Archive for the ‘Alcohol’ Category

Opioid Treatment Programs and Crime

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In a recent study, violent crime rates were found to be lower in areas surrounding methadone clinics than around other neighborhood businesses. [1]

This study, published in Journal of Studies on Alcohol and Drugs in January, 2016, followed violent crime statistics around fifty-three publically funded outpatient drug addiction treatment centers, including methadone clinics, in Baltimore, Maryland. The study was done by a research team out of the Johns Hopkins Bloomberg School of Public Health, and headed by Dr. Furr-Holden.

Crime rates around methadone clinics were compared to crime rates around liquor stores, convenience stores, and other “corner stores” defined as mom-and-pop small businesses. The researchers didn’t count actual robberies of the liquor, convenience, and corner stores, since these are robbed much more often than addiction treatment centers, to avoid a bias in favor of the addiction treatment programs.

Neighborhoods around addiction treatment programs still had significantly fewer violent crimes than neighborhoods around retail stores, even controlling for the socioeconomic status of each area. The treatment centers had 25% less crime around their neighborhoods than did retail stores

This data dovetails with previous data from a similar Baltimore study. [2]

In 2012, Dr. Susan Boyd, from the University Maryland School of Medicine, released a study that mapped violent crimes in Baltimore by distance from the city’s fifteen methadone treatment programs. These programs were located in various types of communities; some were in the inner city, some in working-class neighborhoods, and others in middle-class neighborhoods. Her study found that violent crimes were no more likely to occur within 25 meters of the methadone facility than they were 100 meters away.

Again, when this researcher looked at retail stores like convenience stores, they found significantly more violent crimes committed within 25 meters of the stores, compared to 100 meters away from the stores.

The establishment of new methadone clinics, now better termed “opioid treatment programs” since they  also prescribe buprenorphine, is often opposed by local citizens. Usually these citizens cite increased crime as the reason for their opposition. These studies show this reason is not valid, and that if citizens wanted to base their protestations on fact instead of bias, they should object to the establishment of new liquor stores and convenience stores, shown by both studies to be much more associated with violent crime.

  1. “Not in My Back Yard: A Comparative Analysis of Crime Around Publicly Funded Drug Treatment Centers, Liquor Stores, Convenience Stores, and Corner Stores in One Mid-Atlantic City” was written by C. Debra M. Furr-Holden; Adam J. Milam; Elizabeth Nesoff; Renee Johnson; David . Fakunle; Jacky M. Jennings; and Roland J. Thorpe.
  2. Boyd, S.J., et al. Use of a “microecological technique” to study crime incidents around methadone maintenance treatment centers. Addiction 107(9):1632–1638, 2012.

 

Alcohol and Opioids (and Benzos) Don’t Mix!

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The Centers for Disease Control and Prevention (CDC) released a report in October of 2014 that analyzed data regarding the contribution of alcohol in opioid overdose deaths and in emergency department visits for opioid misuse. They also looked to see if alcohol was present in benzodiazepine overdose deaths, and emergency department visits related to benzodiazepine misuse. This information was gathered in 2010 by the Drug Abuse Warning System, (DAWN). [1]

The report found that alcohol was a contributing factor in at least twenty percent of the opioid overdose deaths. When they looked at emergency department visits for opioid misuse complications, alcohol was present in about eighteen percent of patients.

In other words, alcohol is a contributing factor in one-fifth of serious opioid overdoses deaths and near-overdoses.

The data was similar for alcohol combined with benzodiazepines; twenty percent of benzodiazepine-related deaths had alcohol present in the decedent’s body as a contributing factor. For emergency department visits related to benzodiazepine use, alcohol was present in over a fourth of these patients.

I don’t find this data to be surprising. If anything, I’d expect a higher percentage of decedents to have alcohol as a contributing factor to both opioid and benzodiazepine overdose deaths. Alcohol and benzos both act on the same type of brain receptors, and have the same sedative effect on the brain. They both also act of the portion of the brain that tells us to breathe while we are asleep. Since opioids have the same effect, particularly at higher doses, any combination of these three substances can result in death. The person goes to sleep, stops breathing, and dies.

Other bits of data in this report were interesting. For example, more men than women had alcohol as a contributing factor in opioid-related and benzodiazepine-related emergency department visits. That’s not a surprising finding, since men have a higher rate of binge-drinking than women.

In this study, older people were more likely to have used alcohol along with their opioid than younger people. Overdoses in people aged 40 to 59 had alcohol in around one-fourth of the deaths.

The study found people who used hydrocodone were more likely to consume alcohol. That’s an interesting finding. Maybe opioid addicts who have hydrocodone available, as compared to stronger opioids like oxycodone, tend to supplement with alcohol in order to boost the effect of the opioid. That’s merely conjecture on my part, but it’s based on conversations with opioid-addicted patients over the last ten years. Opioid-addicted patients will use anything to ease opioid withdrawal symptoms: alcohol, benzos, even cocaine or methamphetamine

For people who overdosed on benzodiazepines, twenty-eight percent were over age 60. There’s another good reason to avoid or reduce benzodiazepines in people over sixty.

I think this data shows we need to do a better job of educating patients not only of the danger of benzodiazepines and opioids mixed together, but that alcohol can be just as deadly with either benzodiazepines or opioids.

I really worry about my patients who drink alcohol while being prescribed either methadone or buprenorphine (Suboxone). Too many of my patients are cavalier about mixing alcohol with other drugs and medications. Many of them say they don’t see alcohol as a real problem, because they’ve been able to start and stop alcohol, unlike opioids. They say alcohol is legal, so what’s all the fuss? They say they don’t drink any more than their friends. Everybody drinks, don’t they?

No, they don’t. About thirty percent of the U.S. population doesn’t drink alcohol at all. Only fifty-six percent have had an alcoholic drink over the past month, which means nearly half of the people in this country haven’t had any alcohol over the last month.

One of my patients told me it was his right as an American to drink alcohol, and was angry at me when I told him of the dangers of mixing alcohol with methadone. I told him I didn’t know if drinking was a right or not; I was only telling him about how alcohol and drugs affect the body.

Sometimes I ask patients what they think about the warning label on their pill bottle that says, “Do not take with alcohol.” Some patients say they don’t believe warning labels because they’ve had alcohol with buprenorphine or other opioids before, and nothing bad happened. Some say they think the warning labels are put on all medicine bottles to protect the pharmacy from being sued.

Just because something has never happened before doesn’t mean it can’t or won’t happen in the future. Many factors can influence overdose risk, and it’s dangerous to assume an overdose can’t happen because it hasn’t happened before.

1. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6340a1.htm

Don’t Drink Alcohol if You are Taking Methadone!

Just like benzodiazepines, alcohol can be fatal when consumed by a patient who also takes methadone.

These two substances interact in several ways.

Worst of all, alcohol inhibits the area of the brain that keeps us breathing while we sleep. So do opioids of all sorts, including methadone. But when alcohol and methadone are both in the blood stream, the effects are greater than expected, due to synergy. In other words, 1+1=3, instead of 2, as we would expect. This interaction is unpredictable. This is how overdose deaths occur with the combination of alcohol and methadone.

Besides this potentially fatal interaction, alcohol also induces, or speeds up, the metabolism of methadone. Both alcohol and methadone are metabolized by the same enzymes in the liver, and alcohol can prime the pump of the metabolic rate. Alcohol gooses the liver, speeding the metabolism of methadone, which means a patient on a previously stable dose of methadone may suddenly notice that his dose isn’t holding for the full 24 hours. This patient may ask for a dose increase, when in truth, he really needs to stop drinking alcohol completely.

Over the long term, alcohol can cause a buildup of methadone to a toxic level, if the drinking goes on long enough to cause liver scarring and shrinkage, called cirrhosis. If this condition develops, liver metabolism slows for any drug or medicine processed by the liver.

Addiction is cunning, baffling, and powerful. It’s incredible to think of a person who’s able to stop using opioids after years of addiction be defeated by alcohol. Cross addiction, which means switching from one addictive drug to another, happens all too frequently. Sometimes it’s hard to convince patients they need to stop the use of all addicting drugs, and that does include alcohol and marijuana.

Bibliotherapy: Women and Addiction

If you’ve looked at my blog before, you know I like to recommend books. I prescribe books as medicine. Looking over my sagging bookshelves, I saw a number of my favorite titles  are specific for women and addiction. While some are a bit dated, all contain information that’s helped me better understand how women, especially pregnant women, have unique needs in their recovery from addiction.

 For example, in the past, when I talked to a pregnant patient who was still using drugs, I would tell her every awful thing her drug use could possibly be doing to the fetus. I thought I could scare her into sobriety.

  It turns out that studies show this approach is associated with a worse outcome for baby and mother than an approach that emphasizes compassion and hope. Pregnant addicts carry a tremendous burden of shame and guilt, as arguably the most stigmatized people in our society. Even other addicts look down on pregnant addicts. So when physicians add to their shame, they tend to run. They leave treatment (physically or mentally), and everyone suffers. With a gentler approach, these women tend to participate in their own treatment and mother and baby have better outcomes.

 Duh. Don’t we all do better with gentler approaches?

 Anyway, here’s a list of books about women and addiction. Some I have mentioned before, like Women Under the Influence, by the National Center on Addiction and Substance Abuse at Columbia. This is maybe the most comprehensive book, full of references, about addiction in women. Happy Hours by Devon Jersild is more conversational, with excerpt from interviews with women addicted to alcohol, but it also contains solid information. One of the most entertaining, because it is a well-written story told by a female alcoholic is Drinking: A Love Story, by the late Caroline Knapp. And Lit: A Memoir, by Mary Karr, is a current best-selling book about the experience of a female alcoholic.

 Parched, by Heather Kind, is similar to Ms. Knapp’s writing, and also worth a read. This book is a well-written, entertaining documentation of an intelligent woman’s descent into alcohol addiction. Thankfully, she also describes her recovery. This is a better-than-average addiction memoir, and hasn’t gotten the recognition it deserves.

 Using Women: Gender, Drug Policy, and Social Justice, by Nancy Campbell, written in 2000, is an unusual and fascinating book. It describes how society has viewed female addicts throughout history and how they are frequently judged more harshly than male addicts. Throughout the decades, addicted women don’t do what’s expected of them by their society, and society’s expectations often shaped U.S. drug policies. The author contends that female addicts cause more outrage than male addicts because they stray so far from assumed female roles. The book is filled with cool black and white photos of sensationalized news stories from the girl addicts of the 1950’s to the crack moms of the 1990’s. This book has not gotten the accolades it deserves.

 Women, Sex, and Addiction: A Search for Love and Power, by Charlotte Davis Kasl, PhD, 1989, focuses more on the way the inequities of power in relationships shape female behavior with sex and drug use and addiction. The author discusses all sorts of addiction, not just sex or drug addictions.  For many female addicts, codependency and sex are strongly intertwined. The book also has sections of lesbian and bisexual lifestyle and addiction, and male codependency and addiction. Some sections were interesting and helpful, and others…not so much. The author uses older terminology, from the time when codependency was more in vogue.

 Women on Heroin, by Marsha Rosenbaum, 1981. This book follows the careers of 100 female addicts in a street study. The author talked with a hundred women of many ages and various races to hear what their lives are like while addicted to heroin. One theme of the book is that initially, drug use gives the illusion of empowering the women, but eventually the need to support their habit steals their power. Women resort to criminal means to support their habits, and this is more difficult for women caring for small children. Treatment programs often don’t consider how children can be a strong motivating factor for a woman to get clean, but not if she’ll lose her kids while she goes off to treatment. Lots of quotes from the women she interviews are scattered through the book.

All counselors working with female patients need to read this book to more fully understand how effectively to engage women into treatment. Besides containing useful information, it’s just a really interesting book.

 Crack Mothers: Pregnancy, Drugs, and the Media, by Drew Humphries, 1999. Here’s a book bound to stir controversy. The book describes how the “crack baby” was a media invention, not a medical reality. While some children born to women addicted to cocaine had medical issues, we now know these kids didn’t grow up to be the permanently and hopelessly damaged human beings as conjured by the media. This book talks about the racist prosecution of pregnant minority addicts, and how they tended to be the ones to be jailed, while middle and upper class pregnant addicts were able to use their resources to avoid prosecution. In some cases, pregnant women had asked for treatment but were turned away because it wasn’t financially accessible, and they were jailed instead. I thought this book was very interesting and I read it in just a few days. But then, I am a book nerd.

 Substance and Shadow: Women and Addiction in the United States, by Stephen Kandall, The author is a renowned neonatologist, and this book is scholarly, filled with references. I’m reviewing the book from memory, since I loaned it to a friend and I can’t remember who has it. The author talks about the paternalistic methods of physicians in previous centuries, and how their attitudes increased the risk for female addiction to opioids. Then he traces the history of drug policy in the U.S., paying special attention to how women were treated – or not treated – differently. This book is a bit more intense, and not as light or quick reading as most of the others listed.

 A Woman’s Way Through the Twelve Steps, and A Woman’s Way Through the Twelve Steps Workbook, by Stephanie Covington, 2000. Compared to the method of working the twelve steps outlined in either AA’s Big Book, or NA’s Step Working Guide, this workbook felt a little “fluffy.” It’s a softer way of looking at the steps, and may be quite beneficial for women who have been traumatized by abuse in the past. For some women, harsh rhetoric occasionally heard in 12-step meetings can triggers memories of abuse, verbal or physical. For women who are turned off by more traditional steps guides, this book and workbook offer an alternative. I liked the book better than the workbook. For some people, this could be a great resource. For others, it will feel too mild.

 Women and Addiction: A Comprehensive Handbook, by Kathleen Brady, Sudie Black, and Shelley Greenfield, 2009.  I’ll let you know. I’m just starting it.

 Do you have favorite books about women and alcohol or drug addiction? Please tell me what they are.

 

 

Alcohol and Methadone Don’t Mix!!

Just like benzodiazepines, alcohol can be fatal when consumed by a patient who also takes methadone.

These two substances interact in several ways.

Worst of all, alcohol inhibits the area of the brain that keeps us breathing while we sleep. So do opioids of all sorts, including methadone. But when alcohol and methadone are both in the blood stream, the effects are greater than expected, due to synergy. In other words, 1+1=3, instead of 2, as we would expect. This interaction is unpredictable. This is how overdose deaths occur with the combination of alcohol and methadone.

Besides this potentially fatal interaction, alcohol also induces, or speeds up, the metabolism of methadone. Both alcohol and methadone are metabolized by the same enzymes in the liver, and alcohol can prime the pump of the metabolic rate. Alcohol gooses the liver, speeding the metabolism of methadone, which means a patient on a previously stable dose of methadone may suddenly notice that his dose isn’t holding for the full 24 hours. This patient may ask for a dose increase, when in truth, he really needs to stop drinking alcohol completely.

Over the long term, alcohol can cause a buildup of methadone to a toxic level, if the drinking goes on long enough to cause liver scarring and shrinkage, called cirrhosis. If this condition develops, liver metabolism slows for any drug or medicine processed by the liver.

Addiction is cunning, baffling, and powerful. It’s incredible to think of a person, finally able to stop using opioids after years of addiction, be defeated by alcohol. Cross addiction, which means switching from one addictive drug to another, happens all too frequently. Sometimes it’s hard to convince patients they need to stop the use of all addicting drugs, and that does include alcohol and marijuana.