Archive for the ‘Books for addiction counselors’ Category

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

 

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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.

Bibliotherapy: Women and Addiction

aaaaaaaaagood book

I’m sorry to post another re-run this week, but i just moved, and my time and energy have been taken up with unpacking. I haven’t made time to write a fresh blog entry this week. Meanwhile, here’s an entry from a few years ago:

If you’ve looked at my blog before, you’ve likely seen that I like to recommend books. I prescribe books as medicine. Looking over my sagging bookshelves, I saw a number of my favorite titles that are specific for women and addiction. While some are a bit dated by now, even those 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.

Studies show this approach is associated with a worse outcome for baby and mother than a compassionate and hopeful approach. 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.

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.

Parched, by Heather King, 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 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.

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, being 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 children can be a strong motivating factor for a woman to get clean, but not if she loses 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.

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 is 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.

The Benzodiazepine Dilemma: New Guidelines for Opioid Treatment Programs from IRETA

aaabenzos

I’ve written about benzodiazepines before in this blog (See my post of November 3, 2012). I worry about overdose deaths and other complications in patients for whom I prescribe methadone who are also taking benzodiazepines, prescribed or illicit.

Now doctors at OTPs have help from the Institute for Research, Education and Training in Addiction (IRETA). This well-respected organization located in Pittsburgh, Pennsylvania just issued an evidence-based document titled, “Management of Benzodiazepines in Medication-Assisted Treatment.” You can access this document at IRETA’s website: http://ireta.org/

I love IRETA for tackling this subject. There’s much misinformation about the use of benzodiazepines, even for patients without addiction. But for patients with addiction, benzodiazepines can be deadly when combined with opioids including methadone and buprenorphine.

IRETA’s document first describes how and why these guidelines were created. Opioid treatment programs often have patients who also use benzodiazepines, both by prescription and illicitly. Physicians at OTPs have widely varying responses to these patients. Some programs have zero tolerance, meaning they won’t allow anyone on benzodiazepines to be in their opioid treatment program. Other physicians at OTPs actually prescribe benzodiazepines for their patients when they feel it’s clinically indicated. IRETA wanted to delve into actual scientific literature and consult a panel of experts for interpretation of that data. This IRETA document describes in detail how the literature search was done. It also goes into exhaustive detail about how each statement in the set of guidelines was vetted by experts.

This paper’s guidelines fall into seven categories:

General guidelines
Assessment for MAT
Addressing benzodiazepine use
MAT for patients with concurrent benzodiazepine use
Noncompliance with treatment agreement
Risk management/Impairment assessment
Special circumstances

Here are the general guidelines, taken directly from the document:

CNS depressant use is not an absolute contraindication for either methadone or buprenorphine, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, anti-depressants, or alcohol.
People who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
Clinicians should ensure that every step of decision-making is clearly documented.
Clinicians would benefit from the development of a toolkit about the management of benzodiazepines in methadone treatment that includes videos and written materials for individuals in MAT.

Please note that under the third point of the general guidelines, it says patients shouldn’t be taken off MAT because of repeated benzo use, but need “risk management strategies.” That’s a little vague, but IRETA guidelines go into more detail later in the document.

IRETA’s second section of guidelines is about assessment for MAT. The guidelines say all of the usual things; for example, they say a doctor should do a complete evaluation of a patient presenting for treatment, as described in SAMHSA’s TIP (Treatment Improvement Protocol) 40 and 43. The evaluation should include the patient’s history of medical problems and history of all drug use, even over the counter medication. A mental status assessment and a drug screen should also be included.

Also under the assessment section, IRETA suggests adding patient education about the dangers of mixing benzos with methadone or buprenorphine. I like this idea, and I do something similar. When I ask about past drug use, I always warn patients about the potential bad outcome of mixing benzos and alcohol with the medication I’m going to prescribe, and I repeat the warning at the end of our interaction.

IRETA suggest doctors go farther, and give patients information not only about overdose risk, but also about the other problems benzodiazepines can cause. Benzodiazepines are associated with a greater risk of depression and suicide. Having a prescription for benzodiazepines doubles a patient’s risk for an auto accident, and increases the risk for other accidents, like falls. Taking a benzodiazepine prescription is associated with an increased risk for hip fracture.

The IRETA guidelines remind us that there is “Substantial and growing literature that suggests long term use of benzodiazepines (especially in large doses) leads to cognitive decline.” (page 16 of the report) the guidelines also say that benzodiazepines are associated with emotional blunting, and long-term sleep and mood disturbances. Even more relevant, studies show that patients on benzodiazepines have worse outcomes in medication-assisted treatment.

The third section of IRETA’s guidelines is about addressing benzodiazepine use. They say that a patient should be willing to address their benzo addiction. IRETA says that uncontrolled use of benzodiazepines is a contraindication to treatment with methadone or buprenorphine because of the “extremely high risk for adverse drug reaction involving overdose and/or death during the induction process.”

I’m in the “amen” corner for that one! But it’s hard for me to know which patients use benzos occasionally to help opioid withdrawal, and which patients use benzos heavily in an uncontrolled manner. Most patients, seeing me for admission to MAT, minimize their use of benzodiazepines, knowing it’s a big issue. If they’re getting benzodiazepine prescriptions in large amount from multiple doctors, I can see that on our state’s prescription monitoring program. If the patient is taking benzos illicitly, I may not have a way to know this. Information from family members and friends can sometimes help, if the patient will allow. Or family members and friends may be as heavily involved in addiction as the patient presenting for treatment.

The IRETA guidelines remind us that patients on long-term benzodiazepine therapy are at risk for adverse drug reactions which can include overdose and death. The guidelines say that central nervous system depressants are not absolutely contraindicated with methadone, but also put patients at risk for overdose and death. I assume at this point in the document, its authors are referring to other non-benzo central nervous system depressants like carisopradol (Soma), zolpidem (Ambien), and the other “z” sleep medications, and perhaps pregabalin (Lyrica).

IRETA’s benzodiazepine guidelines for OTPs are extensive, so I’m going to split my review of the contents over two blog entries. Stay tuned…or even better, go read them for yourself:
http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

1. Thomas et al, “Benzodiazepine use and motor vehicle accidents. Systematic review of reported association.” Canadian Family Physician, 1998 April;44:799-808.
2. Smink et al, “The relationship between benzodiazepine use and traffic accidents: A systematic literature review.” CNS Drugs, 2010 Aug.24(8)6390653.