Archive for the ‘History of Opioid Addiction’ Category

Opioid Physical Dependence versus Opioid Addiction: What’s the Difference?

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Many people, including doctors, are confused about the difference between physical opioid dependence and opioid addiction. To further complicate the issue, in the past, psychiatrists used the word “dependence” interchangeably with addiction.

They are not the same.

By physical dependence, I am referring to normal changes human bodies makes when exposed to opioids for longer than several weeks to months.

Our bodies like to keep things level. When we ingest opioids for more than a few days, our bodies compensate, and make changes to help minimize the effects of opioids. Over time, it will take more opioid to have the same effect, which is called tolerance. Then if opioids are suddenly stopped for any reason, we experience a backlash in the other direction, due to the body’s adaptations. We will feel physical withdrawal signs and symptoms: increased heart rate and blood pressure, nausea, vomiting, diarrhea, sweating and chills, goose bumps on our skin, muscle and joint pains, anxiety and insomnia. This happens to human bodies when exposed to opioids for long enough, and then stopped suddenly.

The presence of physical withdrawal symptoms alone is NOT the same thing as opioid addiction.

For addiction to exist, the person taking opioids must have psychological manifestations. Such a person suffers from the obsession and compulsion to use more opioids, even knowing bad things happen with opioid use. A person with addiction neglects other important parts of life in order to focus on the use of opioids. She may use the drug in ways it’s not meant to be use – injecting, snorting, or chewing for faster onset. She may start using opioids to treat negative emotion, and mix them with other drugs for different effects. She may use opioids even when not in pain, for the effect the drug has on her.

Having the brain of an addict is like having a car with the gas pedal stuck all the way down. An addicted brain may be able to see sharp curves ahead, and even recognize that slowing down would be prudent, but still feels powerless to do so.

It’s often a scary ride.

A person with only physical dependence may feel bad if she stops opioids too quickly, but she would be able to taper if done slowly enough, because the mental obsession to keep using more isn’t driving the drug use. She may feel physical pain return as the opioid is tapered, and may have to slow the reduction in dose, but that’s a different issue.

So we see it’s possible to have physical dependence to opioids without actual addiction.

It’s also possible to have addiction to opioids without physical dependence.

For example, if you put an opioid-using addict in jail, she will undergo physical withdrawal. By the time she’s released, she may longer have the physical dependence (Though many opioid addicts have a post-acute opioid withdrawal that can last for days, weeks and even months. These people’s bodies may have lost the ability to manufacture endorphins, our bodies’ natural opioids.). But if nothing has been done to treat her real problem, the obsession and compulsion to use opioids will return, and she will relapse.

Too many family members of addicts, cops, judges, and even doctors have the false expectation that physical detoxification from opioids is the same thing as treatment. Often the addict is judged harshly for failing at treatment, when the addict wasn’t even given effective treatment. Because detox alone is not treatment.

Opioid addiction is treated with talk therapy, consisting of motivational enhancement counseling, cognitive/behavioral counseling, 12-step facilitation counseling, or a mixture of counseling techniques.

Success rates are markedly improved when medication-assisted treatment with buprenorphine, naltrexone, or methadone is added to counseling.

I’m writing this blog after a visit from a new patient at my office. This nice lady had been accused of being a drug addict by her doctor. She’s been on the same dose of opioids for the last three years, never runs out early, doesn’t misuse her medication, and has urine drug screens that show only the medications he prescribes. At her visit with me, she denied shooting, snorting, or chewing her medication for faster onset. She’s never obtained opioids from friends or acquaintances, and doesn’t use any other drugs including alcohol.

Yet she told me that for some reason, her doctor made the comment to her, “If I didn’t prescribe these pills for you, you’d be buying them off the street.” She was appropriately offended, but also worried she might have addiction. She tried to stop her opioids suddenly, but got sick. She took this as evidence she was addicted, so she came to see me for an evaluation.

I assume she’s telling me the truth, because why else would she waste time and money coming to see me? She has no evidence of addiction that I can detect.

I recommended she go back to her doctor, and ask him to taper her dose down, slowly. This should be a gradual process, so that she doesn’t have withdrawal that interferes with her life. Usually, a 15% drop every two to four weeks is a good rate of decrease. I told her that if she develops addiction, I’d be happy to see her again, but for now, she doesn’t need my services. She does need to communicate her desires to taper with her existing doctor.

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

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”

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

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