Archive for the ‘Books for addiction counselors’ Category

The Benzodiazepine Dilemma: New Guidelines for Opioid Treatment Programs from IRETA

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I’ve written about benzodiazepines before in this blog (See my post of November 3, 2012). I worry about overdose deaths and other complications in patients for whom I prescribe methadone who are also taking benzodiazepines, prescribed or illicit.

Now doctors at OTPs have help from the Institute for Research, Education and Training in Addiction (IRETA). This well-respected organization located in Pittsburgh, Pennsylvania just issued an evidence-based document titled, “Management of Benzodiazepines in Medication-Assisted Treatment.” You can access this document at IRETA’s website: http://ireta.org/

I love IRETA for tackling this subject. There’s much misinformation about the use of benzodiazepines, even for patients without addiction. But for patients with addiction, benzodiazepines can be deadly when combined with opioids including methadone and buprenorphine.

IRETA’s document first describes how and why these guidelines were created. Opioid treatment programs often have patients who also use benzodiazepines, both by prescription and illicitly. Physicians at OTPs have widely varying responses to these patients. Some programs have zero tolerance, meaning they won’t allow anyone on benzodiazepines to be in their opioid treatment program. Other physicians at OTPs actually prescribe benzodiazepines for their patients when they feel it’s clinically indicated. IRETA wanted to delve into actual scientific literature and consult a panel of experts for interpretation of that data. This IRETA document describes in detail how the literature search was done. It also goes into exhaustive detail about how each statement in the set of guidelines was vetted by experts.

This paper’s guidelines fall into seven categories:

General guidelines
Assessment for MAT
Addressing benzodiazepine use
MAT for patients with concurrent benzodiazepine use
Noncompliance with treatment agreement
Risk management/Impairment assessment
Special circumstances

Here are the general guidelines, taken directly from the document:

CNS depressant use is not an absolute contraindication for either methadone or buprenorphine, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, anti-depressants, or alcohol.
People who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
Clinicians should ensure that every step of decision-making is clearly documented.
Clinicians would benefit from the development of a toolkit about the management of benzodiazepines in methadone treatment that includes videos and written materials for individuals in MAT.

Please note that under the third point of the general guidelines, it says patients shouldn’t be taken off MAT because of repeated benzo use, but need “risk management strategies.” That’s a little vague, but IRETA guidelines go into more detail later in the document.

IRETA’s second section of guidelines is about assessment for MAT. The guidelines say all of the usual things; for example, they say a doctor should do a complete evaluation of a patient presenting for treatment, as described in SAMHSA’s TIP (Treatment Improvement Protocol) 40 and 43. The evaluation should include the patient’s history of medical problems and history of all drug use, even over the counter medication. A mental status assessment and a drug screen should also be included.

Also under the assessment section, IRETA suggests adding patient education about the dangers of mixing benzos with methadone or buprenorphine. I like this idea, and I do something similar. When I ask about past drug use, I always warn patients about the potential bad outcome of mixing benzos and alcohol with the medication I’m going to prescribe, and I repeat the warning at the end of our interaction.

IRETA suggest doctors go farther, and give patients information not only about overdose risk, but also about the other problems benzodiazepines can cause. Benzodiazepines are associated with a greater risk of depression and suicide. Having a prescription for benzodiazepines doubles a patient’s risk for an auto accident, and increases the risk for other accidents, like falls. Taking a benzodiazepine prescription is associated with an increased risk for hip fracture.

The IRETA guidelines remind us that there is “Substantial and growing literature that suggests long term use of benzodiazepines (especially in large doses) leads to cognitive decline.” (page 16 of the report) the guidelines also say that benzodiazepines are associated with emotional blunting, and long-term sleep and mood disturbances. Even more relevant, studies show that patients on benzodiazepines have worse outcomes in medication-assisted treatment.

The third section of IRETA’s guidelines is about addressing benzodiazepine use. They say that a patient should be willing to address their benzo addiction. IRETA says that uncontrolled use of benzodiazepines is a contraindication to treatment with methadone or buprenorphine because of the “extremely high risk for adverse drug reaction involving overdose and/or death during the induction process.”

I’m in the “amen” corner for that one! But it’s hard for me to know which patients use benzos occasionally to help opioid withdrawal, and which patients use benzos heavily in an uncontrolled manner. Most patients, seeing me for admission to MAT, minimize their use of benzodiazepines, knowing it’s a big issue. If they’re getting benzodiazepine prescriptions in large amount from multiple doctors, I can see that on our state’s prescription monitoring program. If the patient is taking benzos illicitly, I may not have a way to know this. Information from family members and friends can sometimes help, if the patient will allow. Or family members and friends may be as heavily involved in addiction as the patient presenting for treatment.

The IRETA guidelines remind us that patients on long-term benzodiazepine therapy are at risk for adverse drug reactions which can include overdose and death. The guidelines say that central nervous system depressants are not absolutely contraindicated with methadone, but also put patients at risk for overdose and death. I assume at this point in the document, its authors are referring to other non-benzo central nervous system depressants like carisopradol (Soma), zolpidem (Ambien), and the other “z” sleep medications, and perhaps pregabalin (Lyrica).

IRETA’s benzodiazepine guidelines for OTPs are extensive, so I’m going to split my review of the contents over two blog entries. Stay tuned…or even better, go read them for yourself:

http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

1. Thomas et al, “Benzodiazepine use and motor vehicle accidents. Systematic review of reported association.” Canadian Family Physician, 1998 April;44:799-808.
2. Smink et al, “The relationship between benzodiazepine use and traffic accidents: A systematic literature review.” CNS Drugs, 2010 Aug.24(8)6390653.

A Really Good Book – For Free

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If you haven’t read CASA’s (Center on Addiction and Substance Abuse, at Columbia University) masterpiece publication from June, 2012, titled “Addiction Medicine: Closing the Gap between Science and Practice,” you should do so. This publication can be downloaded for free, and has essential information about addiction and its treatment. http://www.casacolumbia.org/addiction-research/reports/addiction-medicine

Casa also has other free and informative publications about other issues, like how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), the cost and impact of untreated addiction on society (“Shoveling Up”), substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet ( “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

“Addiction Medicine: Closing the Gap between Science and Practice” outlines all aspects of what is wrong with addiction treatment in the U.S., along with recommendations about how we can fix this broken system. When it was published in June of 2012, I thought it would be would be widely read and discussed. However, I’ve only heard it mentioned once, and that was at an ASAM meeting. I wish popular press, so eager to write sensationalistic pieces about addiction, would write more fact-based information.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report describes these factors and how they have contributed to our present situation.
Our nation hasn’t waged a war on drugs, but rather on people who use drugs.

The CASA report describes how public opinion about addiction isn’t based on science. Science proves addiction is a brain disease, yet this fact is still debated. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that half of the risk for developing addiction is determined by genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report pointed out that most addiction treatment and prevention isn’t done by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Primary care providers may not be adequately paid for screening and brief intervention for problem drinking and drugging, and valuable opportunities are lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for medical consequences of problem alcohol use.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I would – literally – give patients with serious addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I assumed if there was a better way to treat addiction, I’d have learned about it in my training.

Wrong. The doctors who trained me couldn’t teach what they didn’t know themselves.

In my Internal Medicine residency, I admitted many patients to the hospital for endocarditis (infected heart valve) contracted from IV heroin use. Each time, this required six month of intravenous antibiotics. Back then we kept such patients in the hospital the whole time. You can imagine the cost of a six week hospital stay, not that these addicts had any money to pay. Just a fraction of that amount could have paid for treatment at a methadone clinic, the most effective way to treat heroin addiction, and prevent dozens of medical problems.

But I never referred them to the methadone clinic available in that city. I didn’t know anything about methadone or the medical-assisted treatment of opioid addiction, and apparently my attending physicians, responsible for my training, didn’t know about it either. It was a shame, because in those years, the late 1980’s, we were making new diagnoses of HIV almost daily among IV drug users. Since then, a study showed a patient using IV heroin drops his risk of contracting HIV by more than threefold if he enrolls in a methadone clinic.

I didn’t learn about the evidence-based treatment of opioid addiction until I agreed to work at a methadone clinic for a few days, covering for a friend of mine when he wanted to go on vacation. I was amazed to learn about decades of evidence showing the benefits of such treatment.

Most addiction-related medical expenses are paid for from public funds. In fact, over ten percent of all federal, state, and local government dollars are spent on risky substance use and addiction problems. Sadly, over 95% of this money is spent on the consequences of drug use and abuse. Only 2% is spent on treatment or prevention.

Untreated addiction costs mightily. People with untreated addiction incur more health care costs than nearly any other group. An estimated one third of all costs from inpatient medical treatment are related to substance abuse and addiction. Untreated addicts (I include alcohol addicts with drug addicts) go to the hospital more often, are admitted for longer than people without addiction, and require more expensive heath care than hospitalized non-addicts. The complications these people suffer could be from underlying poor physical health and lack of regular preventive healthcare, but most of the cost is incurred treating the medical problems directly caused by addiction and risky substance use.

Family members of people with untreated addiction have higher health costs, too. Families of people with addiction have 30% higher health care costs than families with no addicted member. I presume that’s from the stress of living and dealing with a loved one in active addiction. Often family members are so caught up in trying to control the chaos caused by active addiction that they don’t take time for routine health visits.

The costs of untreated addiction aren’t only financial. Addiction and risky drug use are the leading causes of preventable deaths in the U.S. Around 2.9 million people died in 2009, and well over a half million of these deaths were attributable to tobacco, alcohol, and other drugs. Overdose deaths alone have increased five-fold since 1990.

We know addiction is a chronic disease, yet we spend far less on it than other chronic diseases.
For example, the CASA report says that in the U.S., around 26 million people have diabetes, and we spend nearly 44 billion dollars per year to treat these patients. Similarly, just over 19 million have cancer, and we spend over 87 billion for treatment of that disease. In the U.S., 27 million people have heart disease, and we spend 107 billion dollars on treatment.

But when it comes to addiction, we spend only 28 billion to treat the estimated 40.3 million people with addiction, and that includes nicotine!

Most of the money we do spend is paid by public insurance. For other chronic diseases, about 56% of medical expenses are covered by private payers, meaning private insurance or self-pay. But for addiction treatment, only 21% of expenses are paid from private insurance or self-pay. This suggests that private insurance companies aren’t adequately covering the expense of addiction treatment. Indeed, patients being treated with private insurance for addiction are three to six times less likely to get specialty addiction treatment than those with public insurance such as Medicaid or Medicare. Hopefully we will see a change since the parity law was passed. (which told insurance companies they had to cover mental health and substance addiction to the same degree they cover other health problems)

In the U.S., we don’t treat addiction as the public health problem that it is. Some people still don’t believe it’s an illness but rather a moral failing. Doctors, not knowing any better, often have an attitude of therapeutic nihilism, feeling that addiction treatment doesn’t work and it’s hopeless to try.

Families and medical professionals often expect addiction to behave like an acute illness. We may mistakenly think addiction should be resolved with a single treatment episode. If that episode fails, it means treatment is worthless. Families want to put their addicted loved one into a 28-day treatment program and expect them to be fixed forever when they get out. They’re disappointed and angry if their loved one relapses.

This reminds me of an elderly man I treated for high blood pressure many years ago. I gave him a month’s prescription of blood pressure medication, and when he came back, his blood pressure was good. I was pleased, and I wanted to keep him on the medication. He was angry. He said he was going to find another doctor. He thought the one prescription should have cured his high blood pressure so that he would never have to take pills again, and was disappointed with my treatment.
If we keep our same attitude toward addiction treatment, we are doomed to be as disappointed as my patient with high blood pressure. Addiction behaves like a chronic disease, with period of remission and episodes of relapse.

We have a lot of work to do. As this CASA publication shows, we have to change public attitudes with scientific information and do a much better job of training physicians and other health care providers. We should pay for evidence-based, high-quality addiction treatment, rather than spend billions on the medical problems caused by addiction as we are now doing.

Check out this landmark publication at CASA’s website: http://www.casacolumbia.org

Book Review: Clean: Overcoming Addiction and Ending America’s Greatest Tragedy, by David Sheff

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You may recognize this author’s name, as he wrote Beautiful Boy, a gripping account of his son’s addiction to methamphetamine and the effect the addiction had on the whole family. This second book on addiction is more scholarly than personal, but still thought-provoking.

Clean is well-researched. It’s written with great attention to information and opinions given by experts in the field of addiction, and to scientific research in the field. The author successfully assimilated the information and distilled it into understandable paragraphs. The book is divided into seven sections, titled “America on Drugs,” “Why We Use,” “When Drug Use Escalates,” “Getting Clean,” “Staying Clean,” “Treating a Chronic Illness,” and “Ending Addiction.”

In the first section, “America on Drugs,” Mr. Sheff explains why some humans, particularly adolescents, are more susceptible to addiction. He explains why adolescents begin to experiment with drugs, and describes why drug use is more perilous in young adults. The human brain is still developing until age twenty-five or so, and the structure and function of these immature brains may be more impaired by drugs than more mature brains seen in adults over age twenty-five. The author points out that ninety percent of people in the U.S. who develop addiction start using drugs before the age of eighteen. In other words, the younger someone is at first drug experimentation, the higher the risk of addiction.

The author points out that we tend to see drug addiction as bad behavior rather than the disease that science has clearly proven it to be. (The U.S. puts more of its citizens in jail than any other country in the world as a proportion of the total citizens. Cuba, Rwanda, and Russia all have much lower rates of incarceration. The majority of inmates in the U.S. have addiction that remains untreated while they are incarcerated, all because of the criminalization of addiction. Thus the “war on drugs” is really a war on people who use drugs.)

The author not only outlines risk factors for initiating drug use, but also the risk factors for moving from drug use to drug addiction. These factors include the pleasures of drug use, stress, trauma, poverty, family issues, learning disabilities, behavioral disorders and mental illness. Combinations of these risk factors cause a situation ripe for the development of addiction

Then the author has a long chapter containing ways that parents can offset risk factors for addiction in their children, along with ideas for schools and communities, too. All of this is important information, but the positioning of this chapter was a little jarring to me. It felt like a long chapter about prevention was wedged into a book otherwise devoted to treating addiction. I agree it’s an important topic, perhaps deserving a separate section or even a separate book.

Another section of the book describes warning signs of addiction, and provides information about how professionals assess for addiction. There’s a chapter about interventions and how they can be done – as well as some dangers involved with staging interventions.

I liked the chapter about detox. The book explains the different ways of detoxing, and says detox is only the beginning of treatment, an important idea for families and addicts to understand.
The author goes into some specific details about the types of therapies addict receive in the course of treatment for addiction.

The next section of the book is all about getting clean: the difficulties addicts and their families have in finding appropriate treatment. The book describes what usually happens in a drug addiction treatment facility, and gives some ideas about things to look for in a good treatment center.

Twelve step recovery occupies a lengthy chapter in this book. I thought the author was even-handed and presented what we know about these programs, including that they don’t work for everyone

Part of the book describes evidence-based treatments, and that’s helpful, but the author doesn’t mention that many treatment programs don’t use – or under-use – evidence-based treatments. He also describes warning signs which may indicate a program should be avoided. He talks about the cost of treatment, and some of the difficulties of insurance payment for treatment.

There’s plenty of scientific information in the book, and it’s mixed with anecdotes of addicts and family experiences. The information was accurate; I didn’t detect any blatantly bad science.

I enjoyed the chapter titled provocatively titled, “Treating Drug Problems with Drugs.” Aside from a few misstatements and minor misinformation, it’s great. Granted, this chapter is nine pages long, in a three-hundred and thirty-one page book, but that’s better coverage than most popular books on addiction treatment give medication-assisted treatment of opioid addiction (which is, as you know I’m fond of saying, one of the most evidence-based treatments in all of medicine, let alone addiction medicine). This chapter talks mostly about methadone but there are several pages on buprenorphine, too. Sadly the brand name “Suboxone” is used repeatedly in this chapter instead of the more appropriate “buprenorphine” but hey, I’m not gonna quibble too much. I’m just happy this information was included.

The author does point out some of the weaknesses of our prevailing addiction treatment system, but he does so in a gentler manner than in the book, Inside Rehab, by Anne Fletcher. I reviewed Inside Rehab earlier this year on my blog, and I preferred it to Clean. In Fletcher’s book, she’s emphatic to the point of being spew-y; that made her book interesting. Sheff’s book is accurate but more docile and polite. Inside Rehab is more of a “Hey wake up!” in tone.

Both books are good additions to the plethora of books about addiction and recovery, and I recommend both to any readers interested in the subject.

Book Review: “Inside Rehab: the Surprising Truth about Addiction Treatment – and How to Get Help that Works,” by Anne Fletcher

Inside Rehab

This meticulously-researched book is excellent, and I highly recommend it to people entering treatment, and to their families. I also think everyone working in the field of addiction treatment needs to read the book and ponder the truths it reveals.

The book is more scholarly than I was expecting; the author researched studies, statistics, data, and talked to experts in the field of addiction treatment. She visited addiction treatment programs, and though half of them were located in her home state of Minnesota, she did investigate a wide variety of addiction treatment approaches. She talked with the people who worked at these programs and also talked to a large number of people seeking recovery from addiction. Some people had success with treatment, and some didn’t.

The “surprising truth” she refers to in her title isn’t surprising to anyone who read the milestone report issued last summer from Casa Columbia, the New York City think tank that studies addiction treatment. I did a blog on that report (see August 9th, 2012), one of the most important, evidence-based, exhaustive statements made about the state of addiction treatment in this country. I hoped this paper would be talked about and its conclusions taken seriously, but the addiction treatment field appears to have greeted CASA’s landmark paper a collective giant yawn, and gone back to business as usual.

Repeatedly, this author refers to CASA’s report, and her investigative book mirrors CASA’s findings closely. In fact, I would describe Ms. Fletcher’s book as an expanded, more interesting version of that CASA report.

“Inside Rehab” explains how addiction treatment has been abandoned by the medical field long ago. The lack of addiction science in past decades contributed to this exodus, as did the rise of the 12-step movement and the Minnesota Model. Doctors get very little training about addiction and its treatment, and the medical field views addiction not as a medical problem but as a social problem. Most doctors are happy to direct addicts to counselors rather than begin treatment with evidence-based medications. The author points out that even treatment centers rarely use or recommend medications that are proven to work, like naltrexone, acamprosate, disulfiram, buprenorphine and methadone. The author talks about how science takes a very long time to be implemented into real-life practices. This would not be tolerated in any other field of medicine.

The author says many treatment centers have not incorporated evidence-based treatment approaches, and have stayed stuck in the past, using the same treatments now as were used in the 1980’s. She’s right. Older methods that don’t show any benefit are still being used, like educational lectures, aggressive patient confrontation, and the like. The author points out how the addiction treatment field is still dominated by thinking that’s guided by folk wisdom, much of it from laypeople in recovery themselves, rather than science. Few programs offer evidence-based treatments like CBT (Cognitive Behavioral Therapy), MI (Motivational Interviewing), contingency management, community reinforcement approach, and even twelve-step facilitation. Programs promoting 12-step philosophy rarely use the actual Twelve Step Facilitation method as tested in research studies with demonstrated benefits. Instead, they use kind of a freestyle method. It may work; it may not.

The author correctly points out that workers in the field of drug and alcohol addiction treatment often have little training and may lack professionalism. Addiction treatment workers with little education can end up trying to treat people with some of the most complex medical problems, particularly people with addiction and co-occurring mental health issues. Counselors have been allowed to “grandfather in” and obtain certifications because of the length of time they’ve been working in the field, rather than returning to school for additional education.

The author talks about the lack of licensing requirements for the addiction counselors, and how certification organizations like CARF and JCAHO both only ask facilities to comply with state regulations. These organizations could instead call for higher standards for certification, including minimum standards for education.

She is rightfully critical of the “one size fits all” approach to people with addiction. Many treatment programs claim to individualize their treatment to fit the individual, but in reality, everyone gets assigned to the same groups, with little or no attention to specific issues. The claim of individual treatment in some cases appears to be more of a marketing ploy than an actual practice.

She criticizes over-reliance on 12-step recovery as a treatment for all people. I was happy to see Ms. Fletcher included the evidence showing 12-step recovery participation does improve the chances for abstinent recovery. But she feels patients shouldn’t be forced to go to 12-step recovery if they don’t want to go, and I agree with her. She also points out that non-12-step groups likely also improve recovery, though there’s been little if any research on them. She feels treatment programs need to offer these non-12-step options to patients in addiction treatment.

I agree with that too, but unless you live in California, those meetings are hard to find. Women for Sobriety, one of the groups she mentioned in the book, had eight meetings per week held in the state of North Carolina when I investigated that organization a few years ago, trying to find alternatives for a patient of mine who didn’t like 12-step meetings. That’s compared to 12-step meetings, which have hundreds, possibly thousands of meetings per week across the state. Alternative to AA and NA may work…but there are difficult to find, at least in my area. Online meetings may be of some help.

She made some insightful remarks about how when treatment facilities try to associate themselves with AA, it’s AA that suffers. That’s a good point. Some AA members aren’t happy to have their meeting flooded with patients from a local treatment center, who in some cases don’t really want to be there. Some meetings won’t sign attendance forms for a probation officer that’s forcing someone to go to AA. Some groups believe it’s against one of AA’s traditions that says people should come to AA because they’re attracted to it, not enticed or forced to go. I’ve heard AA members talk derisively about inpatient treatment rehabs where the only treatment offered is AA-type group meetings. They argue that people could do this on their own, for next to no cost. If someone seeking recovery lives in a big city, he could probably get to four or five meetings each day. One might wonder how much advantage is there to an inpatient program that costs tens of thousands of dollars where little more is offered than AA-type group meetings?

She has chapters devoted to the treatment of adolescent addicts, an area rife with controversy. Not all adolescent drug abusers will continue on their way to becoming addicts, yet some will. How can we tell who needs treatment and who doesn’t? We don’t have distinct answers yet, and it may lead to over- treatment of adolescents.

I do have a few minor complaints about the book. She’s quoted people who have been to treatment, who describe shoddy treatment they’ve received. I’ve no doubt much of it is true, but some of it sounds exaggerated, to say the least. I might take these descriptions at face value, but I’ve heard many patients tell exaggerated stories. For example, I had a patient (not an addict) tell me her last doctor beat her with a hammer. I was incredulous, but she insisted it was true. As I asked for specifics, it became apparent her previous doctor didn’t beat her with a hammer; he checked her reflexes with a small rubber mallet.

So…patient statements are helpful, but may not be as accurate as Ms. Fletcher believes. I understand the point Ms. Fletcher’s interviewed patients are making, and most of what they say may be true. Or it may not be true.

In one vignette, an addict criticized his doctor for not being willing to “help him out” with prescribed opioid medication to help him avoid opioid withdrawal and taper his opioid use. Unfortunately the book’s author pounced on that bandwagon, apparently unaware that it’s a crime for a physician to prescribe opioids from an office setting to treat addiction, unless it’s Suboxone from a licensed provider. I was sad she criticized the doctor, and that she seemed eager to believe the worst about the physician, when in fact the doctor could be charged with a crime if he complied with the patient’s request.

My other beef with her book is her relatively brief coverage of medication-assisted treatment with methadone and buprenorphine. She does mention these medications throughout the book, and correctly points out how traditional Minnesota model treatment centers aren’t using this evidence-based medication. But I think medication-assisted treatment of opioid addiction deserved a chapter of its own. It’s the most evidence-based treatment, possibly in all of medicine, and is actually being discouraged by most big-name treatment centers. That’s an outrage. (Even though Hazelden last year announced they would start to use buprenorphine, they are using it only for detox, and still discourage maintenance. See my blog post from Nov. 20, 2012.)

I had mixed feelings when reading the book. I agreed with most of what the author said, yet it’s hard to read about criticism of the field when I’m a part of it. I found myself wanting to be defensive, but in the end Ms. Fletcher has written some much-needed truths. The book is directed at the educated layperson, and the information is accurate. If addiction treatment professionals aren’t offering the best of treatments, patients need to take the initiative and get into programs that do offer the best, state of the art treatment. That’s the concluding message of this book. Ask questions before you go to treatment, and vote with your feet and your dollars.

It’s a great book. I wish all addiction treatment providers could read it, along with all medical students, doctors, nurses…OK, everyone should read it.

You can read more about the author of the book here: http://annemfletcher.com/

Craving: a Book Review

cravingI just read a great new book related to addiction.

“Craving: Why We Can’t Seem to Get Enough” was written by Omar Manejwala, M.D., a friend of mine, a nationally renowned addiction psychiatrist, and an expert on compulsive behaviors of all kinds. This nonfiction book is, as the title suggests, all about the phenomenon of craving. It is published by Hazelden and will be released today. You can go to this link to buy the book: http://www.amazon.com/dp/1616492627/?tag=ommamd-20

Dr. Manejwala has been the medical director of Hazelden and other prestigious addiction treatment facilities, and has worked with all sorts of addicts including addicted healthcare professionals. He’s even appeared on television on show like 20/20.

This book is about more than just drug addiction; his information about craving pertains to any substance or activity. I love his definition of craving as a desire so strong that when unfulfilled “produces powerful physical and mental suffering.” (p2) His description of craving is eloquent and easily understood.

In this book Dr. Manejwala explains abstract ideas and concepts in plain language. I’ve heard him give lectures on addiction-related topics and I’ve always been impressed his skill of distilling the complicated into understandable bits. His writing also shows this gift. Though his book is easy to understand, it’s not dumbed down, as too many books on addition written for the public tend to be.

The first part of the book defines cravings and compares them to weaker wants and urges. He tells us why cravings matter: cravings lead all of us to indulge in behaviors that undermine success. In subsequent chapters, Dr Manejwala gives some simple information about brain anatomy and neurotransmitters, and shows how the brain’s structure and function affect our ability to make choices.

In a later chapter he shows how cravings can drive not only behavior, but also thought patterns, in some really interesting ways. When a person intends to act on a craving that is obviously destructive, all sorts of irrational and false beliefs can pop up, and seem to make perfect sense. These thought patterns keep the person stuck in destructive behaviors for long periods of time, leading to negative life consequences.

Another chapter shows how addictive behaviors tend to be related; that is, how a person with alcohol addiction is more likely to have or develop addictions to other drugs. That person is also more likely to develop a behavioral addiction like gambling, compulsive overeating, or compulsive shopping. This chapter explains why these behaviors can occur together.

My favorite chapter is about the brain’s plasticity. The term “plasticity,” when applied to the brain, means the brain is changeable. Our thoughts, actions, and experiences actually change the structure and functioning of the brain. This is important, because it means there are things we can do to change our cravings. Dr. Manejwala explains how thoughts, behavior, and even spirituality can free us from cravings. This fascinating chapter has some great references, too.

The next chapter tells more about how spirituality is important to recovery. The author explains why 12-step recovery and other spiritual approaches work to reduce cravings. He explains specifically how groups help reduce urges and improve behavior in ways that can’t be done by a lone individual.

Later chapters explain how insight into problem behavior is only a start in the direction of change, and how many people mistakenly think facts alone will reduce cravings. This chapter clarifies how apparently irrelevant decisions can actually be subconscious decisions to act on a craving. In this chapter, healthier substitute activities are suggested. The latter chapters have solid advice on where to go to find help with problem behaviors, and have specific tips to help with cravings for smoking, alcohol and other drugs, sugar, gambling, and internet addiction.

This gem of a book is relatively short, at 190 pages, and highly readable. I’m keeping it on my bookshelf for the references listed in the back.

This book will help addiction professionals be better able to explain cravings and addiction to patients. Anyone who has ever tried to squelch a craving – unsuccessfully – by willpower alone will be interested in this book.

Don’t miss this book if you’re interested in book about addiction and recovery.

Check Out CASA’s New Free Publication

If you’ve never browsed CASA’s website, you need to do so. CASA, which stands for Center on Addiction and Substance Abuse, at Columbia University, has helpful information about addiction and its treatment that you can download for free. They have information about how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), information about the cost and impact of untreated addiction on society ( “Shoveling Up”), in formation about substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet (the “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

This summer, they published a masterpiece: “Addiction Medicine: Closing the Gap between Science and Practice.” I’ve read most of this book, and admire the clarity and call to action it presents. This publication outlines all aspects of what is wrong with addiction treatment in the U.S., and how to fix it.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report clearly describes these factors, saying they all contributed to our present situation. We have declared a war on people who use drugs, not on drugs.

The CASA report describes how public opinion about addiction isn’t based on science. We now have science that proves addiction is a brain disease. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that at least half of the risk for developing addiction is determined by one’s genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report illuminates what addiction medicine physicians have been saying for years: addiction treatment and prevention isn’t treated by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Often, primary care providers aren’t paid to do brief interventions, and an opportunity for prevention is lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for the consequences of with alcohol addiction.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I felt like I was slapping Band-Aids on gaping wounds. I would – literally – give patients with addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I thought if there was a better way to treat patients, I’d have learned about it in my training.

Wrong. Instead, I learned about this vast body of scientific literature about addiction treatment by accident, when I worked at an addiction treatment center for a few days, covering for a doctor friend of mine.

In coming blogs, I’ll outline more of the points made by this timely publication. In the meantime, read it for yourself at  http://www.casacolumbia.org

Bibliotherapy: Good Books for Recovering People

Recovering people need different things at different times in their recovery. For the first year or two, efforts are directed toward learning to stay clean, and clearing the wreckage from the past. Most recovering people must spend a great deal of time, energy, and attention on these tasks during the first year or two of recovery.

 

After mastering these essential tasks, recovering people often ask, “What’s next?”  They can experience what I call a mid-recovery-life crisis. Some people go through it after a few years, and some after ten or more. It’s sometimes described as a yearning for something deeper. For some, it means work on relationships – with other people, with one’s Higher Power, and with one’s self. For others, it means finding renewed meaning and purpose in life.  Many people find answers to their mid- recovery-life questions in the twelve steps, of course, but outside sources can also aid in this phase of recovery.

 

Books containing the wisdom and experience of other people can be a tremendous help. Here are a few titles that have helped recovering people on their journey of recovery:.

 

The Mindful Addict, by Tom Catton

This is a tale of one man’s spiritual journey in recovery. The author describes his addicted life in the first fourth of his book, then moves on to tell of his eclectic approach to spirituality. He embraced Buddhism, mindfulness, and meditation. The author elaborates on spiritual principles he’s found to be keys in his recovery. Toward the end of the book he explains how his spirituality helped him face some serious medical conditions. He talks about the importance of being wide-awake to life, and about the importance of showing up, serving others, and of radical acceptance. This is a book to read and re-read.

 

Mindful Recovery, by Tom Bien and Beverly Bien

This book discusses mindfulness and its relation to spirituality. It contains options for people, even in early recovery, who object to concept of a Higher Power. Mindfulness can be used to help heal addictions and other ailments, such as anxiety or other strong negative emotions. The book not only describes spiritual practices of awareness and enjoying the present moment, but also gives practical exercises to help. Short stories, scattered throughout the book, serve as examples for how these techniques can be applied. The authors explain how journaling, meditation, and storytelling can help recovery. This book contains tools for change, and may be a place to start with patients who object to the phrase “Higher Power,” but who are still open to a spiritual approach to recovery.

 

The Spirituality of Imperfection: Storytelling and the Search for Meaning, by Earnest Kurtz and Katherine Ketcham

This book promotes the idea that spirituality is attained by admitting and accepting our imperfections. The book also says our imperfections make for some really great storytelling, and our stories contain great truths. This book and the ideas in it are compatible with AA and 12-step recovery. Parts are interesting and inspiring, but it’s not a quick and easy read. Sometimes the book felt scattered, but after all, it is an imperfect book. I highly recommend this book to people with perfectionistic tendencies.

Sermon on the Mount: The Key to Success in Life, by Emmet Fox

This book, written sixty-five years ago or so, is still mentioned in AA meetings as a source for spiritual ideas. When I first read this book many years ago, I was intrigued by the idea that positive thoughts bring positive effects. I think there’s a certain amount of truth to this, but now I have difficulty with the book’s vending machine concept of God. The author states that we can control the events in our world by having positive thoughts, and that God will give us our hearts’ desires. I don’t think it’s that simple, and it fails to acknowledge our lack of control over many things. This book has no explanations of why bad things happen to good people.

 

Simply Sane: The Spirituality of Mental Health, by Gerald May

This wonderful book, written about twenty years ago, is thin at just 180 pages, but packed with interesting ideas. The book emphasizes the importance of being tolerant and patient not just with other people, but also with ourselves. We don’t have to try so hard. We don’t have to endure the stress of “having it all.” This book is the same author who wrote Addiction and Grace, another book worthy of reading and re-reading.

 

A Hunger for Healing: The Twelve Steps as a Classic Model for Christian Spiritual Growth, by Keith Miller

Warning: this is a book written by a Christian for other Christians. And it’s relatively old, published originally in 1992. The author discusses how Alcoholics Anonymous’ 12-steps can be used as a pattern for spiritual growth for anyone, not necessarily only for people with alcohol addiction. Unfortunately, too many people in churches think they dare not be completely honest about how broken and needy they are. Some church people believe that after salvation, Christians shouldn’t struggle with addiction. But it’s that façade of self-sufficiency that cuts off the healing available from other people. It takes humility to admit we need the help of other people. Many people would prefer God heal them privately, and leave other people out of the process.

 

You Can’t Make Me Angry, by Paul O.

This author is the guy whose story is in the Big Book of Alcoholics Anonymous, and contains that oft-quoted bit about “acceptance is the answer to all my problems.” This book elaborates on that idea. When I first picked it up, I thought, “How silly. Of course people can make other people angry,” but by the end I agreed with Dr. Paul: an emotionally mature person doesn’t have to let other people make her angry. This book is all about growing up emotionally, and taking responsibility for our own emotions and reactions. This is a book to keep, read and re-read. It’s written in a light-hearted manner, with nice vignettes for examples, so it’s enjoyable, not heavy. Also read his other book, “There’s More to Quitting Drinking than Quitting Drinking.”

 

Of Course You’re Angry: A Guide to Dealing with the Emotions of Substance Abuse, by Rosellini and Worden

This Hazelden book is kind of a counterpoint to the above book, and also is excellent. This book explains why addicts need to acknowledge angry feelings rather than suppressing them. When we suppress and deny feelings, they often come out sideways, and cause problems. The book explains that we can chose how and when to express angry feelings, instead of acting out anger in ways we later regret. I highly recommend this book for all recovering addicts, their families, and all other members of the human race.

 

Stage II Recovery: Life Beyond Addiction, by Ernie Larsen

More than any other book, this book is excellent for people in recovery who start asking “What’s next?” The author puts special emphasis on restoring relationships. He also discusses some of the more common ruts people can fall into during recovery. See also: Stage II Relationships: Love Beyond Addiction by this same author.

 

Lit by Mary Karr

This autobiography tells of the author’s struggle with both addiction and recovery. Full of zinging metaphors, the book elegantly tells an addict’s story. I particularly like how her book didn’t end at getting clean, but continued to describe her peaks and valleys in recovery.

Have you found books that helped you find meaning and purpose in your recovery and your life? Please write a comment to tell us about them.

Christmas Special

For anyone interested in a copy of my book, it’s now available in pdf form, on EBay, for $2.

If you are a patient at Stepping Stone, don’t get it on EBay. Stepping Stone patients can get it for free –  just give your email address to Amy, our receptionist, and I’ll email you the pdf.

 I’m also bringing a few paperback copies to Stepping Stone tomorrow, to give away.

Harmed by HARM’D

HARM’D (Helping America Reduce Methadone Deaths) is an organization that lobbies against methadone, or at least against methadone- related deaths. Though they fall short of advocating abolishment of methadone completely, they do advocate for stronger federal regulations of methadone clinics.

 As part of the research I did for the book I wrote last year, (“Pain Pill Addiction: Prescription for Hope”) I looked carefully at the HARM’D website, http://harmd.org. Recently, I was surprised to see the website appears to be abandoned. In the past, one could find extreme and inflammatory statements on the website’s discussion boards. The statements on HARM’Ds website were fueled by grief from the deaths of loved ones, who died from methadone overdoses. They used to have a video on the website, describing loved ones who died with methadone in their system. Most were young people, and many were not addicts, but made a bad choice and died as a result of it. Watching the video was very sad.

Listening to the videos on HARM’Ds website, and reading comments posted by HARM’D’s members gave me the impression the organization was completely opposed to methadone. However, last year I emailed the organization with some questions, and the president of HARM’D’s board responded quickly.

HARM’D advocates special training and licensure for physicians who work at methadone maintenance clinics, and mandatory drug testing for patients (though these are already mandated, by federal regulations for patients in opioid treatment centers). They want naloxone (brand name Narcan, a drug that reverses the sedation of an opioid overdose) to be dispensed so if a patient overdoses at home, their family can learn to inject them with Narcan and thus revive them.

HARM’D advocates the use of methadone only as a last resort, after safer drugs fail. (I presume they are speaking about pain patients, since opioid treatment centers only have two medications they can legally prescribe to treat addiction). HARM’D wants to make sure patients in pain clinics and methadone clinics are adequately informed about the dangers of methadone. They say doctors treating chronic pain patients have other drugs from which to choose. They want to eliminate take homes for patients who are still using drugs, and want clinics to be open every day of the year, for new or unstable patients. They recommend that methadone clinics have a “no benzo” policy. They would like to see a reduction in the number of take home doses allowed for stable patients, so patients on methadone would have to come to the methadone clinic more often. They promote quick detoxification from a methadone clinic, if urine drug screens are positive.

I wish the members of HARM’D could meet and talk with stable and successful patients on methadone. Many, if not the majority, of patients who start in methadone programs do extremely well and have no further drug use while on a program. They return to their work and to their families, and become functional citizens. These patients are anonymous. They keep quiet about taking methadone, because they don’t want to face the stigma attached to being a methadone patient. They know that some people in their lives would criticize them harshly for choosing this treatment option. HARM’D doesn’t see these patients. Nobody sees these patients, except the staffs at their methadone clinics.

Some of HARM’D ideas are good; additional training for physicians working in methadone clinics is a great idea. Perhaps doctors who work in opioid treatment clinics should be required to have American Society of Addiction Medicine (ASAM) certification or the equivalent in the field of psychiatry. If a physician who wants to work in an opioid treatment center has no previous experience with addiction and its treatment, required attendance at a comprehensive, one day training course would assure that this physician understands the pharmacology of methadone. This would increase the quality of care at opioid treatment clinics, and doesn’t seem overly burdensome for physicians who desire to work in clinics. In fact, my state has held several such training courses for new and established doctors who work at opioid treatment centers.

To further complicate the issues, many personal injury lawyers are becoming involved in filing lawsuits on behalf of patients who have died from methadone overdose deaths, and their families. A search of the internet reveals many similar advertisements. One law firm advertised themselves as “Dangerous Drug Lawyers.” This probably wasn’t the best wording they could have chosen. (What’s dangerous, the drug or the lawyer?)

Thankfully, there is also an advocacy group for patients on methadone: NAMA, for National Alliance for Medication-Assisted Therapy. They have wisely asked members to take an advocacy training course, before speaking out about methadone. This is smart, because it gives NAMA more credibility. It’s easy to state your position and support it with facts when you know the facts. Many members of HARM’D seem to be talking from a place of emotion, while members of NAMA focus on the facts, as revealed in forty years’ worth of scientific studies and forty years’ worth of outcome studies for addicts.

Opioid treatment centers already have many regulations they must follow. Even following all of these regulations, a small amount of methadone will inevitably spill into the black market, but this amount is small, in comparison to the amount of methadone diverted to the black market from pain patients. In the last several years, I’m happy to see that pain medicine specialists are prescribing less methadone.

 I don’t know if HARM’D is still a functioning organization. Perhaps they will open another website, perhaps not. Either way, I hope their members have found peace. Even though I don’t agree with them on most things, I feel compassion for anyone who has lost a loved one to addiction, because I have, too.

A Bit of History

             In the 1980’s, President Ronald Reagan helped guide the thinking of the nation, and emphasized law enforcement as the solution to the war on drugs. The War on Drugs was born. Spending increased for police and other enforcement agencies, but decreased for addiction research and addiction treatment. When crack cocaine captured the attention of America in the mid-1980’s, it re-ignited old fears.

            As in times past, what people thought of drug addicts depended in part on who was addicted. There was much rhetoric about the nature of crime committed by minorities, addicted to drugs, and of crack babies, based more on media exaggeration than on science. As a result, the drug laws were again re-written.

          During the Reagan years, laws were passed that were quite similar to the draconian Boggs Act of the 1950’s. The death penalty was even re-introduced for drug dealers, under certain circumstances. Laws mandating sentences for simple possession were resurrected, and in general, drug laws were set back to the way they were thirty years prior.

            Parents of the 1980s observed with alarm the rise in cocaine abuse, with its hazards and easy availability. They leapt into action, by forming the Parent’s Movement.  They were a powerful political voice that helped coerce lawmakers into passing tougher drug laws. The American public had once again demanded more punitive drug laws.

             Laws passed against the possession of crack were different from those for powder cocaine. The penalty for five grams of crack was the same as the penalty for five hundred grams of powder cocaine. African Americans, of lower socioeconomic status, tended to use crack because it was cheaper than powder cocaine. Therefore, African Americans were more likely than whites to receive a mandatory sentence for drug possession, because it took so little crack, a hundred-fold less, to carry the same sentence. (1)

             State and federal laws differed considerably, because federal convictions could not, by new law, be shortened by more than fifteen percent. This meant that being convicted in federal court lead to longer sentences than being convicted in state courts. District attorneys had the power to decide in which jurisdiction to try an offender, and this gave them considerable influence over the fates of arrestees. Predictably, prisons filled around the country, and prison censuses doubled, at both state and federal levels. (1)

             Shortly before the first of the George Bushes took office in 1989, the 1988 Anti-Drug Abuse Act was passed, which re-organized the bureaucracies assigned to overseeing the drug addiction problems of the nation. Under this Act, the Office of National Drug Control Policy (ONDCP) was formed, and William Bennett was designated drug czar. This agency was given the task of monitoring all of the anti-drug programs in government agencies. The forerunner to the Center for Substance Abuse Prevention (CSAP) was formed in the Substance Abuse and Mental Health Services Administration (SAMHSA). There was much fanfare about new policies, which would both emphasize a zero tolerance toward drug use and also give more attention to treating addiction. However, Bennett resigned abruptly and the fanfare fizzled.

              When Clinton took office in 1993, he cut funding for the ONDCP by eighty-three percent, and exhibited a general lack of interest in addiction and its treatment. His Surgeon General, Jocelyn Elders, angered many when she appeared to advocate legalization of drugs. (2) Probably in response to public pressures, and concerns about the rising rate of marijuana use among adolescents, Clinton publically announced a new attack on drugs, just before the next election year, and nominated Barry McCaffery to head the revived ONDCP.

              Throughout the 1990’s, heroin purity on the U.S. streets was gradually increasing. In 1991, heroin was about twenty-seven percent pure, while by 1994, it had risen to forty percent. That was a dramatic increase in purity, compared to 1970’s and 1980s, when an average purity of three to ten percent was found in U.S. cities. Many potential addicts, scared off cocaine by high profile deaths of people like Len Bias and John Belushi, turned to experimentation with heroin. (1). Columbian drug cartels, diversifying from dealing only with cocaine, began selling heroin to meet an increasing demand by the U.S. Because heroin was so pure, it could be snorted, rather than injected, and many people who balked at injecting a drug would snort it, and did. By 1997, heroin accounted for more treatment center admissions than did cocaine. (2). “Heroin chic”, a trend of thin and ill-looking models as the ideal of beauty, came into vogue in the mid-1990s.

             At that same time, in the mid-1990s, several more ingredients besides higher potency heroin were thrown into the simmering caldron of opioid addiction: the pain management movement and access to controlled substances over the internet. Then, with the release and deceptive marketing of OxyContin, the cauldron began to boil. 

1. David Musto, The American Disease: Origins of Narcotic Control, 3rd ed., (New York: Oxford University Press, 1999) p 274.

2. David T. Courtwright, Dark Paradise: A History of Opiate Addiction in American, (Cambridge, Massachusetts, Harvard University Press, 2001) pp180-181.

excerpt from “Pain Pill Addiction: Prescription for Hope”

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