Archive for the ‘Books for addiction counselors’ Category

Book Review: “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America,” by Beth Macy

Dopesick, by Beth Macy

This well-written book has it all: compact information about how the opioid epidemic started, how our nation failed to act early to mitigate the damage of the epidemic, and how the epidemic shifted into our present predicament. The author did a great deal of research and talked to experts with vital information, but she humanized this data with personal stories about people affected by the opioid epidemic. She told this story not only from the view of the person with opioid use disorder, but also illustrated the grief of families who lost loved ones. The prolonged grief of families who have lost loved ones to opioid overdose deaths is rarely examined as well as it is in this book.

This is a book that will be staying on my shelf for a re-read.

The author is a journalist who works for the Roanoke Times newspaper, so this book focuses mostly on events in the western part of Virginia.

Avid readers on this topic will recall the book “Painkiller,” by Barry Meier, who also covered rural Western Virginia. Ms. Macy’s book picks up where Mr. Meier’s left off. They talk about many of the same communities and the same treatment providers, fifteen years later.

Mr. Meier’s book, published in 2003, could have been an early warning to the U.S. healthcare system. Unfortunately, the book wasn’t widely read, so few people took any note of what was going on, other than those of us already working in the field. I understand Mr. Meier wrote a second edition of “Painkiller” this year, and I plan to read and review it.

The most remarkable theme of Ms. Macy’s book is how the opioid use disorder epidemic grew worse over the past fifteen years. After physicians finally stopped prescribing so many opioid pain pills, these pills were less available on the black market. Many people with opioid use disorder switched to cheap and potent heroin.

In Ms. Macy’s book, she tells the experience of a rural physician, Dr. Art Van Zee, who was also interviewed for Barry Meier’s book. He was one of the brave people who stood up at conferences and raised the question about the ethics of Purdue Pharma, manufacturer of OxyContin, when it wasn’t easy to question anything about that drug company. He’s the first physician I can recall who actively sought answers about his perceived over-prescribing and mis-marketing of OxyContin.

This isn’t in the book: I remember Dr. Van Zee at an Addiction Medicine conference called “Pain and Addiction: Common Threads,” that I attended in 2003 o4 2004. I bought the recordings of the conference, because I was so excited to learn more about Addiction Medicine. I remember a recorded session where Dr. Van Zee asked a question after a lecture, asking – as I remember it many years later – why Purdue Pharma was still peddling their OxyContin as a relatively harmless opioid for chronic pain, while he was seeing patients with lives destroyed by this drug.

It was one of those moments where all you hear are crickets. His question wasn’t answered, but rather he was reprimanded by the speaker. He was cautioned to remember our conferences were sponsored in part by Purdue money, and that appropriate prescribing of OxyContin was a huge benefit to patients. He was told it wasn’t the drug, it was the prescribing that needed to be fixed.

Fast forward to 2007. As described in “Dopesick,” Purdue Pharma pled guilty to fraudulent marketing of OxyContin, which was a felony misbranding charge. Purdue paid $600 million in fines. Its top three executives pled guilty to misdemeanor versions of the same crime, and ordered to pay a total of $34.5 million.

So yes, inappropriate prescribing was a big part of the problem, but Purdue deliberately misinformed physicians about potential dangers of the drug, which contributed to inappropriate prescribing. From a 2018 perspective, that speaker’s answer to Dr. Van Zee seems disingenuous at best.

Dr. Van Zee’s perceptions, based on his clinical experiences, were correct. Around that same time, I was seeing the same thing in rural Western North Carolina. I remember having twenty to thirty new patients show up on admission day, all of them were using OxyContin, almost exclusively. This drug was easy to crush to snort and inject, and Purdue knew it.

Purdue Pharma testified before congress in 2003 that they were nearly ready to release a new formulation of their OxyContin pill that was more abuse resistant. As it turns out, that new formulation wasn’t released until 2010. With that change, people with opioid use disorder changed to other opioids, easier to misuse, such as Roxicodone and Opana. Eventually Opana underwent reformulation to a less abused form.

But I digress; back to the book. The author’s first few chapters summarize the history of opioid use disorder and the factors that lead up to the release and promotion of OxyContin. It related how this drug crept into the social fabric of Southwestern Virginia, and how early attempts to sound an alarm about its abuse were met with contempt from drug company representatives.

Chapter Three tells of the “unwinnable” case brought against Purdue Pharma by Virginia attorney general John Brownlee. He went up against the famous Rudy Giuliani, who was one of the lawyers who represented the drug company, and successfully negotiated the eleventh-largest fine against a pharmaceutical company. This chapter contrasts this legal victory with the devastating grief of parents who lost their children to overdose death with OxyContin. The book describes the creation of the “OxyKills.com” message board, which became a sort of a database for overdose deaths. The chapter after that contains depressing descriptions of how Purdue Pharma’s corporation executives and the owners, the Sackler family, distanced themselves from the profound harm caused by their medication and criminal mis- marketing.

The next several chapters contain the tragic stories of people who became addicted to opioids, and their journeys through the criminal justice system, the addiction treatment system, and the pain their families felt, every step of the way. The author illustrates the ridiculousness of our patchwork system of care for people with opioid use disorder, and how ineffective treatments are often pushed as first-line options.

Then the book details efforts to pursue the heroin ring that sprang up in Virginia, and how the ringleader, a man named Ronnie Jones, was eventually arrested, charged and convicted of trafficking heroin from Baltimore to the Roanoke suburbs. Many of Jones’ drug runners were addicted young adults, many female, from Roanoke’s suburbs. Families were shocked when they found out their children were involved with the drug trade. Heroin used to be an inner-city drug, but times have changed. Heroin is now plentiful in suburban and rural areas, as this book illustrates repeatedly.

I was most interested in the author’s description of available treatments. Usually I dread reading writers’ summaries of treatment for opioid use disorder. If they describe medication-assisted treatment at all, it’s often couched in negative terms. However, this author did her homework.

She describes the accurate reasons why medication-assisted treatment with buprenorphine and methadone is the gold standard of treatment, and even writes about some of the success stories. However, she also writes about the more common public perception of buprenorphine: “shoddy” prescribers located in strip malls who don’t mandate counseling or do drug testing patients. She writes about the poor opinion of Virginia law enforcement officials, who criticize doctors for not weaning people off the drug, and for allowing patients to inject the drug & sell it on the street.

However, it’s clear the author was able to grasp harm reduction principles, and latest research findings, since she said (on page 219) the unyielding opposition to MAT was the single biggest barrier to reducing overdose deaths.

I felt gratified to read this in print. I underlined it.

She also pointed out how some states’ refusal to expand Medicaid when given the opportunity kept many people with opioid use disorder from being able to access treatment. That’s more perceptive than I expect from a writer who isn’t trained in public health or substance use disorder treatment.

But my favorite part of the book was on page 221, where an addiction counselor named Anne Giles said of the opioid overdose death epidemic: “We should be sending helicopters!”

I underlined this too.

She pointed out that if the same number of people dying from opioid overdoses were dying of Ebola, the government would be sending helicopters of medical help to rescue people and contain the epidemic, and she’s right. We ought to be sending helicopters….helicopters loaded with emergency medical personnel and treatment medication. (By the way, per most recent data from NIDA, over 49,000 people in the U.S. died from opioid overdose in 2017. That’s one-hundred and thirty-four people per day. If they were dying from Ebola…helicopters for sure.)

So I heartily recommend this book to anyone interested in this topic. Even if you aren’t interested, it’s so well-written that it will entertain you. I particularly appreciate the author’s talent at describing so many facets of this opioid epidemic and the obvious scope of her research.

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The Recovering: Intoxication and Its Aftermath, by Leslie Jamison

This book will stay on my bookshelf to read again; that’s the highest praise I can give any book. Any person interested in substance use disorders and recovery from substance use disorders will find the book interesting and informative.

This is a memoir of the author’s drinking days and her forays into recovery, but it’s more than that too. Intertwined with her story, she divagates down some interesting roads.

She talks about artists, and the relationship between intoxication and the artistic temperament. Since she is an author, most of the examples she gives are of other authors, like David Foster Wallace, who wrote Infinite Jest, or Charles Jackson, who wrote The Lost Weekend. She does talk about the singer Billie Holiday, and about the misery her heroin use brought into her life, and about many other artists.

By page 352 (out of a hefty 448 total pages), the author reveals that her PhD dissertation was about authors who got sober, and how their sobriety affected subsequent work. No wonder she had interesting details about these writers and their struggles. In some cases, she could point out their best works were in sobriety.

I appreciate this idea. I’m bored to death of the cliché of intoxication as artistic muse. Sure, some works of art, be they literature, paintings, music, or other forms, were inspired by intoxicants. Yet how many renowned artists’ lives have been cut short by substance use disorders? The main examples that spring to my mind are musicians, like Janis Joplin, Kurt Cobain, Michael Jackson, Prince…how much enjoyment has the world be cheated out of from the early demise of these artists?

Dead artists don’t create. I hate to hear people imply that great talents must have substance use problems, as proof of how much they suffer for their art. That’s a tired, inaccurate lie.

In her narrative segments, she gives a window into the mind of an alcoholic, or anyone with an obsession that causes harm. She describes the usual justifications and rationalizations she used while drinking, and the same thoughts that came to her while sober.

In other segments, she talks about how race, class, and sex impact how society regards people afflicted with substance use disorders. She points out the inequities of the legal system, and how the percentages of blacks in prison is higher than of whites. She uses the cocaine laws of the 1980’s to make her point. Then, crack cocaine, which was more often used by blacks, carried the same penalty as ten times that amount of powder cocaine, more often used by whites. This meant blacks received much stiffer sentences of incarceration than whites for the same amount of drug. That’s one example of many of how minorities face more consequences for drug and alcohol use disorders.

She gives some history of the Lexington, Kentucky, Narcotic Farm, where people with opioid use disorders went voluntarily or were sentenced for recovery.

She gives a little history of how Alcoholics Anonymous was formed, and how the 12 steps and recovery community work together. She describes what scientists found years later – that peer support and contingency management treatments work, and AA has offered a version of them since the 1930s.

She also writes about the negative aspects of AA. She writes about how simplistic it is, how it’s too reductionist for complex people, and how some people may feel too smart for AA. It’s obvious that she is highly intelligent, and she admits, throughout the book, to her struggles with AA’s basic concepts.

She didn’t have an easy recovery. During her first try at sobriety, she tells how her primary relationship suffered, how depressed she felt much of the time, and how she didn’t feel as creative. She planned her relapse ahead of time at her seventh month of sobriety, with predictable results. She initially enjoyed her return to drinking but it didn’t take long to become more miserable than ever.

Her second try at sobriety went better. She was more enthusiastic about AA, and she eventually sponsored other people. She stopped focusing on herself and saw the importance of being part of a bigger community. She saw the value of people’s stories, even when they were so similar. Indeed, she saw value in the similarity of the stories, because people in AA could relate to one another even though their life experiences were different.

The emotions behind the events of drug and alcohol use connected people seeking recovery. People from different lives and lifestyles bond over shared emotional experiences common to during substance use disorder and their recovery. That’s why it’s not unusual to see a tattooed biker dude hugging a nun at a 12-step meeting

Though much of the book is about her struggles with alcohol, she describes traveling to and working in some exotic places, all of which became dreary under the influence of alcohol. She describes similar drabness in her relationships while drinking, coloring her world gray.

I have few criticisms about the book. I got bored with her constant relationship problems before, during, and after sobriety, but then I tend to have little patience with that sort of thing. If the relationship isn’t working, then end the relationship instead of bemoaning the dysfunction. I understand that sometimes relationships, even the best ones, need work. But she described mostly the work and rarely the rewards of these relationships.

I thought she should have ended her relationship with her long-term boyfriend Dave when she suspected he was cheating on her. While I read about her painful moments when she was at home and he was out doing who knows what, I kept muttering, “Dump him! Dump him!” But who among us hasn’t held on to a relationship longer than we should? So, I do understand. I won’t spoil the book by telling you whether they stay together or not.

Best of all, I like how the author ultimately embraced Alcoholics Anonymous in all its imperfections, while acknowledging other recovery paths are valid. At the end of her book in the section “Author’s Note,” I was happy to read her clear statements that one treatment doesn’t work for everyone, and that medications should be made available to help people. She specifically mentions buprenorphine, which of course warmed my heart.

She also talks about the War on Drugs, and about countries who have found a better way to deal with substance use disorders, without the moral disapproval that is so common in the U.S.

In short, it’s an interesting book with information tucked into an entertaining narrative about one woman’s alcohol use disorder and recovery. It’s the best book I’ve read on this subject since Caroline Knapp’s “Drinking: A Love Story.”

I highly recommend this book.

 

Book Review: “American Pain,” by John Temple

 

This nonfiction book, published in 2016, describes in amazing detail the rise and fall of one of the biggest of South Florida’s pill mills, named American Pain. The book reads as easily as a novel. It describes the casual criminality and greed that fueled one of our nation’s biggest drug overdose epidemics.

The book starts by describing how a felon, his twin brother, and a body-building buddy decide to open a pain clinic. They hire doctors to work there, but still manage clinic, in appallingly unprofessional ways. These owners and managers show a shocking lack of concern for human life and the suffering they saw daily. For example, they talk derisively of their customers as “druggies” and “zombies,” yet the owners were also drug users. Bribes were taken for all sorts of unethical activities, from advancing a patient through the line more quickly, falsifying drug screen results, or getting the patient seen by a doctor with a reputation for being a generous prescriber.

This pill mill saw mostly people from Appalachia – as the book points out, 43% of the clinic patients lived in Kentucky, 20% in Florida, 18% from Tennessee, and 11% from Ohio.

The methods developed by the addicted patients and their handlers were astounding. Appalachian families who in the past may have distribute moonshine, marijuana, or methamphetamine used the same organizations to distribute these pain pills transported out of Florida. People called “sponsors” would arrange for a group of people to come to American Pain, located in Broward County, Florida, sometimes traveling hundreds in buses or vans or just carloads of people. Each of these people would be given money by the sponsor to be seen by the physician and to buy the pain pills and benzodiazepines dispensed on site. They gave a portion of these pills to their sponsor to be sold through the networks of drug dealers already established, or they could give all the pills to the sponsor in return for a tidy profit.

Some airlines offered cheap flights from the Appalachians to Florida. So many pain patients flew on one flight that it was called the “Oxy Express.”

MRI owners and operators profited because the pain clinic made every patient get an MRI, to maintain a veneer of medical respectability. Patients could bribe their way to the head of this long line, too. Pharmacies profited, as long as they didn’t ask too many questions. Many times, the pain clinics had their own pharmacies and dispensed on site, to make yet more money and to keep legitimate pharmacies from asking uncomfortable questions.

Flea markets in Kentucky sold urine in Mason jars to pain clinic patients who were required to pass a drug test. Dive motels in Florida rented rooms to “oxy-tourists,” and some overdosed and died in these places.

Between 2007 and 2009, Broward County went from having four pain clinics to having one hundred and fifteen. In one area, there were eighteen pain clinics within a two mile radius.

Everyone was happy; the people with addiction got more pain pills to inject or snort, the sponsors made money, the doctors made money, and the clinic owners made staggering amounts of money.

Of course, in the long run, irreparable harm was done. Patients of the clinics died, people who bought pills from American Pain patients died, and families suffered from the deaths of their loved ones. Many people were incarcerated, children were put into foster care, and medical costs of complications from addictions soared. The cost to taxpayers and U.S. social fabric can never be calculated.

Police routinely pulled over cars traveling north on the interstates if they had Kentucky, Tennessee, or West Virginia license plates and were filled with people. Usually, some crime could be detected. If one person had pill bottles from multiple doctors, this was the crime known as doctor shopping. If a pill bottle had too few pills remaining, the owner could be arrested for drug dealing. Many times, there would be drug paraphernalia in the vehicles. The driver could be impaired.

The book is painfully funny in places; the manager of the pain clinic describes what he calls “addict stunts,” like when an RV filled with three generations of a family from Appalachia rolled into their parking lot, spread an outdoor carpet on the asphalt, and set up folding chairs and a grill, planning to make a day of it at the pain clinic. It was a family outing, going to a Florida pain clinic to get pills to fuel one’s addiction.

Pain clinic patients would pee in the hedges, fornicate near other businesses, and shoot up in the parking lot, all of which appalled the owners, who were trying not to attract attention.

The owners even asked themselves, “How could this be legal?” But it was.

Apparently Florida didn’t have any corporate practice of medicine laws, which prevents non-physicians from owning any medical facility. I’ve derided these types of laws in the past, but here’s one situation which cried out for this kind of law.

Florida also had no prescription monitoring program, as I pointed out in my blog of March 8, 2011. Long after Florida’s pain clinic problem exploded, their governor inexplicably blocked development of a PMP. They have one now, but only after Purdue Pharma (manufacturer of OxyContin) offered money to the state to start one.

Florida also allowed physicians to sell pain pills and other medication directly, without involving a pharmacy. This allowed much of the mis-prescribing to go unnoticed.

Of course, things finally ended badly. The FBI got involved, and did investigations, undercover work, and eventually got wire taps to prove RICO indictments of all the main people. After they were arrested, the owners and operators, who talked big about how they would never turn on each other, all ratted on each other to get favorable plea deals.

The main owner got 14 years in prison for his part in the scheme that earned him 40 million dollars, and his twin was sentenced to 17 years in prison. Their friend, the manager of American Pain, was sentenced to 14 years.

All but two of the physicians took plea deals, and most lost their medical licenses and had various criminal penalties.

The two doctors who refused to take plea deals were both charged in the deaths of patients who had overdosed on medications these doctors prescribed. Both doctors said they had no idea they were working for a pill mill, and the juries acquitted both of them

However, they were both convicted of money laundering, under the premise that they would have to be willfully blind not to know the operations of this place weren’t legitimate medical care. Prosecutors said the doctors had to have known they were prescribing to people with addiction or people who intended to sell their pills. In one doctor’s case, she would see in excess of sixty patients per day, and was the largest prescriber in the nation for certain drugs.

She also made 1.2 million dollars in just the sixteen months she worked there. That last fact alone is so far out of line for what legitimate physicians make in that same time period that she had to have known she was committing crimes. She was sentenced to 6.5 years in prison.

The only other physician not to take a plea deal made around $160,000 for working at the pill mill, and was sentenced to 18 months in prison.

This is a fascinating book, about an incredible time in Florida’s history. Of course, as the book illustrates, Florida’s problem bled into other states, and poured gasoline of the raging fire of opioid use disorder that already existed in Appalachia.

The book illustrated the mindset of people who operate such pill mills, their derision towards the people who are making them all this money, and their disregard to the human misery caused by addiction.

One of the most poignant scenes in the book is when the mother of a young man who dies of an opioid and benzodiazepine overdose goes to talk to the doctor who prescribed him the pills. This mother left the hills of Kentucky and drove to Florida for the confrontation. But the doctor said nothing, only looked downward to the floor. For what could she say? Under the best light, she was guilty of willful blindness, and under the worst, something much more sinister.

The events in this book took place not even ten years ago, and we were about ten years into the opioid epidemic when American Pain opened its first clinic. The owners and operators and doctors weren’t the only ones at fault. Why did it take Florida so long to get an operational prescription monitoring program? Why did their governor, Rick Scott, block efforts to establish this important program? Where was the state’s medical board, and why didn’t they investigate the doctors’ actions at American Pain?

I highly recommend this book to anyone interested in the opioid use disorder situation in the U.S., to get better insight into how it started and how it was perpetuated

 

Book Review: “Dreamland: The True Tale of America’s Opiate Epidemic,” by Sam Quinones

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I’m happy to tell my readers of a great new book. Published in 2015, this book is about the pain pill epidemic in the U.S., and how black tar heroin from Mexico quietly filled the void when pain pills became less plentiful.

The story of how this nation found itself in the middle of an opioid addiction epidemic isn’t a new tale, but the scope of the story has rarely been told with the completeness found in this book. The author talked to, or attempted to talk to, key people in all the realms affected by addiction: pain management experts, drug company leaders, addicts, parents whose children died from opioid addiction, doctors who prescribed OxyContin, everyday members of drug rings, prominent leaders of drug rings, law enforcement personnel, and addiction treatment personnel.

This book covered the pain management movement of the late 20th century, and how pain management experts grossly underestimated the risks of prescribing opioids long-term for chronic pain. Those experts taught other doctors that the risk of triggering addiction was almost zero, and that physicians had an obligation to relieve pain in their patients. Pain was described as the “fifth vital sign,” with the implication that a patient’s reported pain level was as objective as their pulse, blood pressure, body temperature, and heart rate.

All of these recommendations were based on thin evidence. Some of the pain management experts were also employed by drug companies marketing powerful opioid pain relievers, creating at the least the appearance of a conflict of interest.

The author described the inappropriate marketing of pain medications in general, and then focused on Purdue Pharma’s criminally inaccurate promotion of OxyContin. Purdue taught its young and attractive drug representatives to say things about OxyContin that were not true. These drug reps pushed their product with fervor, using falsified material provided to them by their company (p. 265). Purdue wasn’t the only drug company to oversell its products, but they did the best job of it. Ultimately, their marketing strategy lead to a criminal case brought in Southwest Virginia, and resulted in Purdue Pharma, along with their three top executives, pleading guilty to a felony count of misbranding. They were ordered to pay a fine of $634.5 million…but the company’s profits have been estimate to exceed three billion dollars thus far.

For me, the most interesting part of the book described the Mexican drug dealers. In a relatively small, agricultural area of Mexico, sugar cane farmers switched to growing opium poppies. The crop was easier to harvest, and much more profitable. Then young men from the area were recruited to travel north to the U.S. to sell the semi-processed heroin known as black tar. This was not a centralized drug unit, but rather multiple small organizations of growers, transporters, and driver-salesmen. Many of these groups were from Xalisco, a city in the Mexico state of Nayarit.

Each group had a handful of drivers located in smaller U.S. cities, ready to deliver black tar heroin to young addicts who called them on the phone. By delivering the product, middle and upper class addicts didn’t have to travel to bad neighborhoods for their drug. The drivers carried only small amounts of black tar heroin with them, in balloons which they carried in their mouth. If stopped by the police, they could swallow the evidence. Even if they were caught, the amount of heroin was so small that they were only deported, not jailed.

The drivers-dealers didn’t use the product, so they weren’t tempted to dilute the product for personal use. Drivers were paid by the hour, so that also gave no financial incentive to dilute the product. These young Mexican men were polite, and taught to give the best possible customer service, to keep the business of the addicts. In fact, they frequently ran sales on their product, as an incentive for customer loyalty.

This heroin was cheap and potent. Opioid pain pill addicts who were desperate to avoid opioid withdrawal switched to heroin because they could get high with less money. Because the tar could be snorted, the stigma of IV use was avoided – at first. Ultimately as the addiction progressed, addicts who started using intranasally eventually switched to IV use.

Groups of heroin sellers competed with each other to sell the most heroin, but they didn’t engage in violence. Since they were all from the same relatively small area of Mexico, and violence in the U.S. would bring repercussions from relatives back home. The drivers delivering the product were cautioned to stay away from blacks, since the Mexicans believed blacks to be more violent.

Because these heroin-selling groups avoided all violence, they were able to concentrate of profits. They didn’t call attention to themselves, making it easier to pass under the radar of law enforcement.

Groups of heroin dealers from Nayarit settled in mid-sized cities. They avoided cities where established drug cartels controlled the sale of heroin, such as New York City, Los Angeles, Philadelphia, Baltimore, or Detroit, fearing there would be violence from the cartels. Instead, they settled into cities like Salt Lake City, Portland, Oregon; Columbus, Ohio; and Charlotte, NC. They needed cities where other Mexicans worked in order to blend in with the populace. The book tells of opioid addiction in Huntington, WVA; Denver, Colorado; Boise, Idaho; Santé Fe, New Mexico; Nashville, TN; and Myrtle Beach, South Carolina.

These Mexican farm boys returned home with money and spent ostentatiously in order to impress their neighbors and friends. They hired bands, threw parties, and built houses with the money they earned from selling heroin. In a relatively poor area, young men saw there was a way to make their fortunes, so recruiting new drivers wasn’t difficult. In fact, the supply appeared to be inexhaustible.

The author makes the point that all of this happened slowly and without much publicity, but I question this conclusion. He says that it was only when Phillip Seymour Hoffman died that the U.S. sat up and took notice.

Maybe I have a different view since I’ve been treating opioid addicts since 2001, and saw a rapid rise of opioid addiction in my state since then. At conferences we seem to talk little about anything else – but then, I go to Addiction Medicine conferences.

The book has its flaws. It was a little repetitive, and many chapters were short, giving the book a choppy feel, but this was because the author described events chronologically, and described what was happening in multiple areas to multiple people.

He described drug abuse in Portsmouth, Ohio, which he called the birthplace of the pill mill. I don’t agree with this. Ever since doctors could prescribe medications that caused euphoria, there have been pill mills. Sadly there are always a handful of unscrupulous doctors who prescribe freely to patients willing to pay. I don’t think Portsmouth was the location of the first pill mill, and sadly it won’t be the last.

The most distressing thing that I read was how the Mexican drug families would move into a new city and go to the methadone clinics to recruit its first customers. From there, word of mouth via the addict grapevine resulted in plentiful business for the Mexicans.

That’s appalling. I’m sure it seems like no big deal to people wanted to make money off of addicts, but to target people who are in treatment to get well, and then tempt them into a relapse…that is low down. The book also describes how drug rings would pay more attention to an addict if he said things about quitting heroin. The dealers would offer this person an exceptional deal to remain a customer.

I know this is good business. But this business breeds death and misery.

I struggle with how to provide security at opioid treatment programs. I don’t like it when an armed guard in the parking lot makes it feel like a police state, but then I want our facility to be safe, and free from interlopers such as these described in the book.

I was also disappointed about the lack of information about treatment. Granted, the title implies only coverage of how the opioid epidemic emerged and evolved, but it would have been nice to add even a small section to readers who are addicted themselves, or who have relatives who are addicted.

Aside from the few nit-picky flaws, this book is great – it’s well-written, informative, and entertaining. It’s one of the best books I’ve read about this country’s story of opioid addiction. It picks up where “Pain Killers,” by Barry Meier left off.

This book should be read by anyone interested in our pain pill epidemic. Addicts should read it so they can realize where their money goes. Families of addicts should read it to better understand the compulsion of addiction. Law enforcement personnel should read it to hear the stories of the addicts, and come to see them as people with a disease, not just as criminals. Every doctor should read it, to better understand risks to patients who are prescribed heavy opioids. Treatment center personnel should read it to get a better idea of the milieu of addiction in the U.S.

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.

Harm Reduction

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I just read a wonderful book, “Coming to Harm Reduction Kicking and Screaming: Looking for Harm Reduction in a 12-Step World,” by Dee-Dee Stout. The book is as delicious as its title. The first part of the book describes a little bit about what harm reduction is, and the latter parts of the book are interviews of treatment professionals. Half are from the “old timers” of harm reduction, including Bill Miller of Motivational Interviewing fame, and the famous Alan Marlatt. The other half of the interviews are from “12-stepping harm reductionists.”

It’s a fascinating read. These professionals describe their mental journey from believing abstinence-only recovery should be the goal for every addicted person, to believing whatever works is a much more practical approach. I’ve made a similar journey in my own mind, so I can relate.

Lately I’ve been reading, thinking, and talking to other professionals about harm reduction. This is an interesting topic because it inspires very strong feelings on both sides. Indeed, just the fact that there are two sides is somewhat remarkable. Who wouldn’t be enthusiastic about harm reduction?

It turns out that these two innocent words are laden with veiled meaning. A harm reductionist’s definition of the term may be something like, “Strategies for drug users and drug addicts, intended to reduce the harm caused by drug use.” But an anti-harm reductionist may see the term to mean, “Strategies which may reduce some harm to drug addicts, but that also prevent them from finding real recovery from drug addiction.”

The desire to get into recovery exists on a continuum. Some addicts want to stop all drugs and learn to live life drug-free. Those patients may embrace abstinence-only addiction treatment and feel comfortable with that approach. Other people may want to stop problematic use of one drug, but see no need to stop another. I see this often at my opioid treatment program. Some people want to quit opioids because of all the negative consequences, but don’t have any desire to stop marijuana, since they can’t see that it causes them any problems.

Other addicts don’t wish to stop using drugs at all, but prefer not to develop some of the negative consequences.

Here are some examples of harm reduction strategies:
 Needle exchange programs (NEPs). Clean needles are distributed to intravenous addicts, sometimes exchanged for used needles. NEPs have been shown to reduce transmission of HIV, and of other infectious diseases. Additionally, patients are less likely to get skin infections like cellulitis and abscesses when new needles are used
 Distributing information about safe injection practices. This can involve things like telling IV addicts about strategies like never using alone, and staggering injection times so that if one person has an overdose, the other one can summon help or use naloxone. It may include instructions on how to use a test dose, in case the product is higher purity than expected.
 Safe injection sites. You won’t find these in the US, but Canada and European nations have sites staffed with medical personnel where intravenous users can come to inject. If they have an overdose, personnel are immediately available to revive them.
 Naloxone kits. These kits can revive people who have had opioid overdoses. I have written much about them in the past, and it’s becoming more main stream to distribute these kits to opioid addicts and their families. Some pain management doctors and OTP doctors also prescribe these kits for their patients, in case of an overdose.

An astute observer will notice I did not list medication-assisted treatment among harm reduction strategies. This is because treatment of opioid addiction with methadone and buprenorphine should be considered a primary and definitive treatment of opioid addiction, not merely as one stop along the road of recovery. Some patients may wish to transition to drug-free recovery in the future, but it shouldn’t be required. Many patients will do better with less risk of relapse if they stay on MAT.

A false dichotomy between the ideas of “abstinence-only” and “harm reduction” proponents has been set up. Instead, we should view all treatment options as complementary to each other. All evidence-based addiction treatment options should offer improved quality of life for the people who use them.

Why not offer options to people who want to reduce the risk of drug use?

As a person with a strong twelve-step background, I found it difficult to embrace all of the harm reduction measures when I entered this field ten-plus years ago. Time, experience, and the medical literature have been my teachers, along with vivid human examples. Most of all, my patients have revealed to me how recovery from addiction rarely happens in a miraculous flash. Mostly, it involves small changes over long periods of time, with some setbacks along the way.

Book Review: “Her Best Kept Secret: Why Women Drink-and How they can Regain Control,” by Gabrielle Glaser

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This book disappointed me. The title suggests a book of interesting research and conjecture about the reasons women drink. I was hoping for new insights that I could use in my practice with patients who drink alcohol. As it turned out, most of the book wasn’t about what the title implied. That topic was lightly touched on in the beginning, and there was a bit of summary at the end, but way too much of the book was about why AA sucks and why women don’t get the right treatment.

I liked the first third of the book, as it was basically history of alcohol and history of addiction treatment. She wrote about the shame women feel about having alcohol addiction, but that was brief. Overall, that portion of the book was mildly interesting, if a little tedious.

Then the next third of the book felt like an attack on AA. I admit I’m sensitive to AA bashing. I know AA works for many people, and I also know AA has never claimed to be the answer for every problem drinker. Given AA’s stance of “we will help you if you want help,” I don’t think it’s productive to berate the organization if you don’t want to go to their meetings.

My own opinion is that if you don’t like AA or don’t think it works for you, then fine. Take your ass on out of the meetings and go find another way that helps you. After all, AA members are under no obligation to help anyone; they help only because they want to, because it helps keep them sober. They don’t recruit new members, and they don’t ask for any money.

The author’s logic isn’t consistent. First she says AA isn’t helpful for women because it tells them they have to admit powerlessness and that interferes with women’s recovery process, rather than helping it. She says it’s insulting for women to be told that “your best thinking got you here,” and the slogans are too trite or hackneyed to help intelligent female problem drinkers who have problems with alcohol. She says women should be told they do have the power to make changes and stop drinking.

But then the next section, she says women are often victimized by men in meetings who have more time in sobriety, and thus more able to take sexual advantage of the fragile newcomer women. So which is it? Are the newcomer women tender blossoms with have no idea how to thwart a creepy man’s advances? Or are these women so powerful and capable that the simplicity of AA is insulting to their intelligence and capabilities?

Alcoholic Anonymous is made up of humans. Humans with drinking problems. It seems disingenuous to expect these humans to behave better than people in other human organizations (Catholic Church, for example). Also, I suspect some alcoholic women may have encountered creepy male advances in bars.

What kind of treatment does this author say works best? She correctly champions cognitive behavioral therapy and Motivational Enhancement therapy.

As an example, she describes an excellent treatment program that consists of treatment sessions from two therapists, with the addition of other services as needed (primary care consult, mental health provider). This treatment is done as an outpatient, where the person stays in a nice hotel close to the therapists’ office.

It costs ten grand. Ten thousand dollars.

This author gushes about how these therapists are so caring and dedicated that they even eat lunch with the patient. I would hope so. If I were paying ten thousand dollars for a few weeks of therapy, I’d expect my therapists not only to eat lunch with me, but also tuck me in at night and tell me a bedtime story!

So overall, I don’t think the ideas in this book extend to any new territory. Twelve step bashing has been done by many authors, so that’s dull. I found much of the book to be derivative, containing ideas from earlier books about women and addiction. Plus, I was surprised by how little time this author spent describing real barriers many women face when they are seeking help for alcohol addiction. For example, women are the primary caregivers for their children. Male partners may not want to take over childcare responsibilities while the woman gets treatment. Many times the woman’s partner is also in active addiction, and seeks to deter or undermine her efforts to get help and to stay in recovery. Transportation is a big problem, especially in rural areas with no public transportation. She may not have a car she can drive to treatment each day.

These issues were not addressed at any depth.

If you want to read a book about women and addiction, I highly recommend you read, “Substance and Shadow,” by Stephen Kandall, or “Women Under the Influence,” by the CASA program. Both are better written and with more information.