Archive for the ‘History of addiction’ Category

My Favorite Patients are Drug Addicts

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Feeling exceptionally lazy again today, I decided to post a blog containing an article I wrote for the physician magazine Medical Economics. It was published in April of 2010, and I got some great feedback from other doctors. And since I’m a wannabe writer, I also submitted it to the annual Writers Digest writing competition in the magazine article category, and I won 8th place. I was over the moon about this, because this is a huge competition. I got a certificate which I framed and put on the top of my bookcase at home.

I’m prouder of this article than anything else I’ve written, because I was able to be heard by people in my profession.

Here it is:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency twenty-three years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone. However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction. Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office.
In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there’s a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. Initially, Suboxone was expensive, but now generic forms have been approved, and prices have come down a little. Opioid treatment programs, formerly known as “methadone clinics” have started offering buprenorphine in addition to methadone.

The opioid addicts I met both in the opioid treatment program and in my private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients seen in the office setting were professionals. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on buprenorphine.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine. Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another”, when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug-free recovery is ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence proving the effectiveness of medication-assisted therapies with buprenorphine and methadone.

Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I think it’s important to get each patient involved in a recovery program before tapering their medication. This can be an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine or methadone indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.

Epic Fail: Tennessee’s Department of Mental Health

I admit I’ve been a little obsessed with Tennessee’s misguided approach to treating opioid addiction. It sticks in my craw. I can’t get over how backward their attitudes and approaches to the treatment of prescription opioid addiction have been, and I’m struggling to find out why Tennessee is the way it is. I hate bad science and ignorance. It grieves me to see the senseless suffering of the state’s addicted citizens.

I’ve been combing the internet and have found information that makes my right eyelid twitch. In the January 28, 2012 issue of the Tennessean, (1) Doug Varney is named as the new head of Tennessee’s Department of Mental Health. According to this article, he says Tennessee’s opioid treatment programs should to do a “better job” of weaning people off methadone and into detoxification programs. He says there’s no evidence to show methadone helps pain pill addicts as it does heroin addicts. He feels there are more appropriate treatments. In the past, Mr. Varney has been on record as saying methadone doesn’t accomplish anything because it’s merely switching one drug to another.

Yikes. This shows he understands about as much as the person who says methadone is “like giving whiskey to the alcoholic.” I’m not surprised when an average person says such things, because most people don’t know much about methadone, and are misinformed. But this person is the head of Tennessee’s Department of Mental Health!

I suspect he’s also behind the new proposed rules for Tennessee’s opioid treatment centers. Some of the proposed rules are good, and deal with quality of care. And others are harmful, and contradict what we know to be good medical practice.

For example, the new rules say an opioid addict needs to fail at two attempts at drug-free treatment before being allowed to enter an opioid treatment program. Where’s the science to back up that position? There is none. I challenge Mr. Varney to produce evidence showing two attempts at drug-free treatment do anything to help the addict. We know with detoxification alone, relapse rates are consistently in the range of 92-98%. We’ve known this since the old days at the Lexington, KY Narcotic Farm, established in 1935. The data are unchanged today with pain pill opioid addicts.

Besides, where will Tennesseans get this drug-free treatment? I’ve tried, and watched addition counselors try for hours to get opioid addicts into drug-free treatment in Tennessee. On the rare occasions when I’ve seen an opioid addict from Tennessee for whom methadone isn’t the best treatment, it’s next to impossible to find an inpatient treatment center eager to admit this patient. Even if there’s no waiting list for beds, the patients don’t have the money to afford it. And if state money pays for treatment, opioid addicts are rarely kept long enough to really help them. As above, short inpatient admissions accomplish little besides just detoxification, and that’s insufficient. With opioid addiction, patients need more than a month-long admission if drug-free treatment is undertaken. Otherwise it’s a waste of time and money,  sets the addict up for failure. and their family for disappointment.

The proposed rules say that after four positive urine drug screens within six months, the patient on methadone maintenance should be discharged from treatment. Are you kidding me? That runs counter to good medical practice.

Of course, people could say I’m biased because I make my living treating opioid addicts. OK, don’t take my word for it. Let’s consult the American Society of Addiction Medicine, the nation’s most prestigious group of medical doctors, educated and dedicated to the treatment of addiction. The Society has a position paper regarding methadone maintenance which says,

 “Discontinuation of methadone maintenance should be attempted only when strongly desired by the rehabilitated patient…” (2) ASAM’s paper correctly explains the high risk of death for a patient discharged from methadone maintenance. The literature shows death rates for patients who leave or who are terminated from opioid treatment programs spike significantly, to at least eight times the rate of patients who stay in medication-assisted treatment.

Another ill-advised new rule says that permission must be granted for doses higher than 120mg, and the state methadone authority must be notified for any dose rising about 100mg. Again, what does the evidence show? Let’s go to ASAM’s position paper: “Arbitrary caps on the number of patients who can be treated by a physician, the dosage of medication which is allowed, or the duration of treatment with methadone are not supported by medical evidence and should not be imposed by law, regulation, or health insurance practices.” Their position paper is backed by numerous study citations, and thus based on solid eveidence, not personal feelings.

In other words, the addiction medicine physicians have warned against the very actions that Mr. Varney is proposing. ASAM says it’s bad medical practice. They are physicians. Mr. Varney is not.

Mr. Varney needs to realize how serious this is. These proposed new rules for opioid treatment programs have the potential to further increase Tennessee’s opioid overdose death rates. It’s high enough as it is, as 13th highest in the nation. And remember from my past blogs, Tennessee is second highest in the nation for number of opioid prescriptions written, adjusted for population.

How did this guy get into a position of such power? What a disaster! State officials with this kind of authority to impact the lives of citizens have a moral obligation to do what’s best for citizens. Clearly, Tennessee’s Department of Mental “Health” is allowing personal prejudice to get in the way of sound medical practice. Is this even legal?? It makes me wish I lived in Tennessee, if only to vote against whichever administration selected this man to run the state’s Department of Mental Health.

There are actions we can take. Write to Mr. Varney and let him know you don’t think he should propose legislation for actions that knowledgeable physicians have deemed bad medical practice.

Here’s the mailing address:

Tennessee Department of Mental Health
Central Office

11th Floor, Andrew Johnson Tower
710 James Robertson Parkway
Nashville, Tennessee 37243
(615) 532-6500

Or, even quicker, send an email: OCA.Tdmh@tn.gov

Join with other advocates of appropriate, evidence-based medication-assisted treatment at the website of the National Alliance of Medication Assisted Recovery. You’ll see on their homepage that Tennessee is at the top of the list of their advocacy concerns: http://www.methadone.org/  They have some alternative email and regular mail addresses that may work better than the ones above.

  1. http://www.tennessean.com/article/20120128/NEWS07/301280024/TN-methadone-clinics-could-get-new-rules
  2. http://www.asam.org/docs/publicy-policy-statements/1methadone-rev-10-061.pdf?sfvrsn=0#search=”methadone

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”

Top Ten Books for Methadone Counselors

I have a fair number of methadone counselors who read my blog. I’m often asked by these counselors what books I recommend, which is like asking me what kind of dessert is good. The list is so long. But here are the ones all methadone counselors should read:

  1.  Medication-assisted Treatment for Opioid Addiction in Opioid Treatment Programs, by the Substance Abuse and Mental Health Services Administration. This is better known as “TIP 43,” because it’s the 43rd book in the series of treatment improvement protocols published by SAMHSA. You can get any book in the series for FREE! Yes, this book and several others are free resources. The website is: http://store.samhsa.gov. While you’re there, order TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, and TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment. Then browse around, and see what else interests you. This is a great website, and all addictions counselors should be very familiar with it. There’s great material for counselors and their clients.
  2.   Pain Pill Addiction: Prescription for Hope, by….me. Hey, it’s my blog, so of course I’m gonna list my book. At least I didn’t put it at number one. But seriously, I do think my book describes what opioid addiction is, why this country is having such problems with opioid addiction now, and the available treatments for this addiction. I focus on medication-assisted treatments, which means treatments with methadone or buprenorphine, better known as Suboxone. After reading my book, any substance abuse counselor should be able to talk intelligently with patients and their families about the pros and cons of medication-assisted treatment. I tried hard to base this book on available research and not my own opinions, though I do state some of my opinions in the book. My book also has summaries of the major studies done using medication-assisted treatments, so that if you need resources to prove why methadone works, you’ll have them. OK. I’m done blathering. Order it on EBay and you’ll save some money.
  3.      Motivational Interviewing by William Miller and Stephen Rollnick. This is a book all addiction counselors should have… and read. I’ve learned so much about how to interact with people as they consider if, how, and when to make changes in their lives by reading this book. The authors demonstrate how the Stages of Change model easily fits with this style of counseling. There are some solid examples of how to incorporate MI techniques.
  4.      Cognitive Therapy of Substance Abuse, by Aaron Beck et. al. This is a venerable text describing cognitive therapy as it applies to substance abuse. The book is relatively concise, but it’s still dense reading. Get out your underliner because you’ll want to find some parts to read again. The dialogues in the book that serve as examples are instructive. This book has been around for some time, as texts go, since it was published in 2001.
  5.     Narcotics Anonymous Basic Text, by Narcotics Anonymous World Service. Now in its sixth edition, this is one of the books that serve as a foundation for 12-step recovery in Narcotics Anonymous. If you are a counselor who’s in recovery, you’ve probably already read it. If you’re not, you need to get it, read it, and be able to talk intelligently about the 12-step recovery program of this 12-step group. The AA “Big Book,” which is AA’s version of a basic text, has much of the original old-time words and phrases, and speaks mostly of alcohol. For these reasons, some addicts won’t like the Big Book as well as the NA Basic Text. However, the Big Book does have a certain poetry that will appeal to others. (….trudge the road of happy destiny…) You can order it at http://na.org or go to that site and download it as a pdf.
  6.  The Treatment of Opioid Dependence, by Eric Strain and Maxine Stitzer. Written in 2005, this is an update to a similar title written in the 1990’s. This book reviews the core studies underpinning our current treatment recommendations for patients in medication-assisted treatment of opioid addiction. I don’t know why more people haven’t read this book, because it’s relatively easy to understand. Don’t make the mistake of assuming it will be too advanced for you. Get it and read it.
  7. Addiction and Change: How Addictions Develop and Addicted People Recover, by Carlo DiClemente. This book describes the paths people follow as they become addicted and as they recover. It’s focused on the transtheoretical model of the stages of change, so named because it can be used with many counseling theories. I think this is a practical book, and easier to understand than some texts.
  8.  Diagnosis Made Easier: Principles and Techniques for Mental Health Technicians, by James Morrison M.D. This is an improvement of his earlier book, DMS IV Made Easy, written in 1992. At any work site, addictions counselors will have to be familiar with the criteria used to diagnose mental illnesses. Since around 30 – 50% of addicts have another co-occurring mental illness, you need to be familiar with the criteria used to diagnose not just addiction, but these other illnesses as well. And this book makes learning relatively painless. It’s practical and easy to read, and based on common sense. It contains many case examples, which keep it interesting.
  9. The American Disease: Origins of Narcotic Control, by David Musto. This book has been updated and is on its third edition, but so much has happened since this last edition in 1999 that the author needs to write an update. This is an interesting book, and it moves fairly quickly. This information puts our present opioid problem into the context of the last century or so. As an alternative, you can read Dark Paradise: A History of Opiate Addiction in America, by David Courtwright in 2001. I included this book, but be warned it’s heavier reading. This author is an historian, so maybe his writing style didn’t resonate with me as much. Still, he has much good information. You can’t go wrong with either book. You could also read The Fix by Michael Massing, which is another book about the history of addiction and its treatment in the U.S… This last book doesn’t focus on just opioid addiction, but still gives all the pertinent history. This book is written by a journalist and will keep your interest. It was written in 2000.
  10.  Hooked: Five Addicts Challenge Our Misguided Drug Rehab System, by Lonnie Shavelson. This book, written by a journalist, follows five addicts through the labyrinth of addiction treatment. You’ll see the idiotic obstructions addicts seeking help are asked to negotiate in our present healthcare system. I was angry as I read the book, seeing obvious simple solutions that couldn’t be enacted for one administrative reason or another. Let this book make you angry enough to demand change from our system. Be an advocate for addicts seeking treatment.

 Have I left out any? Let me know which book have helped you be a better counselor or therapist.

The Pain Management Movement

 In the late 1990’s, organizations like the American Pain Society and the American Academy of Pain Management declared that doctors in the U.S. were doing a lousy job of treating pain, and were under-prescribing opioid pain medications, due to a misguided fear of causing addiction. As a result, there was a national push to treat pain more aggressively. Some states even passed pain initiatives, mandating treatment for pain. Lawsuits were brought against doctors who didn’t adequately treat pain. The Joint Commission on the Accreditation of Healthcare Organizations (JACHO), the organization that inspects hospitals to assess their quality of care, made the patient’s level of pain the “fifth vital sign,” after body temperature, blood pressure, heart rate, and respiratory rate. Pain management specialists encouraged more liberal prescribing of pain medication. These experts told their primary care colleagues that the chance of developing addiction from opioids prescribed for pain was about one percent.

With these limited facts, the pain management movement was off and running. Many pain management specialists, some of whom were paid speakers for the drug companies that manufactured powerful opioid pain medications, spoke at seminars about the relative safety of opioids, used long term for chronic pain. Pain management specialists taught these views to small town family practice and general medicine doctors, who were relatively inexperienced in the treatment of either pain or addiction.

The problem was…the specialists were wrong.

These specialists, in their well-intentioned enthusiasm to relieve suffering, used flawed data when reciting the risk for addiction. The one percent figure came from a study looking at patients treated in the hospital for acute pain, which is quite different from treating outpatients with chronic non cancer pain. (1) In other words, they compared apples to oranges.

To many addiction specialists, an addiction risk of only one percent seemed improbable, since the general population has an addiction risk estimated from six to twelve percent. Surely, being prescribed pain pills would not lessen the risk for addiction. Yet the one percent figure was often cited by many pain management professionals, as well as by the representatives of the drug companies selling strong opioids. 

Some pain management specialists even took a scolding tone when they spoke of some primary care physicians’ reluctance to prescribe strong opioids. They often muddied the waters, and grouped patients with cancer pain, acute pain, and chronic non-cancer pain together, and spoke of them as one group. This can feel insulting to doctors who, though reluctant to prescribe opioids endlessly for a patient with chronic non cancer pain, are adamant about treating end-of-life cancer pain aggressively with opioids. No compassionate physician limits opioids for patients with cancer pain or with acute, short term pain. However, chronic non-cancer pain is different, with different outcomes than acute pain or cancer pain.

 We didn’t learn from history, or we would have learned that when many people have access to opioids, many will develop addiction.  We are scientifically more advanced than one hundred years ago, but we still have the same reward pathway in the brain. The human organism hasn’t changed physiologically. The present epidemic of opioid addiction is reminiscent of the early part of the twentieth century, just after the Bayer drug company released heroin, which for a short period of time was sold without a prescription, before physicians recognized that over prescription of opioids caused iatrogenic addiction.

 Few pain patients intended to become addicted. Some addicted people blame their doctors for causing their opioid addiction, but most doctors were conscientiously trying to treat the pain reported by their patient, and the pain management experts had told these doctors the risk of addiction was so low they didn’t have to worry about it.

Certainly many patients made bad choices to misuse their medications, either from curiosity or peer influence, pushing them farther over the line into addiction. Patients need to recognize their own contribution to their addiction. But with opioid addiction, as the disease progresses, the addict loses the power of choice that he once had. If the addict is fortunate enough to have a moment of clarity, before the disease progresses too far, he may be able to stop on his own, without treatment.

 By their very nature, opioids produce pleasure. Any time doctors prescribe something that causes pleasure, we should expect addiction to occur. Some people, for whatever reason, feel more pleasure than others when they take opioids, and seem to be at higher risk for addiction. As discussed in previous chapters, genetics, environment, and individual factors all influence this risk.

Opioids treat pain – both physical and emotional. Many of the neuronal pathways in the brain for sensing and experiencing pain are the same for both physical and psychological pain. For example, the brain pathways activated when you drop a hammer on your toe are much the same as when you have to tell your spouse you spent the rent money while gambling. Opioids make both types of pain better. Chronic pain patients with psychological illnesses are at increased risk for inappropriate use of their pain medications.

 In a recent study, the rate of developing true opioid addiction in patients taking opioids for chronic pain was found to be increased fourfold over the risk of non-medicated people. (2) Instead of a one percent incidence, as estimated by pain medicine specialists in the past, it now appears eighteen to forty-five percent of patients maintained long-term on opioids develop true addiction, not mere physical dependency. (3) If this information had been available in the late 1990’s, doctors may have taken more precautions when they prescribed strong opioids for chronic pain.

 Researchers have identified the risk factors for addiction among patients who take opioids long-term (more than three months) for chronic pain. Studies now show that a personal past history of addiction is the strongest predictor of future problems with addiction, as would be expected.  A patient with a family history of addiction is also at increased risk for addiction, as are patients with psychiatric illness of any kind, and younger patients. (4)

However, at the height of the pain control movement, there were no good studies of the addiction risk when opioids were used for more than three months. The little information that did exist was misused, resulting in an incredible underestimation of the risk of addiction in patients with chronic pain, who were treated with opioid medications for more than three months.

 With the momentum of the movement for better control of pain, both acute and chronic, the number of prescriptions for opioid pain pills increased dramatically. In the years from 1997 through 2006, prescription sales of hydrocodone increased 244%, while oxycodone increased 732% during that same time period. Prescription sales for methadone increased a staggering 1177%. (5)

It’s not just patients who are at risk for abuse and addiction. The increased amount of opioids being prescribed meant there was more opioid available to be diverted to the black market. When an addicting drug is made more available, it will be misused more often.

  1. Porter and Jick, New England Journal of Medicine, 302 (2) (Jan. 10, 1980) p. 123.
  2. Michael F. Fleming, Stacey L. Balousek, Cynthia L. Klessig, et al. “Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy,” Journal of Pain, 207; Vol. 8, issue 7: 573-582.
  3. 7. Steven Passik M.D., Journal of Pain and Symptom Management, Vol. 21 No. 5, (May 2001), pp.359 – 360.
  4. Chou, R, Fanciullo, G, Fine, P, et. al., “Opioid Treatment Guidelines: Clinical guidelines for the use of Chronic Opioid Therapy in chronic, non-cancer pain.” The Journal of Pain, 2009, Vol. 10, No. 2. pp. 113-130

5. Andrea Trescott, MD, Stanford Helm, MD, el. al., “Opioids in the Management of Chronic Non-cancer Pain: An Update of American Society of the Interventional Pain Physicians’ Guidelines,” Pain Physician 2008: Opioids Special Issue: 11:S5 – S 62.

The Narcotic Farm: A Bit of History

We don’t have to keep re-inventing the wheel.

We can investigate the success rates of addiction treatment methods used over the past century, see what worked, and what didn’t work. We can use programs of proven benefit or we can continue to spend money on programs repeatedly shown to have little benefit.

From 1935 until 1962, drug addicts were treated at a unique facility, part jail and part treatment hospital. Initially named the United States Narcotic Farm, it was later changed to the U.S. Public Health Service Narcotics Hospital. Even after this name change, most people still called it the Narcotic Farm.

This facility was located on twelve acres of Kentucky farmland. The facility was created by the Public Health Service and the Bureau of Prisons, meant to serve a dual purpose. It was a treatment hospital, where drug addicts could voluntarily be admitted for treatment of their addiction, and it was also a federal prison, where drug offenders were sent to serve their sentences. About two thirds of the inpatients were prisoners and the other third were addicts, voluntarily seeking help for opioid addiction. Both types of patients were treated side by side. For over forty years, it was the main drug addiction treatment center in the United States, along with a similar facility in Ft. Worth, Texas, which opened in 1937.

            The Narcotic Farm was a massive institution for its time. It had fifteen-hundred beds, and housed tens of thousands of patients over its forty years of operation. It was located in a rural area of Kentucky, which gave it space for numerous operations to engage the prisoners – now called patients – in all types of job training. (1)

             The Narcotic Farm really was a farm. Besides growing many types of vegetables, there was a working dairy, and livestock including pigs and chickens. These operations provided food for the patients and staff of the facility and provided work for the patients. The patients provided the labor to keep the farm going and it was hoped they would simultaneously learn useful trades. In addition to farming, they learned skills in sewing, auto repair, carpentry, and other trades. Besides teaching new job skills, it was hoped that fresh air, sunshine, and wholesome work would be beneficial to the addicts. (1)

            For its time, the Narcotic Farm was surprisingly progressive in its willingness to try multiple new treatments. For the forty years it operated, many different treatments were tried for opioid addicts. It offered individual and group talk therapies, job training, psychiatric analysis, treatment for physical medical issues, Alcoholics Anonymous meetings, art therapy, shock therapy, music therapy, and even hydrotherapy, with flow baths to soothe the nerves. Despite these options, the Farm apparently retained many of the characteristics of a prison, with barred windows and strict security procedures. (1)

             The Narcotic Farm had its own research division, the Addiction Research Center (ARC), which became the forerunner of today’s National Institute on Drug Abuse (NIDA). The Narcotic Farm did pioneering work, using methadone to assist patients through withdrawal, and helped establish the doses used to treat opioid addiction. Methadone was used only short term, for the management of withdrawal symptoms, and not for maintenance dosing at the Narcotic Farm. The Farm also trained a dedicated group of doctors and nurses, who were pioneers in the field of addiction treatment. It provided new information on the nature of addiction.

             Admission to the Narcotic Farm allowed an opioid addict some time to go through opioid withdrawal, eat regular meals, work in one of the farm’s many industries, and have some form of counseling. However, after leaving the hospital, the addicts were entirely released from care and supervision, with no assistance to help re-enter their communities. Most times, they returned to their same living situation and old circumstances encouraged relapse back to drug use and addiction. As a result, two follow up studies of the addicts treated at the Narcotic Farm showed a ninety-three percent and ninety-seven percent relapse rate within six months, with most of the relapses occurring almost immediately upon returning home. Many addicts cycled through the Public Health Hospital multiple times. (1)       

            The Narcotic Farm was eventually turned over to the Bureau of Prisons in 1974, as the treatment for addiction was de-centralized. Since the studies found high relapse rates for addicts returning to their previous communities, it was hoped by moving treatment centers into communities, these addicts could have ongoing support after they left inpatient treatment.

  1. Nancy P. Campbell, The Narcotic Farm: The rise and fall of America’s first prison for drug addicts, (New York, Abrams, 2008)

 

This is an excerpt from my new book, “Pain Pill Addiction: Prescription for Hope.” 

Available at http://prescriptionforhope.com

 and on Amazon and Ebay

and many bookstores

Pain Pill Addiction: Prescription for Hope

Finally, here’s the cover of my book about pain pill addiction and its treatment. It’s available at http://prescriptionforhope.com or you can order it from Amazon, and soon from Barnes and Noble.

My book contains much of what I’ve been blogging about. I wrote the book because there are so few sources of reliable information about the treatment of opioid addiction (pain pills). It seems  that abstinence-based programs don’t like to talk about medication-assisted programs, and some methadone clinics don’t let their patients know about other options. Methadone and buprenorphine can be life-saving when used appropriately, but they have some drawbacks, as well.

There’s not one single right answer for all opioid addicts. Some treatments work for some patients, but no treatment works for all patients. In my book, I present the data supporting treatment methods, so opioid addicts and their families can chose the best course.

If you like this blog, you’ll like my book. I also have a chapter in the book about the unjust stigma patients face when they are treated with medication-assisted methods. It takes a strong person to stay on a treatment that helps them, despite criticism from friends, family, law enforcement, and even unenlightened medical professionals.

Bibliotherapy: Books About the History of Addiction and Treatment

Great books about the history of addiction and its treatment have languished in obscurity, never getting the recognition that these bits of history richly deserve.  I’m going to do my small part to encourage people to read these great books.

 The Addicts Who Survived: An Oral History of Narcotic Use in America, 1923-1965, by Courtwright, Joseph, and Des Jarlais. This book, published by the University of Tennessee Press in 1989, is now out of print, so hopefully you can find a copy at your library. I’m so glad I bought one of the few copies. This amazing book is filled with interviews with intravenous heroin addicts who lived through the so called “classic era” of opioid addiction. I got a feel for how fragile life is for IV addicts, and how miraculous it is to survive addiction for 30 years. Many of the survivors went into methadone programs, and credit methadone with saving their lives. Other addicts went on methadone, but are frank about their criticisms of methadone treatment, and their regrets. As an added bonus, this book has interviews with key people who made history during the classic era of opioid addiction in the U.S.: Vincent Dole, M.D., one of the three original investigators of the efficacy of methadone maintenance as a treatment. Dr. Dole describes the harassment and interference he experienced during his work, both from law enforcement and the medical community.

 The Fix, by Michael Massing.  There’s much great history in this book. Much of the book talks about the governmental decisions regarding the treatment of addiction and addicts. The author describes effective treatments for addiction which weren’t continued, because of political pressures. It also describes how policies that didn’t work nonetheless remained in practice because of politics. This book gives us insight into dealing with the present wave of pain pill addiction. If you have to read one book on the history of addiction treatment in the U.S., make it this one. It’s interesting because the author also includes stories of real-life addicts and their struggles to find treatment and recover.

 The American Disease: Origins of Narcotic Control, by David Musto. This may be the best-known book about the history of opioid addiction and treatment in the U.S. The author gives exhaustive references, valuable in their own right. This book may be dense reading for anyone not already interested in the topic, but I loved it. He gives a painstaking history of drug addiction against the background of American culture and politics. Anyone who has input into drug policies needs to read this book.

Dark Paradise: A History of Opioid Addiction in America, by David Courtwright. Much like The American Disease, it is packed full of information, along with insights and interpretation of the information. It covers much of the same information as the other book. It differs in the interpretation of opioid addiction history.

 Hooked: Five Addicts Challenge our Misguided Drug Rehab System, by Lonnie Shavelson. The author, a physician and journalist, follows five addicts with no money through the process of accessing addiction treatment. He documents in excruciating detail the pitiful systems called “treatment” for these addicts. Gaps in care and communication breakdowns would frustrate anyone, but these people are more fragile than most. The roadblocks they face are depressing. This is a fascinating and entertaining book, and left me with a feeling of frustration. It’s a vivid description of how broken our healthcare system is for the indigent.

Slaying the Dragon: The History of Addiction Treatment and Recovery in America, by William White. Written in 1998, this book has it all. It’s probably the most comprehensive book about the history of addiction treatments. Even if you don’t work in the field, you’ll think the book is interesting. It’s a well-written and scholarly book.  Particularly interesting was the descriptions of quack cures for addiction promoted throughout the ages. Some things never change. People desperate and suffering from a disease are vulnerable to different species of snake oil treatments now, as ever in history.

Addiction: from Biology to Drug Policy, by Avram Mack. Written nearly 10 years ago, parts of this might be a little out of date, but it’s still packed with information. It covers technical material, but is accessible to the educated layperson. He has some interesting stories to illustrate his meanings.

 The Narcotic Farm: The Rise and Fall of America’s First Prison for Drug Addicts, by Nancy Campbell, 2008. In this little-known book, the author explains how drug addiction was treated from 1935 until 1975. The Narcotic Farm was a unique facility that served both voluntary patients and prisoners who had addiction. For its time, the Farm was moderately open-minded and willing to try new treatments. Sadly, most of the addicts treated to the Farm relapsed, probably because they had no continuing treatment when the addicts returned home. The pictures in the book are great, and tell much of the story of the Narcotic Farm.

We need these books. We don’t have to keep re-inventing the wheel because we can look to the past for guidance about the treatment of the addicts in this country. Our past method of incarcerating addicts clearly did not, is not, working. Public policy makers all over the country at all levels of government need to read these books.

If you know of more such books, tell me.

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