Just for Fun

Holiday 2014

I’d like to wish all my readers a Happy Thanksgiving, whether you are in the U.S. or in another country.

To celebrate at my opioid treatment program, we all decided to dress up as either Pilgrims or Native Americans. You can see from the picture above that no one actually came as a Pilgrim (although a few said they were dressed as descendants of Pilgrims). I guess everyone had clothing more suitable to be a Native American.

I participated a little reluctantly, but I’m glad I did. This is a fun group of people that I work with. To a person, they are dedicated to helping their patients recovery from addiction and achieve their goals. They are passionate about their work, and even though they come from very different backgrounds, work together well as a team. I am honored and blessed to be able to work with them.

I am so thankful for my co-workers and the wonderful patients that we serve.

I’ve said it before…I have the best job in the world.

Buprenorphine and the Liver

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When buprenorphine was approved for office-based treatment of opioid addiction in the U.S, doctors worried about possible liver toxicity. We’d seen case reports of acute liver necrosis (death of liver tissue) in patients with Hepatitis C who injected buprenorphine illicitly. So was this damage due to the drug itself, from intravenous use of the sublingual product, or from buprenorphine interaction with Hepatitis C? Until we had more information, experts recommended checking liver function tests before starting buprenorphine and periodically during treatment to monitor for liver damage.

Fortunately, further studies show no liver damage in patients prescribed buprenorphine.

In 2012, Saxon et al followed over 700 patients on buprenorphine or methadone over 24 weeks, and checked their liver function tests periodically, looking for elevations that would indicate liver inflammation or damage. Neither patients on methadone or patients on buprenorphine had significant increase in their liver function test levels, leading the study’s authors to conclude that neither methadone or buprenorphine cause liver damage. Patients with Hep C who were in this study did have elevated liver enzymes, but did not get worse over the twenty-four months while taking either medication.

In the November/December, 2014, issue of American Journal on Addictions, a new study by Soyka et. al. found the same thing. This study looked at 181 patients on buprenorphine/naloxone and followed their liver enzymes for over a year. Thirty-six percent of these patients had Hepatitis C, a group who may be at increased risk for liver damage due to drugs and medications. Liver tests were done at baseline, then at 12 and 24 weeks, and at the end of the first year at 52 weeks. One to two percent of these patients showed mild elevation of liver tests but none had evidence of drug induced liver injury.

This latest study adds to the medical literature that shows buprenorphine isn’t damaging to the liver, even in patients with Hepatitis C, in patients who take the medication as intended. (For obvious reasons, no one would ever do a study asking patients to inject the sublingual form of buprenorphine, since the medication isn’t sterile and the study would put test subjects at risk for all sorts of complications.)

So do we still need to check liver function tests for patients on buprenorphine? Most of the published guidelines about how to prescribe buprenorphine in an office setting still recommend checking liver function tests, but this data from Saxon study and the Soyka study seem to indicate this isn’t a particularly helpful thing to do.

About half of my buprenorphine patients have no insurance. After reading these studies, I’ve decided not to ask my patients to get routine liver function tests. I still think they need screening for Hepatitis C. Some doctors would say liver function tests can suggest Hep C if they are elevated, but since it’s possible to have Hep C and normal liver function tests, I think their money would be better spent on Hep C testing. Patients who test positive would then need to get further testing, which would likely include liver function tests, as well as confirmatory testing for Hep C.

Let’s use new information to spend health care dollars wisely.

ABAM EXAM

asam

I’ve neglected my blog lately, because I’ve been doing extra reading, preparing for my American Board of Addiction Medicine (ABAM) re-certification exam. I took the exam yesterday, so now I’ll have more time.

I took (and passed) this test for the first time in 2004. Doctors who wish to remain certified in Addiction Medicine need to take the test (and pass it) every ten years. We also have to demonstrate commitment to lifelong learning by doing a certain number of continuing education hours each year, and a few other things.

This exam used to be administered by the American Society of Addiction Medicine (ASAM). The first time I took the exam in 2004, ASAM sponsored the testing. But in order to get recognition from the American Board of Medical Specialties, a separate entity had to be created, and ABAM was born in 2007. ABAM’s purpose is to establish standards for physician education in the field, to assess competency of the physicians it certifies, and to track life-long learning of these physicians.

I didn’t mind studying for the exam, because I find the material to be so interesting. Our main textbook is “Principles of Addiction Medicine,” and at over 1700 pages, it’s a long read. There’s also a great review course, sponsored once every other year by ASAM, called “ASAM’s Review Couse of Addiction Medicine.” I couldn’t go to the meeting in Orlando, Florida, but I listened to the whole thing on ASAM’s e-learning site. On that, I could listen to each of the over 20 hours of information over and over again if I desired. The lecturers were fantastic, and among the top in the field. Even though it’s supposed to be a review I always learn new things.

It was a fair exam. I won’t know if I passed until February of 2015, but I’m feeling confident.

If you want to know if your physician has been trained in Addiction Medicine, ask her if she is a member of ASAM, or is certified by ABAM. Doctors don’t have to be certified to be good, but if you want to know for sure that your doctor is well-educated, ask about that certification, or the equivalent in the psychiatric field, the American Association of Addiction Psychiatry.

Office-based Treatment of Opioid Addiction

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When DATA 2000 was passed, the office-based treatment it created was envisioned
as another option for opioid-addicted people. There was, and still is, a large gap between the numbers of people in the U.S. who need medication-assisted treatment for opioid addiction, and the number of treatment slots available at traditional opioid treatment programs. DATA 2000, it was hoped, would create treatment slots to shrink that gap.

DATA 2000 succeeded in making medication-assisted treatment more available, but there are still too many opioid addicts dying from their addiction.

Just like with other chronic diseases, opioid addiction exists on a continuum. Some opioid addicts get to treatment only after they’ve lost everything, have serious co-occurring mental health issues, and have few emotional supports. Others are able to reach for help earlier in the course of addiction, have no co-occurring mental health issues, and a supportive network of friends and family. One opioid-addicted patient will need more intensive treatment than another, just like some patients with diabetes are so ill that they need hospitalization. Other diabetics manage fine with outpatient doctor visits every three months. One form of treatment doesn’t fit all patients.

The American Society of Addiction Medicine (ASAM) created the Patient Placement Criteria over twenty years ago. This textbook, just revised again late last year, is widely used to determine the appropriate level of care for a patient with addiction. The Patient Placement Criteria describes the levels of care needed for addiction treatment. ASAM says there are six dimensions doctors should look at before deciding what intensity of care the patient needs:
Dimension 1 – Acute Intoxication and/or withdrawal potential
Dimension 2 – Biomedical conditions and complications
Dimension 3 – Emotional/behavioral/cognitive conditions and complications
Dimension 4 – Readiness to change
Dimension 5 – Relapse/continued use/continued problem use
Dimension 6 – Recovery environment

Depending on the severity in these six dimensions, the appropriate level of treatment can be recommended. This can be anything from an early intervention service to intensive outpatient treatment to inpatient hospital care. The length of treatment at each level of care is based on the patient’s severity of illness, with frequent re-evaluations of the patient’s status as it changes. This is a more objective and scientific way to treat addiction, as opposed to treating all patients with addiction with inpatient treatment for twenty-eight days.

Prescribers of medication-assisted treatments for opioid addiction should use the ASAM criteria when deciding which level of care is most appropriate. Ideally, MAT could be provided at any level of care, though in real life, many abstinence-based programs won’t admit patients on methadone or buprenorphine. In real life, at least in my neck of the woods, MAT is provided at opioid treatment programs, which follow more stringent federal, state, and local regulations, and at office-based programs, with few regulations.

I think it makes good sense to save office-based treatment for the most stable patients on MAT. Opioid-addicted patients with a higher severity of illness should be treated at an opioid treatment program, at least initially, due to the added accountability built into the system at an OTP. The patient can be re-evaluated periodically, and if the patient is doing well on buprenorphine, could be encouraged to transition to an office-based program.

That’s what we do at one of the opioid treatment programs where I’m medical director. I have patients in three types of treatment: in the OTP on both methadone and buprenorphine, and then office-based patients on buprenorphine. Having an office-based option for buprenorphine patients encourages then to meet treatment goals of stability in order to transition to a less restrictive treatment setting. Sadly, there is no office-based option for patients on methadone, due to the increased risk of the medication.

Patients can move seamlessly from one treatment to another as needed. If an office-based patient suffers a bad and continuing relapse, I can move him back to the opioid treatment program arm, where he can be seen and dosed every day until stability is regained. With this model, the intensity of treatment is determined by patients need.

In an ideal world, providers at both opioid treatment programs and office-based programs would work together in a cooperative rather than adversarial manner. This would benefit the patients and the treatment programs.

Expanding Access to Buprenorphine

aaaabalance

My last blog post stimulated some lively debate, and I thought this topic deserved further discussion. However, I would like to ask commenters to talk about the issue and please refrain from mentioning specific names of previous commenters. Please and make your points in a thoughtful and respectful manner. Thanks for your cooperation.

Given our present epidemic of opioid addiction and opioid overdose deaths, authorities are considering lifting the 100-patient limit for physicians who prescribe buprenorphine from office-based settings. Some people in the addiction treatment field oppose expanding access to buprenorphine in the office setting, saying some of these patients don’t get the counseling that they need, but only medication. They say there aren’t enough regulations to prevent shady physicians from opening buprenorphine mills.

Experts on both sides of the debate make good points. It’s a tough topic, but let’s explore the issues further.

1. “You don’t provide enough counseling.”

Weirdly, this used to be a main complaint against OTPs, but now OTP personnel are directing the same complaint toward office-based buprenorphine physicians.

Is there any data to help us decide how much counseling is enough for opioid-addicted patients who are started on medication, either buprenorphine or methadone?

The POATS trial gives some information on this topic. (Weiss et al, 2010, http://ctndisseminationlibrary.org/protocols/ctn0030.htm )

POATS showed that opioid-addicted patients maintained on buprenorphine/naloxone were likely to reduce illicit opioid use during treatment with the medication, but most relapsed after being tapered off the medication at twelve weeks. So this part of the study supported keeping patients on medication longer, just like the older data with methadone for heroin users. No surprises so far.

Now comes the interesting part: POATS showed similar outcomes for patients getting standard medical management versus standard medical management plus fairly intense counseling. The group with added counseling didn’t do any better than the standard medical management group.

However, the standard medical management consisted of an hour-long first visit with the doctor, and a fifteen- to twenty- minute visit per week for the first four weeks, then every two weeks.
This may be more than an average buprenorphine doctor provides in real life. It’s a little more than I do for my office-based patients. My first visit with new patients is one hour, and usually I see them back in one week for a twenty-minute visit. But then, if they are doing well, I see them every two weeks, until the patient is established in counseling. After that, if all is going well, I cut down to monthly visits. I conclude that the average buprenorphine doctor may have to increase visit frequency to get the results seen in the POAT study.

The group with enhanced counseling treatment got 45 minutes with a counselor twice per week for the first four weeks, then twice per month. At present, patients of OTPs must have two counseling sessions per month, even at the beginning of treatment. Opioid clinic opponents say twice per month isn’t even close to enough counselling, and use this point as a reason to say opioid treatment programs deliver bad care.

The POAT study was relatively short. Twelve weeks may not be long enough to detect an improvement in patients getting enhanced counseling. We know life changes usually don’t happen quickly. Maybe it is unfair to say the counseling didn’t help, because the patients weren’t followed long enough.

Now let’s look at interim methadone. Interim methadone was proposed as an alternative to long waiting lists for patients to enter an opioid treatment program. People were concerned about the welfare of opioid addicts who wanted help, but had to wait for a treatment slot to open. Interim methadone is a short-term, simplified treatment where methadone medication is started for the opioid addict, until the patient can be admitted to an OTP. With interim methadone, some counseling given, but only for emergency situations. Drug screening is still done, but is more limited than for OTP patients. These interim patients can transition to a traditional opioid treatment program when a slot opens for them.

It appears that starting just methadone, with limited other services, still helps the patients. Studies show these patients are less likely to continue to use heroin, are less likely to commit crimes, and more likely to enter a full-service OTP when admission is offered. [1]

Would “interim buprenorphine” work as well? I don’t think there are any studies to give us data, but it seems logical that it would.

2. “Just apply to be an OTP”

Government officials have said that if office-based physicians wish to see more than one hundred buprenorphine patients, the physician should apply to become an opioid treatment center.

When I first read this suggestion, I laughed, because it sounded so silly to me. Well-intentioned though this statement might be, it starkly exposed a lack of knowledge of the average physician’s economic circumstances.

I don’t know many doctors like me who have the necessary capital to do this. Some professionals in the field estimate it takes starting capital of around a quarter of a million dollars. I’ve seen one OTP fold due to inadequate financial support and management, and another escape closure by a narrow margin. These days, it takes deep pockets to afford the eighteen to twenty-four month process to establish an OTP. Getting the certificate of need alone can take years. (Just look at Crossroad’s struggles to get a CON in Eastern Tennessee, an area with arguably more opioid addiction per capita than most other states!)

OTP sites must be approved by multiple agencies: the DEA, CSAT, SOTA, and local authorities to name a few. The pharmacy has to meet strict regulations, as do personnel. If you want to accept Medicaid, that’s another avalanche of regulation and paperwork.

I’m not saying it’s impossible for a physician to open an OTP, but I am saying that it would cost so much that most doctors who treat opioid addiction wouldn’t consider it. I could be wrong – maybe my colleagues are making a whole lot more than me…

3. “In it for the money.”

Experts in the field who work for opioid treatment programs oppose expansion of office-based treatment, saying doctors charge exorbitant fees for their patients. Sadly, in some cases, they are right. But many office-based doctors charge reasonable fees. If we allowed doctor to treat more than one hundred opioid-addicted patients at one time with buprenorphine, wouldn’t that reduce demand for services? And when demand decreases, shouldn’t cost of treatment drop too?

For example, let’s take a community where one buprenorphine doctor is price gouging, and charging $500 per month for only one doctor’s visit. The second buprenorphine doctor charges $250 per month for the same service plus addiction counseling. Both are at their one- hundred patient limit. If both were allowed to increase the number of their patients, wouldn’t the second, more reasonably-priced doctor get some of the more expensive doctor’s business?

Conversely, some advocates for office-based treatment say that opioid treatment programs are upset because they have lost money in recent years. They accuse organizations like AATOD of wanting to limit further expansion of office-based programs because it cuts into their business. With more access, more patients would abandon OTPs for these less restrictive programs

DATA 2000 changed the landscape of opioid addiction treatment. OTPs aren’t the only option for patients seeking treatment for their opioid addiction.

My point is, both OTPs and buprenorphine doctors can accuse the other group of being in it for the money. But as I pointed out in my last blog…no medical treatment in this country is free.

4. “My medication is better than your medication.”

Patients entering opioid addiction treatment often ask me, “Which is better, buprenorphine or methadone?” I say, “Both.” Each has its advantages, and I’ve discussed this in previous blog entries. Briefly, buprenorphine is safer, since there is a ceiling on its opioid effects, but it’s more expensive. Patients on buprenorphine also seem to leave treatment prematurely more often than methadone patients. This isn’t a good thing, since the majority of these patients relapse back to illicit opioid use.

Methadone, as a full opioid agonist, may be more difficult to taper off of, and maybe fewer patients leave treatment prematurely because of that feature. Methadone has been around for fifty years now, with a proven track record. It works, and it’s dirt cheap. Methadone does have more medication interactions, but those can usually be managed if all the patient’s doctors communicate with each other.

Buprenorphine isn’t strong enough for all opioid addicts. Because it’s a partial agonist, there’s a ceiling on its opioid effect. This property means it’s much safer than methadone, but it doesn’t work for everyone.

Buprenorphine is safer than methadone, which to me is its best quality. I’ve started hundreds of patients on buprenorphine and never had an induction death. Sadly, I cannot say the same of methadone. I am not saying overdose death is impossible with buprenorphine…I’m saying it’s much less likely, and that’s worth a lot to me.

Buprenorphine’s superior safety profile is one reason it was approved for use in an office setting. Methadone is riskier to prescribe from an office, because misuse and diversion is more likely to be fatal with this drug. That’s why buprenorphine has fewer restrictions on it. Neither medication is good or bad; the difference between the medications is pharmacologic, not moral.

Next week, I’ll describe my OTP, where we provide methadone, buprenorphine under the OTP license, and buprenorphine under my office-based license, all on the same premises. I think we’ve created a continuum of care that’s able to meet the needs of patients as their recovery evolves.

At our program, it’s not one program versus another. Difference patients need different things, and the same patient may need different things at different points in recovery.

1. Schwartz et al, “A Randomized Control Trial of Interim Methadone,” Archives of General Psychiatry, 2006

Office-based Opioid Addiction Treatment: Raising the One-hundred Patient Limit

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The hearts of addiction medicine doctors nationwide are aflutter at rumors that the limit on office-based buprenorphine patients may be raised or lifted. As it is now, the DATA 2000 law says each doctor who prescribes buprenorphine from an office setting for the treatment of opioid addiction can have no more than one hundred patients at any one time.

DATA 2000 was a big deal. Until it passed, it was illegal for any doctor to prescribe any opioid to treat opioid addiction, unless they worked at a specially licensed opioid treatment program. In other words, doctors in an office setting had to refer opioid-addicted patients to opioid treatment centers for medication-assisted treatment. And the only medication available was methadone.

Then DATA 2000 allowed Schedule 3 opioids to be prescribed from physicians’ offices for the purpose of treating opioid addiction, as long as these medications were FDA-approved for this purpose. Thus far, buprenorphine is the only medication that meets the DATA 2000 requirements.

But the law had other limitations. For example, each physician had to get a special DEA number to prescribe buprenorphine. And as above, no physician could have any more than one hundred patients on buprenorphine at any one time.

My office gets multiple calls each week from people seeking treatment for opioid addiction in an office setting. These callers say they’ve already been to the websites that list doctors. (http://buprenorphine.samhsa.gov and http://suboxone.com . They’ve made multiple calls and discovered these doctors aren’t taking new patients because they’re already at their one hundred patient limit. This is happening all over the country; patients want treatment but can’t get it. For many such people, opioid treatment centers are geographically impractical, so that’s not an option either.

Since addiction is a devastating and potentially fatal disease, government officials feel pressure to do something to help our nation’s opioid addiction problem. Lifting the one- hundred patient limit has been suggested as one option to improve the situation. This would seem to be the best, easiest, and quickest way to get more people into treatment. At least, most Addiction Medicine doctors like me think it makes sense.

Not everyone agrees.

Opposition has come from some unexpected sources. I went to an opioid addiction treatment conference in a neighboring state lately and heard the president of AATOD (American Association for the Treatment of Opioid Dependence), Mark Parrino, MPA, speak against lifting the limit.

First let me say I admire Mr. Parrino immensely. He has been and continues to be a huge advocate for this field. He’s done more good in the field of opioid addiction treatment than most people I can think of, and has been doing this good work long before I ever even entered the field.

But that doesn’t mean I agree with him on everything.

When he spoke at the conference, he said he was opposed to expanded buprenorphine treatment in the office-based setting because patients don’t get the counseling that they need, so it really isn’t medication-assisted treatment, it’s just medication assistance. He says opioid treatment programs provide on-site counseling, drug testing, and other services that can help patients, and that most office-based programs don’t offer such comprehensive services. He also said diversion of buprenorphine from office-based practices is a huge problem, and that much of the black market use is actually abuse of the medication. He raised the uncomfortable issue of price gouging by some unscrupulous buprenorphine doctors who charge large fees and deliver little care.

You can read a statement on the AATOD website that fully describes their opposition – or at least call for caution – regarding raising the one hundred patient office based treatment limit:

http://www.aatod.org/policies/policy-statements/increasing-access-to-medication-to-treat-opioid-addiction-increasing-access-for-the-treatment-of-opioid-addiction-with-medications/

I don’t completely disagree with the points Mr. Parrino made at the conference, but I do think the same arguments can be made against OTPs if one were inclined to do so.

What about opioid treatment programs that pay lip service to the counseling needs of the patients? What about OTPs that hire people to be counselors with little or no experience in the counseling field? Just as Mr. Parrino can point to the worst examples of office-based buprenorphine treatment, I can point to OTPs who aren’t doing a great job. How can an OTP counselor provide Motivational Interviewing as a therapeutic technique if that counselor has never even heard of MI? Yet I’ve seen these problems at opioid treatment programs.

Don’t paint all office-based practices with the same brush. Many of us want to provide good treatment with adequate counseling. For example, my office has a therapist who is a Licensed Professional Counselor with a Master’s in Addiction Counseling. He does a great job, and as an added bonus has great legs. (He’s my fiancé, before you assume I’m sexually harassing him at the workplace).

Alternatively, if the patient prefers to do only 12-step meetings, I’m OK with that, so long as they provide me with a list of meetings they’ve attended each month. Or if they’re already working with a therapist, it’s OK with me if they want to continue, as long as they agree to allow me to speak with their therapist about issues directly relating to the treatment of their addiction.

Diversion of buprenorphine to the black market is a big problem. Not all office-based buprenorphine doctors are as careful as we should be. We will never be able to get rid of all diversion of any controlled substance that we prescribe, but all buprenorphine doctors should be doing drug screens and have diversion controls in place to limit the problem.

Not as much methadone is diverted, but only because of the very strict regulations on methadone take- home doses at the OTP. Many patients – and OTP personnel – feel present regulations on methadone take- home doses are overly strict and limit flexibility of treatment for patients who are doing well. Is the answer then to regulate take -home doses of buprenorphine as closely as methadone?

What about the predatory doctors who prescribe buprenorphine just for a quick buck, sensing they can charge exorbitant fees from desperate opioid addicts? I can’t say anything in their favor. They embarrass me. As with many things in life, the actions of a few give the rest of us a bad reputation. But I do think these doctors are in the minority.

And don’t believe everything you are told about office-based practices; I’m sometimes told by patients that I’m in it “for the money” though I charge the same for an office visit for a buprenorphine patient as I would for any other medical ailment. Some patients feel like their treatment should be free, but the U.S system of medical care is not usually free for any disease.

In short, though I recognize there’s some truth in many of Mr. Parrino’s statements, I still think most buprenorphine doctors try very hard to do things right so that they provide good care for opioid addicts who can’t or won’t go to an opioid treatment program. Expanding access by raising the one-hundred patient limit will allow more people to get addiction treatment.

NSDUH Data Released

NSDUH Data on Heroin Use

NSDUH Data on Heroin Use

Each fall, the National Survey on Drug Use in Households releases data from their yearly survey, and data from 2013 is now being released. It’s a gradual process, with more information released as data is analyzed and compared to years past.

The NSDUH report compiles data collected about drug and alcohol use in the nation and in individual states. This annual survey of around 70,000 people in the U.S. over age 12 also collects data on mental health in the U.S. This research information is collected from phone calls to individual households and is the primary source of data on the abuse of drug including alcohol in the U.S. Data can be compared to past years to look at drug use trends, among other information.

Since this survey is conducted on household members, some scientists say the data underestimates drug use since its methods exclude populations living in institutions such as prisons, hospitals and mental institutions. Such populations are known to have the highest rates of drug use and addiction. But the annual NSDUH report is still one of the best sources of information we have at present. This data can be evaluated for new trends of drug use and abuse, and can help direct funding toward problem areas. Researchers use this data to assess and monitor drug use, as well as the consequences.

Data from 2013 shows that around 9.4% of U.S. citizens use illicit drugs at least monthly. This includes marijuana, cocaine, heroin, hallucinogens, and misused prescription medication. This rate of use hasn’t changed much over the past two years, but it’s a little higher than it was ten years ago.

Of the people who used illicit drugs at least monthly, two thirds used marijuana as their only illicit drug. Marijuana, not surprisingly, is still the most frequently used illicit drugs in the nation. This percentage of people using marijuana has been slowly but steadily increasing over the past ten years. Interestingly, the number of people surveyed who said they were daily or near-daily users of marijuana increased from 5.1 million in 2007 to 8.1 million in 2013.

I do not see this as a good thing, but my blog is dedicated to opioid addiction and its treatment, so I’ll let you make up your own minds about marijuana.

I was happy to see that non-medical use of all prescription medication continued to drop, though slowly, down to 2.5% of the population. Non-medical use of prescription opioids specifically has also shown a slight drop from 2009 to 2013. I hope this means people (and their doctors) are beginning to understand the dangers of illicit opioid use. Tranquilizer use also has shown a slow decline over the past three years, a trend I hope will continue.

Of the group of people who said they were non-medical users of opioids, over half still said they obtained their drug from friends or family, for free. Around 11% bought their drug from a friend or family member, and 21% got the drug from one doctor. Only 4.3% said they got their prescription opioid pills from a drug dealer or a stranger, and only .1% bought them off the internet.

This data tells us – again this year – that the main suppliers of illicit opioids aren’t drug dealers on the corner or dealers over the internet. Main suppliers are friends and family members of the user.

Why is this still a thing people do?? This has got to stop. Sharing medication, controlled substance or not, is dangerous – not to mention illegal. Sharing medication causes harm. You aren’t helping anyone by sharing.

The youngest age group surveyed, aged 12 to 17, showed a drop in the non-medical use of prescription opioids over the last decade, from 3.2% in 2003 to 1.7% in this 2013 survey. That’s reason to hope that youngsters now either have less opioids available to them or that they know how damaging opioid addiction can be. I hope this drop forecasts an overall drop in the number of people addicted to opioids in the coming years.

Now for the bad news: NSDUH shows that heroin use continues to rise, from around 373,000 people in 2007 to 681,000 people in 2013. That’s not quite a doubling over the past six years, but pretty close. That strongly correlates with what I see at my work; people addicted to opioid pain pills tell me it’s harder to find opioids, and also more expensive. Mexican drug cartels have seen this, and moved in to supply heroin as an alternative to opioid pain pills.

It’s an unintended and unfortunate consequence of efforts to limit illicit prescription opioid use.

This 2013 survey showed that there were an estimated 2.8 million new users of illicit drugs in people over age 12. Over 70% of these new illicit drug users started with marijuana. Only about 13% of new users started with non-medical use of opioid pain pills, and this is a lower percentage than in past NSDUH surveys.

This NSDUH data will be released in other reports as more analysis is done on this information.

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