him all these years. Jimmy had finally acknowledged and fully embraced the message that he could not blame his actions, his addiction, on others. He, and only he, must be accountable for his behavior. He acknowledged and accepted the Twelve Steps of Narcotics Anonymous, a self-help program modeled after Alcoholics Anonymous.  Although he could not relate to what he considered to be the subliminal religious connotations of NA or AA, he did ascribe to the message that he needed to admit that which he had no control over and do his best to stay abstinent from drugs and alcohol.

As a member of a program of rigorous honesty, it was problematic to conceal that he was taking a prescribed replacement medication like methadone. He was not alone, as other participants withheld information about medications prescribed by their doctors to treat symptoms and manifestations of illnesses related to the disease of addiction. Many individuals become addicted after turning to either illicit drugs and/or illegally obtained prescription medications in an attempt to self-medicate a primary brain disorder such as depression, anxiety, or bipolar disease. The diagnosis of underlying mental illness can be more difficult to determine for those with the disease of addiction, but many participants in NA and AA do benefit from prescribed medications, some of which have value in the detoxification from drugs and alcohol. Even though many NA and AA groups discourage the use of some prescribed medications that may have effects on the mind, believing that a medication-free approach is always best, most physicians and many Twelve-Step followers disagree with this philosophy.

Jimmy learned through NA and counseling that he could no longer use as excuses the pressure he felt from his father’s professional success or the abandonment by his mother due to her premature and tragic death when he was barely three years old. It had taken him over thirty years to be able to talk about the “what ifs.” What if his mother, had lived? What if she had not left the house that evening to check on an elderly neighbor when the electricity failed? Why couldn’t her friend, Marjorie, have gone instead? These were questions he would never be able to answer, but he was finally able to forgive her and to stop blaming himself for her death. He finally felt at peace with his mother and thought about her daily. He kept her picture in his wallet. He was no longer angry; sadness replaced that destructive emotion. How could he be angry with his mother; she had been so thoughtful and caring in her actions that evening. He was so proud of her and whenever he looked at her photo he could feel her warm eyes looking back at him. He desperately wanted her to be proud of him.

“Jimmy, are you okay?” inquired Dr. Tolson in one of their last sessions.

“Ahh, yes, I was just thinking.”

“I knew that, but what about? It must have been important. You were scratching again at your hand.”

“Yes, I know. When you asked me if I had fully given up my anger and was ready for this transition, I started thinking again about my mother. I really am not angry anymore, but I’ll always wish I could have gotten to know her better. It still hurts that I have no real memory of her when she was alive.”

Dr. Tolson, whom Jimmy called Saul, let silence rule the moment. In his mid-sixties, about the age of Jimmy’s dad, his wiry body was clothed in blue jeans and cowboy boots. He had planned to retire after giving up his private practice of psychotherapy five years earlier and saying good-bye to his many neurotic middle-aged clients. But after two years of retirement he became restless and took his PhD in Psychology into a different arena, first as a part-time consultant and then as a full-time drug counselor at NewBeginningsAddictionCenter. He had never enjoyed work more. The fact that he could trade in his sport coat and tie for more relaxed attire was not an insignificant aspect to the enjoyment he felt while working in his retirement years. Seasoned, articulate, insightful, and with a professional demeanor and attitude of refined independence, he had mentored many young therapists throughout his professional life, and more recently at New Beginnings. But his greatest contribution was to his own patients. He preferred the word “patient” to “client.” This was not a practice of suburban psychotherapy; this was the psychotherapeutic arm for the treatment of a chronic disease and Jimmy was a patient.

Dr. Tolson understood in a very philosophical manner that Jimmy’s illness, the disease of addiction, was composed of biological, psychological, and social elements. He would give lectures on a regular basis to fellow drug counselors, local school committees, police, and to anyone who would listen. He always started his presentation the same way, with a story about the Harvard crew team.

“When I was at Harvard, more years ago than I wish to remember, I was initially confused about why the crew coach recruited athletes who had no prior rowing experience to try out for the scull team. The coach preferred to train disillusioned or frustrated former football players or other passionate athletes who were not quite talented enough to play their chosen sport at the college level. He wanted to teach these athletes how to row from scratch and to learn his way. He was of the philosophy that it is more difficult to undo a wrong technique than to teach the unindoctrinated the correct method. This strategy seemed to work as the Harvard scull teams were always competitive, even at the Olympic level.”

He continued his presentation with a comparison between the approach of the Harvard crew coach and his own current predicament.

“Well, I do not have the luxury of the Harvard crew coach. Everyone in this room already has an opinion of what an addict is. Usually we use the word addict in a special way—cocaine addict, heroin addict, but rarely do we hear the words alcohol addict or nicotine addict. No one would refer to Vice President Cheney as an addict, despite the fact that we know that nicotine contributes to heart disease. And Mickey Mantle remains a hero despite needing a liver transplant because of liver cancer, complicated by cirrhosis from his years of drinking. I am hopeful that each of you can put aside any bias, any preconceived notions that you bring here today. For thirty minutes I ask that you be like that athlete who has never rowed before and put aside your current opinion of addiction. Give me your cleansed minds for just a brief time. At the end of my presentation you may accept, reject, or modify anything I say, but please start now with a clean slate. Before I begin, I want everyone to join me and tightly close your eyes. For just sixty seconds let us each listen to our own breathing and contemplate nothing.”

Not everyone followed Dr. Tolson’s request, some dumping him into the category of one of those earthy crunchy granola type liberals—precisely the type of labeling he was trying to combat, which is why he would wear a sport coat and tie to the lectures. He would wait a full sixty seconds before saying “Now, slowly open your eyes and without verbally responding, I want you each to ask yourself if the last sixty seconds were spent only listening to your breathing while repressing all thoughts. If you were not successful in completely voiding your mind, you now know the struggles of addiction. It is not just mind over matter. I will do my best to further explain the complexities of addiction.”

Dr. Tolson had a sincere and disarming manner to his presentation. Part professor, part psychotherapist, part scientist, but always human, he discussed in painstaking detail the disease of addiction in a respectful manner while laying out the cornerstones of the disease as a bio-psycho-social illness of lifetime duration. He described it as a disease of incurable nature, possible to be put into remission, similar to some cancers. He elucidated the Scandinavian alcohol studies of identical twins being adopted by different families to illustrate that genetic predisposition as well as Skinner-like conditioning were contributing factors. He explained how veterans who had become heroin-addicted in Vietnam could more easily overcome their drug use when returning stateside as representative of the social aspect of the disease; that the elimination of social cues was such a powerful determinant of remission. But the next eye-opening part of his lecture was the presentation of slides showing the reward centers of the brain. He only spent about two minutes on these projections, but it was compelling information.

“I now wish to briefly bring your attention to these next few slides. Here is the nucleus acumbens, the ventral tegmental area, and the prefrontal cortex. They all are integrated into the activation of the brain’s reward pathway.”

Saul Tolson knew all this scientific mumbo jumbo lulled much of the audience to sleep, but he needed everyone to be alert for his next comment. He purposefully lowered the octaves and raised the volume of his voice while adding brief pauses to summon attention as he continued.

“Now, for those of you who have dozed off . . . and I do understand why . . . this next slide is a must to see. It clearly demonstrates that there is very little disparity between the different chemical addictions. This colorful slide demarcates the areas of the brain affected by various drugs and clearly illustrates that alcohol, nicotine, cocaine, and heroin all create their effects through the same common pathway, which originates directly or indirectly at the level of the nucleus acumbens. In fact, the same medication, called naltrexone, is used to curb the craving effects of both alcohol and heroin.”

Dr. Tolson concluded his medical presentation with a sobering analogy.

“Diabetes is a chronic disease. It is a disease that can be controlled, but, as of yet, cannot be cured. It has a genetic component but is exacerbated by poor diet, lack of exercise, and lack of attention to medical management. Think about a person with uncontrolled diabetes or for that matter a smoker with heart disease who eats a bag of potato chips on Super Bowl Sunday and goes into congestive heart failure. Both of these patients now need emergency care that doctors immediately render. Many of these patients return again and again, and for many it is for reasons at least partially due to their noncompliance with recommended treatment. Nevertheless they are readily evaluated and treated for both their acute and ongoing illnesses, even though their own behaviors are contributing or causative factors to their deteriorating health.”

Pausing while attempting to make eye contact with each and every individual in the audience before proceeding, Dr. Tolson delivered his next few lines in a compassionate tone. “With no disrespect, but as a way to reinforce the point I am trying to make, I’d like to ask you to please tell me the difference between a nicotine or alcohol addict, who in some cases may even receive a heart or liver transplant, and someone addicted to heroin or cocaine? Why are those afflicted with the disease of addiction to certain drugs treated so differently than patients who suffer from nicotine or alcohol addiction or other chronic diseases like diabetes? Are they really any different?”

Dr. Tolson never relinquished the podium without one last attempt to convert the naysayers. “Now for those of you who fail to agree with me, and I know you’re out there, let me appeal to your wallets. To incarcerate one addicted patient—that’s right, jailing patients—costs between $40,000 and $50,000 per year. A one-year stay for a patient in a halfway house costs society about $20,000 per year and this does not include any medical care. But to treat one heroin addict as an outpatient with regular individual and/or group counseling sessions, ongoing urine drug testing to monitor for illicit drug use, a complete admission physical exam including laboratory tests that screen for contagious diseases such as Hepatitis C and HIV, and the daily monitoring of medication administration costs approximately $5,000 per year! That’s right—only $5,000 per year or about one-tenth the cost of putting this patient in jail! And how much does it cost and what is the risk to society when patients are denied access to care and get sick with HIV and spread that disease? So what’s the total economic cost of drug abuse to society? You better be sitting down, because according to a ten-year study from 1992 to 2002 on the economic costs of drug abuse by the Executive Office of the President for National Drug Control Policy, the financial price tag to society related to crime, health care, and lost worker productivity is 182 billion dollars—yes, you heard me correctly—182 BILLION dollars! Is not an ounce of prevention worth a pound of cure? Like they say in the Midas commercial, ‘you can pay now or you can pay later, but you’re gonna pay.’ Thank you all for your attention. I am able to stay for questions.”

Uncomfortable with the inevitable applause, Dr. Tolson kept repeating through the clapping, “So, there must be some questions.” The questions came, but none of his answers carried the consequences of those he would have to give to questions posed while under oath at the murder trial of James Frederick Sedgwick in Downeast Maine.

‘Not in my backyard’ attitude doesn’t work with drug addiction

By Steven Kassels, Special to the BDN

Posted March 06, 2014, at 2:34 p.m. Bangor Daily News  

NIMBY — “not in my backyard” — is the rallying cry when asked if there is a drug problem in one’s neighborhood.

“Sure, maybe we have a problem, but it’s really worse in the next town over.” Or maybe it’s “the next state over.”

That’s just malarkey — it’s in all of our yards, and it does not matter whether we live in the city, suburbia, the mountains or Down East Maine. It is everywhere.

The national annual cost of illegal drug use related to law enforcement, crime, judicial proceedings, incarceration, emergency room visits, hospitalizations, lost job productivity and workers compensation exceeds $180 billion.

The cost to treat one Maine heroin addict in an outpatient, medication-based treatment center with frequent random drug testing is approximately $3,000 per year, while incarceration costs more than $50,000 per year.

Even if one wants to ignore the scientific evidence that treating a heroin or “oxy” addict with a replacement medication is not simply trading one addiction for another, one cannot deny the documented fact that patients who enter into treatment have at least an eight–fold decrease in criminal activity.

Here are some statistics in Maine:

— The number of residents seeking treatment for prescription drug abuse tops the nation.

— Maine’s Medicaid cutbacks leave 400 patients with no access to state-funded treatment.

— More than 7 percent of babies born are addicted to opiates.

— Fatal heroin overdoses quadrupled from 2011 to 2012.

— More people die of drug use than from motor vehicle accidents.

— Maine drug-induced deaths exceed the national rate.

As a nation, we have tried to cut back on the drug supply for decades, yet we are again facing a heroin and opiate epidemic in New England. We can incarcerate all the current drug pushers, big and small, and we can continue to burn the fields in the countries that produce opium. But the profits of drug production and distribution are so great that others rapidly fill the void.

Expanded access and funding for treatment makes fiscal sense, regardless of whether we believe addiction is a disease or a weakness of moral character.

It is time for our politicians to lead by educating through scientific fact and not out of fear. I commend Gov. Peter 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 through treatment. He recognizes that putting more “addicts” in jail may make us feel good in the short term but does not solve the problem.

Gov. Paul LePage, in contrast, focused on expanded law enforcement and judicial response. Unlike many other governors from both parties, he apparently opposes placing the life-saving drug Naloxone in the hands of first responders and others to treat heroin and opiate overdoses.

Naloxone availability will not send the wrong message to heroin addicts that they can use the drug with impunity; heroin users, who are sons and daughters, are dying because the heroin on the street is stronger than they think or cut with other opiates. Without Naloxone readily available over the past couple years there has been a quadrupling of heroin overdoses; so when our politicians state that increasing Naloxone availability will lead to more drug use, well, it’s just baloney.

We allow for life-saving medications and oxygen to be readily available to treat diabetics and smokers with emphysema without speculating that, by doing so, we encourage more smoking or poor dietary compliance.

As the death of Philip Seymour Hoffman has again reinforced, drug addiction is an equal-opportunity disease and has no socioeconomic boundaries. This is not a problem of the welfare state or the poor or less fortunate. Making treatment available should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center. NIMBY no longer works.

Dr. Steven Kassels resides in Southwest Harbor and Boston. He has been board certified in addiction medicine and emergency medicine and currently serves as medical director of community substance abuse centers throughout New England, including in Portland and Lewiston. He recently authored the book, “Addiction on Trial: Tragedy in Downeast Maine.”