The Benzo Conversation

Glass head full of pills

Not all of my patient interactions are easy. One of my colleagues, after reading my blog, remarked, “It sounds like you have really easy patients.” While that’s true for the most part, of course there are more difficult patients, as in any practice. Some patients, eager to get into treatment to stop opioid addiction, may not be at all ready to stop other drugs of addiction. That’s not a deal-breaker for me, unless those drugs could be fatal when mixed with methadone or buprenorphine. This means the use of alcohol, benzodiazepines, and sedatives of other kinds must be discussed in detail.

I’ve noticed a conversational merry-go-round that I call “the benzo conversation.” I’ve had versions of this conversation more times than I can remember.

This conversation occurs during my initial assessment of a new patient presenting for medication-assisted treatment. I always look on my state’s prescription monitoring program for each new patient on the day of admission. If they have prescriptions for benzodiazepines (like Xanax, Valium, or clonazepam), or other sedatives (Soma, Ambien, etc.) I need information about the pattern of use. Is my patient taking his prescribed daily dose? Is he then physically dependent on benzodiazepines? Is he selling them? Is he giving part of the prescription away, and taking the rest? Does he binge on benzos for the first few weeks of the month, and then run out for several weeks? Or is he bartering the benzos for opioids, and not taking any of them, despite filling a large prescription each month?

I really don’t care if the patient is breaking the law or not; I just want to get the complete picture of my patient’s health status.

Following is a typical conversation with a new patient whom I will call “Bob.”

Bob sought admission to our methadone maintenance treatment program for his opioid addiction. He had snorted pain pills for six years, and wanted help. He had little if any denial about his opioid addiction. He denied taking any prescription medications, saying he got all his opioids off the street, used no other drugs or medications, and had no other medical problems.

However, when I checked his name on my state’s controlled prescription monitoring program, he was filling a prescription for Xanax 2mg, ninety per month, from a local Dr. Feelgood. This prescription had been filled every month for the last four years. My patient’s admission urine drug screen also tested positive for benzodiazepines.

As part of my initial history and physical, I asked him about the Xanax prescription. I explained to Bob that benzos have the potential to cause a fatal overdose when mixed with opioids. I told him that benzos are especially risky with methadone, and I was concerned about his use of them.

Bob said, “Oh, I don’t use benzos now. I haven’t used Xanax for years.
“But you’ve been prescribed it every month and picked up the last prescription of ninety pills just two weeks ago.”
“Yes, but I don’t take them. I quit them long ago.”
“And you do have benzos in the urine sample you gave us.”
“Well, that’s probably from a little piece of Valium I used four days ago.”
“Ummm…, Valium’s also a benzo, in the same family as Xanax, so when you say you’ve stopped, that doesn’t make sense to me.…”
“As I told you, I don’t take benzos anymore.”
“But four days ago is pretty recent.”
“No,” he said, getting a little worked up. “As I’ve already told you, I stopped benzos years ago!”
“So what do you do with the Xanax pills you pick up at the pharmacy every month?”
“I don’t know. They’re in the house somewhere. But I don’t take them.”
“So you have…how many bottles do you have at home?”
“Bunches, I don’t know.”
I could tell I was annoying him, but this as an important clinical issue, so I pushed on.
“Would you be willing to bring all those bottles in tomorrow so the nurse can watch you dispose of them?”
He sighed deeply, annoyed by my questions. “Yes. I suppose I can. Now can I get my dose?”
“No, I’ll leave an order for you to be able to start tomorrow after you bring in the medication to dispose, since you tell me you haven’t taken them. I worry about a fatal overdose if methadone were combined with all that Xanax you have at home.”
Now he was mad. “I don’t have any Xanax at home! I’m not going to overdose! I know what I’m doing.”
“Will you give me permission to call the doctor prescribing the Xanax, so we can talk about your entry into treatment here? Maybe your doctor would be willing to taper your dose so that we can make it safer for you to be in treatment with us.”
“No! I don’t want everybody to know my business. My doctor is friends with my ex-wife and if she finds out I’m being treated for addiction, she’ll cause trouble. He can’t find out.”
“I’m sorry, but that’s a deal-breaker for me. I’m not going to prescribe methadone for you unless I can talk to your other doctor. It’s just too risky. All of your doctors need to know all medications that you’re on.”
“So you’re telling me to go back out there and use drugs? That I can’t get help unless my ex-wife finds out I’m an addict?” The veins in his neck were standing out.
“No. I’m not telling you to use drugs. I’m telling you…
“I want my money back, since I’m gonna have to go buy dope again ‘cause you won’t help me. It’s just not right. I came here to get help.” He stalked off toward the receptionist, where I heard him demanding his money back, despite the hour he spent with a counselor and the time spent with me in an evaluation. (For some reason, patients who don’t get admitted to the program don’t feel they should have to pay for their evaluation)

This was a difficult, tense conversation, and one I’ve had too many times to count. This patient wasn’t a bad guy, but he was not ready to address his benzodiazepine use. The outcome wasn’t what I’d hoped, and this patient didn’t come into treatment.

There’s no way I could know what this patient was doing with his benzodiazepine prescription. I couldn’t tell if this patient was telling the truth, in denial, or lying. Without being able to talk to his prescribing doctor, I wasn’t willing to start medication-assisted treatment. This didn’t mean he didn’t need treatment, only that perhaps a different form of treatment will be safer for him. I wish I could have given him information about other treatments, but he left too quickly and too angrily.

Sometimes patients tell me I’m violating their privacy by looking at their information on the prescription monitoring database. I tell them I don’t see it that was at all, since they are asking me to prescribe a medication that could have a fatal interaction with other medications. Not only is it my business, it’s my responsibility.

Some doctors would fault me for not admitting this patient despite his refusal to allow me to talk to his prescribing doctor, given the increased risk of death for patients in active opioid addiction who are not in any treatment. But I would feel terrible if I’d admitted this patient and he died during the first few weeks of a methadone/benzodiazepine overdose. Either way, there’s a lot at stake, and I feel stress about these decisions.

Don’t Sweat It

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All opioids can cause sweating and flushing, but methadone is perhaps worse to cause sweating than other opioids. Buprenorphine also can cause sweating, but it is usually less of a problem than for patients on methadone.

We don’t know exactly why opioids make people sweat, but it is related to opioids’ effects on the thermoregulatory centers of the brain.
Excess sweating can also be caused by opioid withdrawal. If other withdrawal symptoms are present, like runny nose, muscle aches, or nausea, an increase of the methadone dose may help reduce the sweating.

At least half of all patients on methadone report unpleasant sweating, but some patients have sweats that are more than just inconvenient. These patients report dramatic, soaking sweats, bad enough to interfere with life.

What can we do about this sweating?

First, non-medication methods can be attempted. These methods include common sense things like wearing loose clothing, keeping the house cool, and losing weight. Regular exercise helps some people. Talcum powder, sprinkled on the areas that sweat, can help absorb some of the moisture. Antiperspirants can be used in the underarm area, but also in any area that routinely becomes sweaty. The antiperspirant can be applied at bedtime so sweating won’t interrupt sleep. There are prescription antiperspirants, like Drysol or Xerac, but these sometimes can be irritating to the skin. Avoid spicy foods, which can also cause sweating.

Make sure the sweating isn’t coming from any other source, like an overactive thyroid, and check your body temperature a few times, to make sure you don’t have a fever, indicating the sweating could be from a smoldering infection. A trip to the primary care doctor should include some basic blood tests to rule out medical causes of sweating, other than the dose of methadone.

Some prescription medications can help, to varying degree, with sweating.

Clonidine, a blood pressure medication that blocks activation of part of the central nervous system, blocks sweats in some patients.

Anti-cholenergic medicines, drugs block the effect of the neurotransmitter acetylcholine in the involuntary nervous system, block sweating. Anticholinergics tend to dry all secretions, causing such common side effects as dry mouth and dry eyes. These medications can cause serious side effects, so they must be prescribed by a doctor familiar with the patient’s medical history.

Some examples of anticholinergics include oxybutynin (also used for urinary leakage), bipereden (used in some Parkinson patients), scopolamine (also used for sea sickness), and dicyclomine (used for irritable bowel syndrome). All of these have been used for excessive sweating with various degrees of success, in some patients.

For unusually bad situations, Botox can be injected under the skin of the most affected areas, like armpits, palms and soles. Obviously, this is somewhat of a last-resort measure.

Patients affected with severe sweats, unresponsive to any of the above measures, need to decide if the benefit they get from methadone outweighs the annoyance of the side effects. In other words, if being on methadone has kept them from active drug addiction, which is a potentially fatal illness, it would probably be worth putting up with sweating, even if it’s severe.

Peaceful Coexistence

aaaagetting along

For years, I’ve asserted that patients on medication-assisted treatment for opioid addiction can find benefits in twelve step recovery meetings. Many of my readers have disagreed with me, vehemently at times. I was surprised and pleased when one of them forwarded me a reference to an article in the Journal of Substance Abuse Treatment that showed participation in 12-step recovery increased retention in buprenorphine treatment. (Thank you Zac). Of note, coercing patients to attend 12-step meetings was not found to be helpful. [1]

I know 12-step meetings work for my buprenorphine patients because I’ve seen it. However, I do think I have unusual patient population in my office-based buprenorphine practice.

I inherited many of my patients from a doctor for whom I worked for several years, until he retired in 2010. He was well-known and well-respected in the recovery community of the city where we worked.

Some people, already in recovery from alcohol addiction, were members of Alcoholic Anonymous when they sought treatment for chronic or acute pain conditions. These patients were prescribed opioids for pain by doctors who underestimated the risk of developing opioid addiction, in these patients with a personal history of addiction to another substance. Some of these patients were dismayed to discover they developed addiction to opioid pain pills, meaning they were misusing them by taking too many and running out early, or having obsessions and compulsions to take ever more pills.

Baffled and angry, those patient sought care from my doctor friend. He started buprenorphine and got them off the pain pills, and directed them back into 12-step recovery.

When he retired, I was fortunate that many of them followed me to my new practice.

Around twenty-five percent of my office-based buprenorphine patients are in this category. Most still go to 12-step meetings, though the frequency of meeting attendance varies widely. Some patients go a few times a month, and some a few times per week. I have one patient who goes two times per day. My patients have varying levels of attachment to the 12-step meetings and their participation at the meetings. All of them say they learn and are reminded of important tools of recovery. They say applying concepts like acceptance, tolerance, and kindness enhances the quality of their lives.

These patients, with very few exceptions, are doing very well in their recovery. They are also delightful people.

For these patients, being on medication like buprenorphine has stopped being as issue. Most of them say they know their recovery is better since starting buprenorphine. They don’t tell people they’re on medication, but neither do they hide it. They don’t really care what other members of 12-step meetings think about their medication; it works for them and improves the quality of their lives, while not causing euphoria or the compulsion to take more and more of their medication.

Let’s present 12-step programs as options for our medication-assisted treatment patients on methadone or buprenorphine. As this study shows, and as I see in my own practice, these two options can benefit our patients. Also, as I tell my patients, you can’t beat the price of 12-step meetings, since they are free.

I know 12-step fellowships aren’t for everyone. Though 12-step fellowships don’t endorse one religion over another, these fellowships are intensely spiritual. Not all people are comfortable with such things, or are uninterested in the spiritual side of life. But for those who don’t object to spirituality, or even enjoy or embrace it, 12-step meetings can be a haven of recovery.

1. Monico et al, “Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes,” Journal of Substance Abuse Treatment, May, 2015.

The Billionaire Pill

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In a recent Forbes magazine article about this nation’s twenty richest families, the Sackler family was number sixteen on the list. The Sacklers are estimated to be richer than the Mellons, Rockefellers, and Busches. (http://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxycontin-clan-the-14-billion-newcomer-to-forbes-2015-list-of-richest-u-s-families/

You say you don’t know the Sackler family? I’ll remind you. They own one-hundred percent of Purdue Pharma, a pharmaceutical company best known for manufacturing their block-buster drug OxyContin.

This is a bitter pill for me to swallow.

I started working in the field of opioid addiction treatment in 2001. At that time, nearly every opioid addict I saw was using OxyContin as their main drug. Opioid addiction in general and OxyContin addition in particular plagued many small towns and rural areas where I worked.

OxyContin was widely prescribed for pain. This powerful drug was advertised as “The one to start with and the one to stay with,” during sales pitches to rural physicians. OxyContin flooded the black market. Opioid addict quickly discovered OxyContin’s time-release coating could be easily defeated, and the pill was often snorted or injected for the rush of opioid euphoria it produced.

I was certainly not the only doctor to notice the rise of OxyContin addiction.

Barry Meier’s book Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale Books, 2003), tells the story of small town doctors trying to get the attention of Purdue Pharma, the government, or anybody else who could help change the destruction OxyContin was doing to Appalachia around that time.

I remember attending a pain and addiction conference around sometime around 2003 or 2004. At the end of the lecture explaining how opioids could be prescribe safely, a doctor from Virginia dared to ask the experts something along the lines of, “What are we going to do about OxyContin?” I thought to myself that I was glad someone had finally said what I was thinking.
This was a long time ago; I don’t remember exact words, but my memory is that he was soundly rebuffed for daring to mention one specific drug by name. He was scolded and told that the real problem was with opioids in general, and one drug company (who happened to have some of the lecturers on their payroll) should not be singled out as the problem.

I remembered wishing those experts could spend a day at my treatment program talking to the OxyContin addicts.

Eventually, the U.S. General Accounting Office asked for a report about the promotion of OxyContin by Purdue Pharma. By 2002, prescriptions written for non-cancer pain accounted for 85% of the OxyContin sold, despite a lack of data regarding the safety of this practice. By 2003, primary care doctors, with little or no training in the treatment of chronic non-cancer pain, prescribed about half of all OxyContin prescriptions written in this country. By 2003, the FDA cited Purdue Pharma twice for using misleading information in its promotional advertisements to doctors. [1, 2] Purdue Pharma also trained its sales representatives to make deceptive statements during OxyContin’s marketing to doctors. [3]

Testifying before Congress in 2002, a Purdue Pharma representative said the company was working of re-formulating OxyContin, to make it harder to use intravenously. This representative claimed it would take several years to achieve this re-formulation. The re-formulated OxyContin was finally approved by the FDA in 2010, eight years later. Currently, this medication forms a viscous hydrogel if someone attempts to inject or snort the medication. It isn’t abuse-proof; probably no opioid will ever be so, but it is much more abuse-deterrent than the original.

Did Purdue Pharma drag their feet in this re-formulation? Experts like Paul Caplan, executive director for risk management for the drug company, said there were issues about the safety of incorporating naloxone into the pill to make it less desirable to intravenous addicts. He also pointed out that some delay in approval was due to the FDA.

For comparison, Sterling Pharmaceutical, when it became widely known patients were abusing their pain medication Talwin, re-formulated within a year, adding naloxone to the medication and reducing its desirability on the black market. Since this was in the 1980’s, I would assume there was less technology to help back then, compared to 2002.

I’ll let readers draw their own conclusions.

In May of 2007, three officers of Purdue Pharma pled guilty to misleading the public about the drug’s safety. Their chief executive officer, general counsel, and chief scientific officer pled guilty as individuals to misbranding a pharmaceutical. They did no jail time but paid $34.5 million to the state of Virginia, where the lawsuit was brought.

The Purdue Pharma Company agreed to pay a fine of $600 million. Though this is one of the largest amounts paid by a drug company for illegal marketing, Purdue made 2.8 billion dollars in sales from the time of its release in 1996 until 2001.

None of the Sackler family members were charged, because they were not involved in the day to day running of the company.

And now the Sackler family is worth billions.

1. General Accounting Office OxyContin Abuse and Diversion
report GAO-04-110, 2003.
2. United States Senate. Congressional hearing of the Committee
on Health, Education, Labor, and Pensions, on Examining
the Effects of the Painkiller OxyContin, 107th Congress, Second
Session, February, 2002.
3. Washington Times, “Company Admits Painkiller Deceit,”
May 11, 2007, accessed online at http://washingtontimes.
com/news/2007/may/10/20070510-103237-4952r/prinnt/ on
12/18/2008.

Increasing Cases of Hepatitis C in Appalachia

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The Centers for Disease Control and Prevention (CDC) released information last month about the increased incidence of Hepatitis C in four states: Kentucky, Tennessee, West Virginia, and Virginia. From 2006 until 2013, acute Hep C cases in those states increased by 364%, in people younger than 30 years old. Seventy-three percent of those new cases occurring in people who injected drugs. The incidence in non-urban areas rose more than in urban areas.

Because many new Hep C infections occur in patients who have few symptoms, the incidence reported by the CDC likely underestimated the true number of true cases.

The authors of the study reminded us that HIV is transmitted the same way as Hep C, and increased incidence of HIV could potentially increase as well. The authors emphasized the importance of making effective addiction treatment available for intravenous drug users, as well as preventive efforts to stop the spread of infectious diseases like HIV and Hep C.

These facts are scary. The surge in opioid addiction over the last fifteen years could be followed by a surge in HIV and Hepatitis C infections. In a recent post (May 7, 2015), I described a micro-epidemic of HIV in a small Indiana town, where 140 new HIV cases were diagnosed in a town of only 4200 people. I don’t want to see this happen again and again in small towns in the U.S.

Let’s learn from the 1980’s, when the AIDS epidemic first emerged. The U.S. did not strongly and immediately support measures that could have limited the spread of this disease. Think how many cases could have been prevented with good information, condoms, needle exchange, and addiction treatment.

Let’s not wait until the situation worsens to do something. We must get serious about harm reduction measures and increased access to addiction treatment.

Needle exchange, where intravenous drug users are provided with clean needle in exchange for used needles, reduces the risk of infectious diseases like HIV and Hep C. Naloxone kits can reverse otherwise fatal opioid overdose deaths. Of course, the ultimate harm reduction measure readily available addiction treatment for addicts who want it.

I know many people at federal and state levels are aware of this problem and have been working on it. Let’s help change happen by giving harm reduction measures our support. For more reading on harm reduction, check out this website: http://www.nchrc.org
This is our excellent harm reduction organization here in North Carolina. Click on the “Advocacy” tab to find out what you can do to help.

Even if you don’t care about what happens to drug addicts, it is in your personal best interest to keep other people in our population from contracting infectious diseases that can affect us all.

New Book About the War on Drugs

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I’ve got a great new book to recommend to anyone interested in the U.S.’s failed war on drugs. It’s “Chasing the Scream: The First and Last Days of the War on Drugs,” by Johann Hari. Published in 2015, I heard about this book at an Addiction Medicine conference when it was highly recommended by one of my colleagues.

As the title implies, the first part of the book describes how the war on drugs was initiated, not by the Reagans, but by Harry Anslinger, our first drug war general, back in the 1930’s. Anslinger is portrayed as an arrogant man, close-minded, filled with hubris, and lacking in compassion. He played on the public’s worst prejudices in order to get draconian drug laws passed, and showed no mercy enforcing them. He fanned the flames of public fears of drug-intoxicated minorities in order to expand his scope of power and prestige. His statements, preposterous from a medical point of view, still echo in the mouths of politicians today.

The author says Anslinger helped to create U.S.’s first drug lord, Arnold Rothstein, who is only the first of many ruthless gangsters to follow. Demand for drugs in the face of strict drug laws creates irresistible opportunities for criminals. The book describes how the war on drugs re-incarnated Anslinger and Rothstein with each generation; the names change but the tactics and destruction remain the same.

It’s an interesting concept.

Part Two of the book describes the lives of drug addicts. The author shows how people with addiction are forced to behave like sociopaths in order to maintain their supply of drugs. For example, many addicts deal drugs on a small scale to help finance their own drug use, an action they would be unlikely to undertake without the strong motivation of their own addiction.

The author goes on to illustrates how police crackdowns on drug dealers actually lead to increased gang violence. When top drug-dealing gang members are jailed, it creates a power vacuum, which leads to increased violence as rival gang members jockey for positions of power. Ultimately, the amount of drug dealing remains the same.

His reasoning does make sense, and is backed by interviews from urban bystanders in the violence of drug wars, both in the U.S. and Mexico.

This section of the book also discusses the inequalities of the drug war. The war on drugs is really a war on people who use drugs, and minorities are much more likely to targets of the drug war. Black drug dealers are more likely to be arrested than white dealers. People with money and influence aren’t targeted, while police go after the downtrodden, less likely to mount legal defenses if treated unfairly. Police do this in order to meet arrest quotas with less trouble from those targeted.

I could believe this, but then in the same section, the author also accuses police of expanding their budgets by confiscating high-dollar cars and homes from the rich people caught in the drug wars. So that was a little contradictory.

The author points out how a youngster who gets arrested for a drug offense is unemployable for the rest of his life, and how he can’t get student loans or public housing. To me that sounded a little overblown, since I know people who have managed to go to school, get their GED, then get a college education and even an advanced degree. I’m sure having a crime in one’s background makes this more difficult, but not impossible. That makes me question the accuracy of the author’s other assertions. For example, I have no idea if a drug charge eliminates all possibility of public housing.

Part three of the book is hard to read. In it, the author describes inhumane treatment of addicts who have been jailed. Arizona is noted for being a particularly brutal state for addicted inmates.
Inmates in general in the U.S. are treated horribly but no one seems to care, since few people have compassion for criminals.

This same section of the book also describes the horrible violence in Mexico brought about by the U.S. demand for illicit drugs. With so much profit to be made, drug cartels become ruthless. The author says in order to make sure other potential rivals stay in fear, dealers must engage in ever-increasing violence and depravity.

The fourth section of the book presents interesting ideas. First of all, the author claims the desire to get high is nearly universal. Far from being a deviant desire, the author advances the theory that the desire for intoxication is found in all humans in all civilizations at all times of human existence. He questions the goal of eliminating all drug use, and says it isn’t realistic.

I agree with him. The desire for euphoria is hard-wired into humans. When that urge runs amok, we may seek to satisfy that desire incessantly with drugs or other destructive behaviors.

The author then describes how life events affect the risk of addiction as if this were something new, but we’ve known for years that stress affects addiction risk. People who have experienced abuse and deprivation as children are more susceptible. But then the book connects our society’s present method of dealing with addiction, which is to shame addicts and cause them more pain. This approach is, predictably, counterproductive.

He says the more drug addicts are stressed, forced to live in poverty, are ostracized and shamed, the less likely they are to be able to find recovery.

Then the book goes into a weird tangent, saying that opioid withdrawal really isn’t all that bad, and the withdrawal is mostly mental in nature. He quotes some scientists who say that people living interesting and productive lives don’t get addicted, because they are happy. The book implies that the biological model has been overblown and scientists ignore the psychosocial components that cause addiction.

He’s wrong. Experts in addiction and its treatment haven’t forgotten the psychosocial components of addiction. But for decades, people have argued addiction is just bad behavior. They say addicts need punishment, rather than coddling in treatment programs. These people completely denied scientific components of the disorder. As a result, scientists interested in treating addiction poured money, time, and energy into proving the scientific portion of the disease. But now the same people who said there was no science to support addiction as a disease complain that scientists ignore the role of psychosocial factors that cause addiction.

In reality, both biologic AND psychosocial factors influence who becomes addicted. It isn’t either/or but both/and. It isn’t productive to argue about which is more important, because both types of causative factors need to be addressed in the disease of addiction.

The fifth part of the book is the most interesting. Chapters in this section describe the changes that occurred when drug addiction was treated more as a public health problem and less like a crime.

In a grass roots organization in Vancouver, Canada, a heroin addict managed to mobilize people to approach heroin addiction in a completely new way. This addict unified addicts and the people who care about them to create political pressure. This group attended town meetings, protested, and organized people who cared about the marginalized addicts of Downtown Eastside of Vancouver. Eventually, this organization managed to create such a stink that the mayor of Vancouver met with this addict-leader, and was so impressed by the insights and arguments that he authorized the establishment of a safe injection house.

Ultimately, Vancouver had one of the most progressive and harm-reduction oriented policies on drug addiction. Their overdose death rate plummeted. Health status of addicted people improved.

Similar harm reduction policies were enacted in Great Britain and in Switzerland, with similar reduction in overdose death rates and in improved health status for drug addicts. In Great Britain, physicians could legally prescribe heroin for opioid addicts for a period of time, from the mid-1980’s until 1995, when this program was ended. All of the health gains – reduced overdose deaths, reduced crime, reduced gang activity, and improved physical health for the addicts – were instantly reversed as soon as the program was stopped.

An entire chapter is dedicated to the changes seen in Portugal, where drugs are now decriminalized, but not legalized. This means thought drug use is not a crime, selling these drugs is still illegal. This chapter describes the changes that happened in Portugal, where harm reduction and public health strategies were enacted beginning in 2001. The nation has one of the lowest rates of illicit drug use in the world, though it’s important to understand that heroin has traditionally been the main drug of this country. Addicts’ lives are more productive and death rates are down. Crime rates dropped, and now the whole country supports these harm reduction strategies to the draconian drug laws that Portugal had in the past.

Near the end of the book is a chapter about what is happening in Uruguay, a small South American country where drugs are now not only decriminalized but legalized.

Anyone interested in the creation of a sound drug policy needs to read this book. It’s extensively researched, and the author spoke with many of the key individuals responsible for changes in drug policy all over the world. I haven’t critically researched all data he quotes in his book about the results of drug decriminalization and legalization, but he gives references for much of what’s contained in the book so that any interested reader can do so.

This book is uniquely interesting because the author combines data and statistics with personal stories of various addicts and their families. This technique combines the power of individual story with the facts of a more objective and detached view.

I don’t agree with all of the authors conclusions. For example, when he tries to say addiction is more about a person’s socioeconomic and emotional status rather than about the drugs…nah. Addiction is not all about the addictive nature of the drug itself, but it is a major factor. When you discount the euphoric attraction of opioids, cocaine, and the like, you risk misunderstanding a huge part of addiction. When a substance produces intense pleasure when ingested, it’s more likely to create addiction. After all, we don’t get addicted to broccoli…

It’s important to know this author has been in hot water in the past, accused of plagiarism. Knowing this made me a little distrustful of his interviews with people throughout the book, but I think the ideas illustrated by the interviews are still valid.

It’s a book filled with food for thought.

Dr. Drew Snafu

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Oh, Dr. Drew. You disappoint me. Again.

Pontificating about the most recent episode of gun violence, Dr. Drew just spewed some gross inaccuracies about the medication buprenorphine.

After listening to his blather, I realized I was going to need to write him an angry letter. Again. I’ve written him twice in the past, back when he had “Celebrity Rehab” on television, but I’ve never received a response. But this time, instead of writing a letter and mailing it, I’m going to post it on my blog.

Dear Dr. Drew,
Just shut up. You make my ears bleed.

If you can’t add anything positive to a conversation, just don’t say anything, please. I shouldn’t have to tell you this nation is in the middle of an opioid addiction epidemic, and there you are on television, demonizing one of the medications proven to be life-saving for this condition.

In an interview about the Charleston, SC, church shooting, you say Suboxone has been linked to violence in its users, and people get “strung out” on it, making it impossible for them to have the personality changes necessary for recovery from addiction.

First of all, don’t use the term “Suboxone.” Please use the more generally accepted way of referring to a medication, by its generic name, since there are so many companies making both generics and name-brand preparations of this medication. That medication is buprenorphine.

Next, I challenge you to present one scrap of scientific evidence for what you said in that interview. What data can you show me indicating personality changes can’t be made while an opioid addict is being treated with buprenorphine?

Of course, it all depends on how you define personality change, but we know patients on buprenorphine are more likely to stop using illicit opioids, have improved physical and mental health, and more likely to become employed than opioid addicts who get non-medication-assisted treatments. They have better relationships with friends and family. These patients’ lives no longer revolve around getting and using opioids in order to get high.

Sure looks like recovery to me.

You criticize this medication because it is difficult to withdrawal from. True, some patients have an extraordinarily hard time tapering off of it, but that’s not a universal experience. I’ve had a few patients say they had no withdrawal at all. Most say they have a withdrawal, and generally it’s not as bad as withdrawal from full opioids.

Besides, I don’t start this medication with the intention of stopping it any time soon. We know the patients who are doing the best are the ones that stay on this medication indefinitely. That’s not a popular opinion, but it IS based in fact. It doesn’t help anyone to ignore what the evidence shows us, and replace knowledge with wishful thinking. Patients should plan to stay on medication-assisted treatments with buprenorphine and methadone indefinitely.

You say Suboxone has been known to cause violence. On what data do you base this? Stories on the internet? Maybe you’ve been in Hollywood so long that you’ve forgotten that stories on the internet aren’t considered medical research.

Just as a reminder, we doctors generally prefer to base our statements on scientific data. To my knowledge, not one of the dozens of studies done on buprenorphine patients over the past twenty to thirty years, both here and in Europe, found any increased tendency toward violence in patients taking the medication. So stop trying to pass off stories on the internet as real data.

Sadly, several news outlets took what you said in that interview and parroted your mistake. Now all sorts of news outlets are saying this drug makes you violent. You and I both know buprenorphine wasn’t the cause of this shooter’s dysfunction. It was highly unprofessional for you to imply that it was.

I understood from watching your unfortunate show “Celebrity Rehab,” which is now, mercifully, off the air, that you were not going to help the viewing public understand opioid addiction and its successful treatment, except to say the only acceptable recovery is drug-free recovery.

Look, I get where you are coming from. I come to this profession from a strongly 12-step, abstinence-only mindset. But time, experience, and medical literature have convinced me that abstinence-only treatment isn’t available or acceptable to many people with addiction. So let’s not deny life-saving treatments with buprenorphine and methadone to people who need them in order to recover. If an opioid addict can get off – and stay off – all opioids and have a contented, happy recovery, huzzah! That person is fortunate, and I’m happy for them that they don’t need medication. But do NOT criticize other patients who do need buprenorphine or methadone in order to live a normal life. Their recovery is just as real as the abstinence-only patients.

If anecdotal evidence is all you care to consider, I can introduce you to hundreds of patients, on methadone or buprenorphine, who are living happy, successful lives in recovery. You dishonor these patients and their journeys when you say they aren’t in real recovery.

But by now, with ever more data, and at a time when our citizens are dying from opioid overdoses in record numbers…if you can’t be helpful, please be quiet.

Sincerely,
Jana Burson M.D.

P.S. If you want to continue to promote yourself as some sort of recovery expert, please get some education. Go to some ASAM meetings, read a book like “Principles of Addiction Medicine,” or read some journals. You are embarrassing yourself, misleading your listeners, and ruining my life with your drivel. (OK, you aren’t ruining my life. But you are irritating me.)

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