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Kratom: Useful for Drug Addiction?

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I had a blog comment from a reader who advocated for kratom as a cure for opioid addiction, and thought it would be a good topic to cover with a full blog post.

Kratom (also called ketum or kratum) is a tree in the genus Mitrogyna, which is related to the coffee tree, and found in Southeast Asia. Kratom leaves have been used for thousands of years by natives of the area to produce stimulant and opioid effects. Fresh leaves can be chewed, or broken up to make a drink, or steeped in hot water to make a tea. Dried leaves can be smoked by users, who say low doses of kratom cause a stimulant effect. Higher doses are said to cause sedation.

Kratom’s active ingredient is mitragynine, an opioid agonist. Mitragynine activates the mu opioid receptor in the human brain to cause an opioid-like effect. Like other opioids, this compound in the kratom tree relieves pain and causes euphoria. Some rat studies demonstrated more potent analgesia from mitragynine than morphine. It’s structurally different than other opioids, and unlikely to show as an opioid on drug testing.

Because of its opioid-like effects, kratom can be used recreationally for the high it produces.
If you google “buy kratom,” more than a million websites appear, offering to sell all sorts of varieties of kratom, and extolling its properties of, “Pain relief, Energy, Prolonged Sexual Intimacy, and Mood Support.” You can buy capsules, dried leaves, and plant extracts. Because of this recreational use, governmental agencies in the U.S. have been reluctant to fund studies on this drug.

Users and marketers of kratom say it’s an herbal pain medication that’s safe and effective.
Sadly, many people accept the idea that “herbal” and “natural” means “safe.” Not so at all. Some of the world’s most potent poisons are found in nature. Hemlock, belladonna, and cyanide leap to mind. And there’s no way to know what exactly you are buying on the internet. It may be kratom, ….or it may be nightshade.

Assuming a person does buy real kratom off the internet – is it harmful? Probably about as harmful as other opioids, though rat studies did show less respiratory depression than other opioids. That may be due to kratom’s activity at the kappa opioid receptor. This drug also has adrenergic and serotonergic activity, so it has a complicated method of action. The increased adrenergic effect of the drug may give users a feeling of energy, like the other stimulants cocaine and amphetamines. This property has led some people to say kratom could be a treatment for methamphetamine addiction.

Chronic and continued use of the kratom leaf can cause opioid dependence, with opioid-type physical withdrawal symptoms when stopped. However, at least one case report showed less physical withdrawal than expected when a heavy user suddenly stopped kratom after having a seizure. [1] There’s talk on internets sites of using kratom as a treatment for opioid addiction, but no scientific literature or human trials have been done.

Mitragynine from the kratom tree has intriguing possibilities for use in the medical world, but we won’t know unless scientific studies are done. Until then, it would be dangerous and irresponsible to recommend use of this product, especially if it’s bought off the internet with no way to know what you are buying.

I hope researchers will explore this drug to see if it has potential to help patients with opioid addiction. For now, there’s not enough evidence to be able to recommend kratom’s use for any purpose.

Even if the compound mitragynine in kratom shows efficacy in clinical trials as a pain reliever or opioid addiction treatment, it shouldn’t be ingested in unprocessed plant form. We don’t have people in pain chew on an opium poppy seed pod, or heart patients chew on the foxglove plant to get their digitalis, and doctors won’t recommend use of kratom in the plant form. Let’s purify the drug in kratom, mitragynine, study it, and produce it as a medication in standardized doses with quality control if it’s found to be effective.

1. http://www.scientificamerican.com/article/should-kratom-be-legal/

Criminally Pregnant

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I usually don’t post a new entry so soon after the last, but this topic is time-sensitive.

I’m getting tired of writing about Tennessee’s crazy politicians but this time their insanity is so egregious that I can’t let it pass without comment.

The Tennessee house and senate passed a bill that allows a woman to be criminally charged if her baby is born drug dependent. If their Governor Haslam signs this bill, it will become law.

As we know, Tennessee has a terrible opioid addiction problem with one of the highest overdose death rates in the nation. Opioid addiction afflicts men and women in nearly equal numbers, and most of those women are in their child-bearing years. Thus, Tennessee has many pregnant women who have the disease of drug addiction.

Naturally, hospitals have seen a growing number of infants born with opioid withdrawal. Small rural hospitals may not have physicians who are educated about how to treat these babies. It’s a frightening situation, and the response is fear-based: make drug use during pregnancy a crime.
Politicians promote draconian laws that will punish these women, who are probably the most vilified segment of society, and gain favor with voters who don’t understand the underlying issues.

So now Tennessee has a law that makes getting pregnant a crime, if you have the disease of addiction. (By the way, there are other illnesses that can harm the fetus if the mom becomes pregnant, but we have no laws making pregnancy illegal for those patients.)

Supporters of this new insane law probably say it should encourage pregnant addicts to get help before their babies are born. That could be true, if Tennessee had adequate treatment programs in place. As we know, methadone and buprenorphine are the best treatments for opioid-addicted pregnant women, yet under this law, this gold-standard of treatment may also be considered illegal.

So should pregnant moms “just say no” and stop using opioids? We know that going through opioid withdrawal while pregnant is associated with bad outcomes for mom and fetus, what with increased risks of preterm labor, placental abruption, and low birth weights. Over the last fifty years, multiple studies repeatedly show better outcomes when you maintain the mom of a stable dose of methadone, or more recently buprenorphine, during the pregnancy.

If this bill is signed into law by Tennessee’s governor, we can predict what will happen.

After all, what would you do, if you are a pregnant addict and know you will be prosecuted if anyone discovers you’re drug user? You avoid prenatal care. Maybe you get an abortion, even if you really want a baby, because you don’t want to go to jail. Maybe you try to stop using opioids on your own, go into withdrawal, and have one of the complications we know to be common in such a situation. Maybe you have preterm labor at 30 weeks and your baby ends up in the intensive care unit for many months. Worse, maybe your baby doesn’t make it. Or your baby does make it, but is taken away from you at birth, because authorities say an addict can’t care for a baby. Your baby enters the foster care system, with its pitfalls.

In short, this law discourages medical care in the very population of women who can benefit the most from medical care and treatment of addiction!

But wait…this law says the woman can be charged if the baby is born dependent. What about pregnant women who smoke? The infants are technically dependent on nicotine, so that meets this law’s criteria. These women can also be criminally charged. Probably Tennessee would have to build a new jail just for those women, and of course Tennessee’s taxpayers would be happy to pay for their incarceration, right?

In the past, laws against drug use in pregnancy have been unevenly implemented. If you look at the cases that have been prosecuted, nearly all involved poor, non-white mothers. Maybe that’s because law enforcement knows that people of higher socioeconomic status can afford hire a lawyer to defend themselves against these ridiculous laws, which always get struck down on appeal, though that can take years.

Policies that inflict criminal penalties on pregnant women with the treatable disease of addiction cause harm to everyone. Hospitals have higher costs when a mom with no prenatal care arrives on their door step ready to deliver, with much higher rates of perinatal complications. Taxpayers end up paying the high costs of incarceration for these women. But most of all, the babies and their moms are harmed.

Let Governor Haslam know how you feel by writing to him: bill.haslam@tn.gov or call at: (615-741-2001)

I Apologize

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Some of my readers were offended by my last post, titled “you might be an addict if…” so I have taken it down. My intentions were not to offend any of my readers, and I apologize for hurting readers’ feelings. I was trying for light-hearted humor. We humans are a funny bunch, and do weird things that I like to write about. So I wrote about some of the odd things people in active addiction will do.

I haven’t written about my own recovery before, preferring to maintain my anonymity at the level of press, radio, etc. However, I feel I need to explain my motivation for the blog post. I’ve lived some of the situations described in the post, and got others from my friends in recovery. I did weird things in active addiction that are funny and goofy. For example, I’ve driven past my house a few times when I saw a bunch of unfamiliar cars, worried my family was planning an intervention. I’ve moved to a different state to get away from my addiction, only to find it followed me. I’m not making fun of addicts; I’m making fun of the weird things addicts do because of their addiction. Even after nearly sixteen years of recovery, I remember the weirdness.

To those of you who thought my post was insulting, I’m sorry. I did not mean to offend.

Good News!

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This blog entry contains only good news.

I often rant about the poor treatment my patients get at the hands of uninformed doctors who don’t know much about medication-assisted treatment (but think they do). This week I’m happy to relate the opposite experience.

I was seeing a new opioid-addicted pregnant patient. She said her OB was a local doctor, but I didn’t recognize the name. My patient said her new doctor had taken Dr. B’s place. (Please see my blog post of April 15, 2012 to see how my interaction with Dr. B went.) My patient said this new doctor, Dr. W., was taking over his practice.

As we went through the intake process, I educated my new patient about how medication-assisted treatment of her opioid addiction gave her a better chance for an uncomplicated pregnancy and a healthy baby. She was already taking methadone illicitly, in relatively low doses, having already heard much of what I was saying from her friends. Wow, I thought – the addicts are better educated than some of their doctors.

I don’t relish making phone calls to other doctors about my patients. Too many times my efforts to coordinate care with other doctors are met with hostility and misunderstanding. I’m wary when talking to a doctor for the first time. But every job has its unpleasantness, so after I completed my patient’s intake, I called Dr. W

The first time I called I was disconnected. The second time, I was put on hold for over six minutes before I hung up and called back. Then at least I got an answering machine and I left my name and phone number, gauging my chances of a return call at 50-50.

I was surprised when Dr. W called me back a few hours later.

“Thank you so much for returning my call! I know you’re very busy” I said, starting to suck up to this doctor like a Hoover, to get on her good side from the start.

“Sure, it’s no problem. You wanted to talk about Jane Doe?” (I’m not using my patient’s real name)

“Yes. I wanted to let you know I am prescribing methadone to her. I just started seeing her today, and I wanted to call to see if you had any questions or concerns about her being on methadone, or about how…”

“Well, we usually don’t want to stop the methadone during pregnancy, do we? I’m glad she’s seeing you to be prescribed methadone. Her pregnancy is more likely to go better because she’s on methadone and not illicit opioids.”

“I know!” I was giggling with relief. “She was hesitant to mention this to you, afraid you wouldn’t continue to see her…”

“Oh no. She’s doing the right thing. We have a Cesarean section planned. Can you tell me how to handle her post-op pain? I usually prescribe Tylenol with codeine or Percocet.”

“As it sounds like you know, we recommend keeping her on her same dose of methadone, but that won’t provide post-surgical pain control, so you can prescribe whatever you ordinarily would for pain. In fact, she may need more than the average patient because of her tolerance to opioids. If you don’t mind, a smaller prescription with more frequent follow-ups would preferable, from my point of view. And we’ve already talked to her husband, who agreed to hold the pill bottle for her, to prevent misuse of that medication. And she’ll be seeing us every day as soon as she’s able to be up and about.”

“OK. That sounds good. We can talk again when she’s closer to her delivery. Thanks for calling.”

“Oh thank you!” Giddy with relief, I started giggling again.

Huzzah! I have found a new doctor for my pregnant patients.

Heroin-Assisted Treatment?

Stretching the Brain

Stretching the Brain

I came across an interesting study in this month’s issue of The American Journal of Addictions, Vol 22, (6) pp 598-604, titled, “Acute Effects of Heroin on Emotions in Heroin-Dependent Patients.”

I almost skipped over it, because I believe heroin-assisted treatment (HAT) to be less legitimate than MAT with methadone and buprenorphine. Then I realized I was doing the same thing anti-methadone people are doing; I was judging a potential treatment before getting all of the facts.

I’ve heard about heroin-assisted treatment before. I went to a lecture at an American Society of Addiction Medicine (ASAM) conference several years ago and heard a Canadian physician talk about North American Opiate Medications Initiative, or NAOMI. Our neighbors to the north did a randomized controlled trial in Vancouver and Montreal. This trial randomized opioid addicts to methadone maintenance treatment or heroin maintenance treatment. Sterile doses of heroin and sterile equipment to inject were provided to the patients in the heroin-maintained treatment arm. Medical personnel were at the injection site to care for patients with overdoses and other medical problems.

The study was designed to look at several endpoints. First of these was retention in treatment. In the heroin-maintained group, 88% were retained in treatment, compared to 54% of the patients on methadone maintenance. They study also looked at illicit drug use or other illegal activities, and found that patients in HAT improve significantly more than methadone maintained patients. HAT patients had a 67% reduction in illicit drug use or other illegal activities, and methadone-maintained patients had a 48% reduction in the same measures. However, serious adverse events were more common in HAT patients, mostly overdoses and seizures. Both groups had counseling made available for them.

Similar HAT programs are ongoing in Europe. Germany did a trial a few years ago, as did Spain, with mostly positive findings. In the Netherlands, HAT is now available for treatment-resistant opioid addicts who have not done well in more traditional methadone maintenance programs. The Swiss have been offering HAT since 1999, at twenty-three treatment centers. Their HAT studies showed reduced illicit drug use and criminal activity, better physical and mental health, and better social integration at the end of a two-year study. That study showed substantial numbers of patients transitioned to methadone maintenance or to abstinence.

A Cochrane review (see my blog post of September 19, 2013 for more information on the Cochrane Review group) concluded that data gathered on HAT shows reduced illicit substance use, reduced criminal activity, and possibly reduced mortality. However, MAT has a higher rate of serious adverse effects, and they recommended it to be considered as a last resort for treatment-refractory opioid addicts.

Can you imagine trying to open a heroin maintenance program in the U.S.? Yet such treatments exist in other countries, where addiction is seen as a medical problem to be solved rather than a moral problem that needs repentance. In Europe, there’s much more acceptance of methods that reduce harm in addicts.

Anyway, getting back to this study, Blum et. al. did a randomized controlled crossover trial with 28 heroin-dependent patients in treatment, and 20 healthy controls. They dosed the patients on HAT with either a placebo (saline) or with their usual dose of heroin, and then graded their emotional state. The study conclusion was that administration of heroin resulted in dampening of craving and negative emotions, and also increased positive emotions. The authors conclude that heroin regulates emotions and that opioid substitution treatment is of benefit for opioid addicts.

Your first inclination may be the same as mine: to say “Duh. Yes, heroin gives positive emotions. That’s why people like to use it.” But the authors of the study are also saying that the relationship between mood and substance use is complex, and that opioid addicts with advanced addiction are using opioids to alleviate negative emotions, rather than for the euphoria that they experienced earlier in their addiction. Of course, this study confirms what we see clinically, and what our patients tell use.

What came first, the depressed mood or the heroin use? And if these patients were in opioid withdrawal, then of course administering an opioid would make them feel more positive.

Some scientists say that some opioid addicts, even with no prior history of depression or anxiety, are vulnerable to negative emotion indefinitely after having an established opioid addiction, and that they may be unable to regulate their emotions like non-addicts do. Maybe this is the same thing as the post-acute withdrawal syndrome we see in opioid addicts after they are through acute withdrawal. Many recently withdrawal opioid addicts continue to feel bad, with sluggishness, depression, and overall malaise.

All of this information on heroin-assisted treatment of opioid addiction challenges me. I’m uncomfortable with the idea of providing pharmaceutical heroin to opioid addicts for maintenance. Heroin is short- acting, and some heroin addicts use it four or five times per day. I think they would be less stable than patients on very long-acting opioids like methadone as buprenorphine, which give a fairly stable blood levels for twenty-four hours. And the studies do show high rates of overdose with heroin maintenance.

I know the data about HAT clearly show this treatment benefits some patients, but I’m not willing to endorse it as a treatment, except maybe, possibly, for patients with severe opioid addiction who have failed other medication-assisted and abstinence-based treatments.

So…Am I all the way there as far as accepting heroin as a maintenance treatment for opioid addiction? No. But then, I’m a work in progress, as most of us are. After all, one person’s harm reduction is another’s enabling. I’m going to ponder heroin-assisted treatment for a little longer.

Recent Deaths From Rapid Detox

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The Centers for Disease Control and Prevention (the CDC), announced in this week’s Morbidity and Mortality Weekly that an anesthesia-assisted rapid opioid detox center in New York City had a spate of deaths and other severe adverse events in patients treated at their center during 2012. (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6238a1.htm?s_cid=mm6238a1_w)

Seventy-five opioid-addicted patients were treated during a nine-month period at this detox facility from January 2012 until September of 2012. Two patients died and five others had serious complications requiring hospitalization. The CDC’s report described in detail what happened that caused these two deaths, and the nature of the complications. Because of these complications, all occurring at this single rapid detox facility, New York State Department of Health issued a health alert, to warn providers against using this form of treatment.

Rapid detox from opioids is a procedure where the opioid addict is put under anesthesia and then given the opioid blocker naloxone, which puts the body into immediate opioid withdrawal. The naloxone throws opioids off the opioid receptors and would cause severe suffering if the patient were awake, so the general anesthesia keeps the addict comfortable. Hours later, the patient is brought out of anesthesia, and according to treatment centers that do this type of treatment, the patient has no further withdrawal.

It’s easy to see why addicts and their families like the idea of rapid detox.. Go to sleep under anesthesia, and wake up drug-free. The addict doesn’t have to go through any painful withdrawal, and the family hopes their loved one is fixed forever.

If only it were so easy. Most opioid addicts and their families have found out – the hard way – that getting off opioids is a very different problem than staying off opioids. Addiction is a chronic disease, and an addict who has had opioids removed from his body still has the disease of addiction. Unless some form of intense counseling treatment is given quickly, the addict is highly likely to relapse.

Besides, patients who undergo rapid detox don’t always feel back to normal after the procedure. Several studies show that post-procedure symptoms of nausea, vomiting, and insomnia can continue for days. Outcomes for patients aren’t any better with rapid detox than with the usual inpatient buprenorphine taper. Plus, rapid detox costs much more; in many places the procedure costs tens of thousands of dollars. (1)

Most reputable treatment centers no longer use this expensive and relatively riskier method of detoxification under general anesthesia since a landmark study was published in 2005 in the Journal of the American Medical Society. Since the studies don’t show greater abstinence rates with this method, it’s difficult to justify its expense and risk. (2)

Studies show that at one year, success rates with rapid detox under anesthesia compared to detox with a short course of buprenorphine are equally dismal, with fewer than 20% of the addicts still abstinent from all opioids at sox month follow up. This underlines the importance of viewing detox as only the preliminary step of drug-free opioid addiction treatment. (3)

Even with the appallingly high incidence of complications at this one rapid detox center, I don’t advocate a complete ban of all rapid detox procedures. The risk for an average patient exceeds the benefits, but there may be special circumstances or patients for whom it’s still a reasonable option. However, in view of the high risk of serious adverse medical events, the patient should be in good health and should be fully informed of the risks. There should be compelling reasons for using this method which has serious medical risks.

References:
1. Singh j, Ultra-rapid opioid detoxification: Current status and controversies, Journal of Postgraduate Medicine 2004; 50:227-232.
2. Collins ED, Kleber HD, Whittington RA, Heitler NE, Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: A randomized trial, Journal of the American Medical Association, 2005; 294 (8) 903-913.
3. Cucchia AT, Monnat M, et.al; Ultra-rapid opiate detoxification using deep sedation with oral midazolam: short and long-term results. Drug and Alcohol Dependence, 1998; 52(3) 243-250.

A Pleasant Surprise

aaaaaaaaaaaaaaaaaaaaaaaaaToo often in my blog I write about the bad behaviors of people who don’t understand or accept medication-assisted treatment of opioid addictions. Today, I write about the positive experience I had when I talked to the medical staff of a local hospital.

Last summer, my opioid treatment program invited our local hospital’s director of nursing, head pharmacist, and some labor and delivery nurses to tour our facility. After the tour we sat down for an exchange of information. We gave them information regarding medication-assisted treatment with methadone and buprenorphine, especially during pregnancy. The hospital’s representatives had specific suggestions for better communication when our pregnant patients came for delivery. We worked out a plan so that hospitalized patients on buprenorphine can remain on their dose, since buprenorphine isn’t on the hospital’s pharmacy formulary.

It was a productive session, and eventually I was invited to speak at the hospital’s monthly doctors’ staff meeting. I was allotted ten minutes to talk about addiction, chronic pain, and medication-assisted treatment. At first I was tempted to decline, thinking I couldn’t say much in ten minutes. But then I realized no opportunity to discuss methadone and buprenorphine with other doctors should be neglected. Besides, I can talk really fast and it’s hard to stop me after I get started.

Initially I was to talk to them at their May meeting, but I broke my leg three days before and had to postpone. I finally talked at their August meeting.

On the appointed evening, the hospital’s director of pharmacy met me and introduced me to various doctors as we ate a fried chicken dinner. Over dinner, the talk lead to why I had to cancel in May, and my broken leg. I was pleased when one of the surgeons asked me specifics of my surgery (I am developing into one of those people who loves to talk about her surgeries, reason enough for everybody to pray for my good health.) I beamed with joy when he expressed surprise that I was already able to go running. (Actually I exaggerated. What I do now – and have always done – is lope – it’s not even a jog).

All of the doctors were pleasant. Some I knew from previous telephone conversations about patients we had in common, and it was nice to have faces to go with names. Most I’d never met. I listened to their conversations, the inevitable shop talk of doctors when they socialize, and was impressed. All of them appeared compassionate and intelligent, trying to do their best for patients during this difficult time to be a doctor.

Then staff meeting started and eventually it was my turn to speak.

I covered many topics. In order to show them I knew what life was like on the front lines, I informed them I worked for ten years in primary care, and had admitted patients to a local hospital very much like this one. Then I explained how I’d gotten interested in medication-assisted treatment (MAT), and how after doing some research, discovered it was one of the most evidenced-based treatments in medicine. I said I felt like I was able to do more for my patients and their families now than I had while working in primary care.

I explained the difference between physical dependence on opioids and true addiction to opioids. I explained that with the latter, psychological symptoms often thwart attempts to taper off medication. I talked about the other treatment options for opioid addiction, and the financial difficulties many opioid addicts have with those options. I talked about how many patients prefer MAT because they start to feel better quickly, and can lead normal lives. I told the doctors that patients are able to function normally at the right dose of medication, and that they are not impaired. I talked about the benefits of MAT, specifically that it has been proven to be very cost-effective, causes reduction in death rates due to overdose and suicide, gives higher rates of employment, produces much lower rates of crime, and improves physical and mental health.

I discussed the safety precautions of OTPs, and about observed dosing, take homes, diversion control methods, and proper dosing of medication. I talked about how we use drug testing as a way to assess the adequacy of both medication dose and counseling “dose.” I described how a positive drug screen isn’t a reflection of bad behavior, but of a disease which may not be getting adequate treatment. I talked about buprenorphine and methadone, their pharmacologic properties and their differences. I talked about some of the regulatory differences, too.

Just as I started talking about possible side effects of these medications, I noticed I was out of time, so I stopped. As I said, I can talk fast, especially when it’s about my favorite topic, to a group of doctors who had no choice but to listen to me.

When I stopped, I was a little worried I might get some hostile questions, but I didn’t. These doctors asked excellent questions. Not only had they listened to me, but they wanted to work with our treatment program. They asked about how to override the blocking effects of buprenorphine if a patient came in with an acute injury, which is a complicated issue. We discussed some options for such situations. I explained I am available at any time through our emergency after- hours line. (The person answering that phone can always contact me with their number and I can call them back immediately.)

They asked some great questions about various aspects of addiction and its treatment. They wanted to do more for addicts looking for help. They asked about the best way to refer addicts, and specifics about continuing medication when current OTP patients are hospitalized.

The evening was a success. I felt welcomed, and felt these doctors wanted to learn about MAT. My esteem for these hard-working local doctors rose a great deal. I think we will be able to work together to provide the best care for our shared patients. I’m told there’s even been talk of inviting me to return for a one-hour talk to expand on the issues raised.

What did I learn? Sometimes advocacy is best done face to face, over a fried chicken dinner.

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