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 13^th 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, 3^rd 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”

Great Book About Opioid Addiction!!!

I orginally started this blog to promote the book I wrote about pain pill addiction. As it’s turned out, the blog has been much more popular than the book (it isn’t exactly flying off the shelves), so I’d like to remind blog readers – again – that if you like the blog, you’ll love my book.

You can order it from Barnes & Noble, or Amazon. But I’m selling it for a much-discounted rate of $13.95 on EBay. That’s with shipping included.

http://shop.ebay.com/i.html_from=R40&_trksid=p5197.m570.l1313&_nkw=pain+pill+addiction&_sacat=See-All-Categories

Are Opioid Pill Addicts Different From Heroin Addicts?

Most of the opioid addicts I have treated over the last ten years have been addicted to pills, not heroin. But information about prognosis and treatment of opioid addiction was gleaned from studies with heroin addicts. I’ve often wondered if the old data fits the new patients.           

Over the last ten years, the number of people addicted to prescription opioids has ballooned. Prescription opioids are now more likely to cause or contribute to drug overdose deaths than heroin or cocaine. As prescription opioids outpace heroin in many parts of the country, scientists have wondered if there are significant differences between these prescription addicts and heroin addicts. Biologically, addiction to heroin or prescription opioids would appear to be the same disease, because both types of drugs are opioids, and opioids affect the body the same way. But do all opioid addicts respond the same to treatment?

 In the latest issue of Addiction, there was an article describing a study that compared different groups of opioid users. The researchers described four separate groups: opioid users of only heroin, opioid users of only prescription opioids, opioid users of both heroin and prescription opioids, and drug users that used only non-opioid drugs. In this study, drug users weren’t further classified as addicts, abusers, or occasional users. (1)

This study of over nine thousand drug users found that users of both prescription opioids and heroin were more likely to use other, non-opioid drugs than the other three groups. These addicts seemed to have worse mental health issues than the other groups, too, while users of non-opioid drugs tended to have less severe mental health issues than opioid addicts of all types.

The prescription opioid-only addicts were found to use significantly more non-opioid prescription drugs, while the heroin-only addicts were significantly less likely than prescription opioid addicts to abuse sedatives and tranquilizers, like benzodiazepines, than the other two groups of opioid users.

 This last fact definitely squares with what I’ve been seeing. So many of my patients are struggling or have struggled with benzodiazepine addiction. I wonder if opioid pill users are at increased the risk of overdose death when treated with methadone, compared to the heroin-only users of past decades.

This article, at the very least, shows there are significant differences in clinical features for at least three types of opioid users. It’s possible people who are addicted to prescription opioid pills have different prognoses and different responses to treatment than heroin-only addicts. Hopefully we’ll see further studies to guide our treatments.

1. Wu, LT; Woody, GE; Yang, C; Blazer, DG; “How Do Prescription Opioid Users Differ From Users of Heroin or Other Drugs in Psychopathology: Results From the National Epidemiologic Survey on Alcohol and Related Conditions,” Journal of Addiction Medicine, Vol. 5, No. 1, March 2011.

Usefulness of Prescription Monitoring Programs

I ranted recently about Florida’s Governor Scott’s bizarre decision to give the axe torpedo their prescription monitoring program (see March 8th, also March 6th). Now I’d like to post a link to a thoughtful piece about how prescription monitoring can have positive effects.

This link was found on Brandeis University’s Center of Excellence. These folks do research for public policy surrounding prescription monitoring, among other things. The first URL below is for their home page; the second is for the specific article that I thought was interesting.

 http://www.pmpexcellence.org

http://www.pmpexcellence.org/sites/all/pdfs/methadone_treatment_nff_%203_2_11.pdf

Am I Addicted to Prescription Pain Pills?

I am a guest blogger on addictionblog.org, and recently had a well-received article published on that site about how to know if you are addicted. I thought I’d repeat a version of that column here.

 There’s so much confusion about the differences between the disease of addiction to opioid pain pills and mere physical dependency on pain pills. Even some doctors don’t understand the differences, regretfully. Any person who regularly takes opioid pain pills for a period of weeks to months, for whatever reason, will develop a physical dependency to these drugs. That’s a biologic event. But addiction is much more than just the physical process. With addiction, there’s also a psychological component. People with addiction think about the drug often, spend time using and recovering from the drug, and continue to use the drug even though bad things happen. In physical dependency alone, this doesn’t happen.

 Here are a few specific questions that I ask patients, that help me decide if they have the disease of addiction:

• Do I take more medication than prescribed? Do I take early doses, or extra doses?
• Do I take medication in ways it’s not intended? For example, do I snort it, or chew it for faster onset? Do I inject it?
• Do I get medication from friends, family, or acquaintances because I run out of my prescription pills early?
• Do I become intoxicated, or high, from my medication? Without telling my doctor?
• Do I drink alcohol with medication, even though the pharmacist advised against this?
• Do I look forward to my next dose of medication?
• Do I get impaired from my medication, to the point I’m unable to function normally?
• Do I take pain medication to treat bad moods, anxiety, or to get to sleep?
• Do I use street drugs like cocaine, marijuana, or others?
• Have I driven when under the influence of pills, when I know I shouldn’t be driving?
• Do I get prescriptions from more than one doctor, without telling them about each other?
• Do I spend a great deal of time worrying about running out of medication?
• Do I spend a great deal of time thinking about my medication, and how it makes me feel? 

One “yes” answer to any of these questions is worrisome, though not necessarily diagnostic of addiction. I think of addiction as a continuum, and it’s easier to diagnose with multiple “yes” answers. For example, people taking prescriptions may have a few worrisome symptoms, like taking an extra pill occasionally. Perhaps they did this because of a temporary increase in pain. Without any other symptoms, I probably wouldn’t diagnose addiction. At the other end of the spectrum, if a patient is crushing pills to inject or snort, I feel confident making the diagnosis of addiction.

 Sometimes addiction only becomes apparent over time. This is why doctors need to see patients frequently who are prescribed potentially addicting medication, like pain pill, stimulant, and benzodiazepines.

 If you had one or more “yes” answers to the above questions, please see a doctor who knows something about addiction, because untreated addiction usually gets worse. In fact, it can even be fatal.

Governor Scott’s Flamingo Express to Misery

Flamingo Express of Florida

All I could think was, “What can he be thinking???”

 I was reading an article about the governor of Florida and his bizarre decision to block the formation of a prescription monitoring program in his state. (1)

 Prescription monitoring programs are databases that contain lists of controlled substances a patient receives, the prescribing doctors, and the dispensing pharmacies. Usually, only approved physicians can get access to these databases. Prescription monitoring programs help prevent “doctor shopping,” which is the term describing the actions of a patient who goes from one doctor to another to get prescription pills, usually opioids, without telling the doctors about each other. Addicts do this to supply their ever-increasing tolerance for the drugs. Drug dealers do this to get pills to sell and make money.

 Forty-two states have approved the formation of prescription monitoring databases, and thirty-four states have operational databases. Florida was one of the last to approve the formation of such a program, in 2009, long after this recent wave of prescription pain pill addiction burned through the country. Now, the new Florida governor wants to cut this program out completely, before it even starts.

 How big of a deal is this?

In the latest survey, 5.3 million people in the U.S. used prescription pain pills nonmedically over the past month. This means they used them in ways not intended, or for reasons not intended by the prescriber… for example, to get high. In the last year, 2.2 million people misused these prescription pain pills for the first time. Our young people are particularly at risk; between 2002 and 2009, the percentage of 12 to 17 years olds misusing prescription opioids rose from 4.1% to 4.8%. Not all of these people will become addicted, thankfully. Some will only experiment, and be able to stop before addiction develops. Many won’t be able to stop taking pills, and will progress into the misery of addiction. Others will die of drug overdoses. (2)

 Why pick on Florida?

Florida is infamous for its pain clinics. As a reporter for Time Magazine pointed out, there are more pain clinics in South Florida than there are McDonald’s franchises. In 2009, 98 of the top 100 prescribers of oxycodone in the nation were all located in Florida. Altogether, these doctors prescribed 19 million dosage units of oxycodone in 2009. Estimates of the numbers of pain clinics located in South Florida vary, but most sources say between 150 and 175. (3, 4) Many of these clinics are “pill mills,” where doctors freely prescribe controlled substances with little regard to usual prescribing standards and guidelines.

 Are all these clinics pill mills?

No. Some of the pain clinics are legitimate, and their doctors follow best practice guidelines, providing quality care to patients with pain. But careful monitoring and screening for adverse events, including the development of addiction, takes time. A conscientious doctor, trying  to do a good job, isn’t going to be able to see fifty pain patients in one day.

 I’ve talked to addicts who were previously patients at these pill mills. They describe how they were shuffled through rapidly, sometimes not even seeing the doctor. Some addicts say they were asked what pills they wanted, and quickly written that prescription, with little or no conversation beyond that. That was the extent of the visit. 

But Florida’s problem doesn’t stay in Florida. Appalachian states like Kentucky, West Virginia, and North Carolina all have addicts who buy these prescription pain pills after they’re transported out of Florida. The DEA sees so many pain pills being transported from Florida to Appalachian states that they call it the “Flamingo Express.” In one of the methadone clinics where I work, I’ve noticed a peculiar upswing in the reported use of Opana, a brand name for the drug oxymorphone. It’s not a drug I’ve seen prescribed much in NC. When I ask patients where the pills come from, many say, “Florida.”

 Governors of several states, including West Virginia and Kentucky, along with congressmen from New York and Rhode Island, have sent a letter to Florida’s Governor Scott, urging him to reconsider his decision to torpedo plans for a prescription monitoring program. Since the leading cause of death in West Virginians for those under the age of 45 is drug overdose, I can see why this governor is protesting Governor Scott’s poor decision. (4)

 It’s estimated that setting up a prescription monitoring program costs about one million dollars. The Florida Prescription Drug Monitoring Program Fund, Inc., a non-profit organization dedicated to raising money for the program, says on their website that they’ve already raised at least half of that from donations. Other states have received the Harold Rogers grant money, available from the federal government to set up these monitoring databases. This leads me to question the excuse of “budget cuts” as the reason for Governor Scott’s poor decision.

 I’ve also seen internet stories that mention the governor’s fear of invasion of privacy. This is a legitimate concern, but there are ways to safeguard the information in such a database, and laws that can regulate who has access. I’m no fan of the government peering into my business, but this database is essential, given the overwhelming numbers of people struggling with pain pill addiction. For a description of the ways in which the North Carolina prescription monitoring database has helped me help my patients, please see the preceding blog entry. It’s been a lifesaver.  

1. http://articles.sun-sentinel.com/2011-03-05/news/fl-prescription-drug-forum-20110305_1_pill-mills-prescription-drug-monitoring-program-attorney-general-pam-bondi (accessed 3/6/11)
2. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.
3. Thomas R. Collins, Invasion of the Pill Mills in South Florida, Time, Tuesday, Apr. 13, 2010,  Ft. Lauderdale, FL
4.  http://manchin.senate.gov/public/index.cfm/press-releases?   ContentRecord_id=f62482b4-f6dd-4adc-8b49-1563d8fa605b&ContentType_id=ec9a1142-0ea4-4086-95b2-b1fc9cc47db5&Group_id=e3f09d56-daa7-43fd-aa8b-bd2aeb8d7777&MonthDisplay=2&YearDisplay=2011 (accessed 3/8/11)

Cotton Fever

An addict still using heroin recently asked me what “cotton fever” was, and how he could tell if he was sick with it.

 Cotton fever is caused by bacteria commonly found on cotton plants, initially named Enterobacter agglomerans, later changed to Pantoea agglomerans. Most intravenous drug addicts filter heroin through cotton filters, to remove particles that could clog both their injection needle and their veins. Sometimes fibers of cotton break off from the filter, carrying the bacteria with it. These bacteria in the bloodstream cause fever and chills, but in a healthy person, this usually resolves on its own. It’s rare to see it cause serious infection. However, doctors still recommend addicts with cotton fever seek medical care and receive appropriate antibiotics. (1)

At least one study isolated an endotoxin produced by this bacteria, so it’s possible that the fever is actually caused by this toxin, released from the bacteria, and not from an actual infection.

 Enterobacter species, while found in feces of both animals and humans, are also found in the plant world. Usually, these bacteria aren’t a particularly vicious, which is why they rarely cause sepsis (overwhelming infection) unless the individual has an impaired ability to fight infection. In the 1970’s, some medical products (blood, IV fluids) were found to be infected with this species, and caused significant infections, but this was probably due to a large amount of the bacteria infused into patients.

 Cotton filters become more fragile with use, so addicts using new filters probably have a lower risk of cotton fever. After cotton filters are used, they remain moist and can become colonized with all sorts of bacteria, especially if they are kept warm, as happens when they are stored in a pocket, close to the body. This bacteria can cause infection when injected. Cotton filters can transmit hepatitis C and possibly other infections, if they are shared with other drug users. (2)

 Filters also retain some of the injected drug, making them of some value in the world of intravenous addicts. It’s considered a gesture of generosity to offer another addict your “cottons” because the addict will get some small amount of the drug. (3)

 Even in view of all of the above, it’s still better to use a filter than to use unfiltered heroin. A new cotton cigarette filter has been shown to remove up to 80% of particulates in heroin, and reduces the risk of thrombosis of the vein from particles. Other makeshift filters are made from clothing, cotton balls, and even tissue paper.

 Syringe filters are manufactured for medical and laboratory use. They can be designed to filter particles down to 5 micrometers. Besides being more expensive and difficult to obtain, studies show these filters retain more of the drug than other makeshift filters, making them less desirable to some addicts. (2)

 Cotton fever itself usually isn’t fatal. The biggest challenge is knowing if the addict has cotton fever or something worse, like sepsis. Sepsis is an infection of the blood stream, and even heart valves can become infected, causing serious and life-threatening problems. 

I asked a former IV drug addict about his experience with cotton fever.

 Me: What does cotton fever feel like?

 Former Addict: You get a fever that kind of feels like withdrawal. You know there’s something bad wrong, and you don’t know what to do about it. I’ve laid on the floor and thought I was going to die. A lot of times people get it when they’re rinsing, and that means they’re coming down anyway. When the dope got short and I was rinsing cottons, that’s when I got it.

 Me: How long does it last?

 FA: It seems like it lasts a long time, but the intensity is bad maybe an hour or two. You shake, you sweat; it feels just like the flu.

 Me: Ever go to the hospital with cotton fever?

 FA: No, no! (said emphatically) I was usually wanted by the police. Only time I went to the hospital is with severe trauma.

Me: I don’t understand what you mean by rinsing.

 FA: Rinsing’s when you squeeze that last little bit of drug out of the cotton [filter]. You rinse the spoon and cotton with a little water. I would save all my cottons. That was my rathole for when the dope ran out. I would actually load the cottons into the barrel of a syringe then draw water in to the barrel of syringe, then squeeze until they were bone dry. I squirted that on to a spoon, and used a new cotton to draw that into a syringe.

 Me: Why do you use cotton filters? Do you use it with every drug you injected?

 FA: I used cotton to strain any dirt that may be in the product, that might get up in the syringe. I didn’t want no dirt. Didn’t have to be cotton. [If you don’t use a filter, you] shoot a bunch of trash up in yourself, and get trash fever.

 I used an itty bitty cotton. Some people would use a quarter of cigarette butt. That was wasteful to me. It got too saturated, could hold too much residue, or dope.

 I didn’t have to use cotton with quarter gram morphine or Dilaudid. Not enough trash to stop it up. If there’s trash in the syringe, I used a cotton.

 Thankfully, this person has been in recovery from addiction for more than thirteen years. When I asked him how he was able to stop, he said Narcotics Anonymous meetings.

 Recovery is the best way to avoid cotton fever. You never have to go through that again.

1. Rollinton, F; Feeney, C; Chirurgi, V; Enterobacter agglomerans-Associated Cotton Fever,  Annals of Internal Medicine 1993; 153(20): 2381-2382.
2. Pates, R; McBride, A; Arnold, K; Injecting Illicit Drugs, (Oxford, UK, Blackwell Publishing, 2005) pp. 41-43.
3. 3.       Bourgois, Phillippe; Schonberg, Jeff; Righteous Dopefiend,(Berkeley, California, University of California Press, 2009) pp8-9, 83-84.

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 43^rd 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.