Archive for the ‘History of addiction’ Category

Top Ten Books for Methadone Counselors

I have a fair number of methadone counselors who read my blog. I’m often asked by these counselors what books I recommend, which is like asking me what kind of dessert is good. The list is so long. But here are the ones all methadone counselors should read:

  1.  Medication-assisted Treatment for Opioid Addiction in Opioid Treatment Programs, by the Substance Abuse and Mental Health Services Administration. This is better known as “TIP 43,” because it’s the 43rd book in the series of treatment improvement protocols published by SAMHSA. You can get any book in the series for FREE! Yes, this book and several others are free resources. The website is: http://store.samhsa.gov. While you’re there, order TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, and TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment. Then browse around, and see what else interests you. This is a great website, and all addictions counselors should be very familiar with it. There’s great material for counselors and their clients.
  2.   Pain Pill Addiction: Prescription for Hope, by….me. Hey, it’s my blog, so of course I’m gonna list my book. At least I didn’t put it at number one. But seriously, I do think my book describes what opioid addiction is, why this country is having such problems with opioid addiction now, and the available treatments for this addiction. I focus on medication-assisted treatments, which means treatments with methadone or buprenorphine, better known as Suboxone. After reading my book, any substance abuse counselor should be able to talk intelligently with patients and their families about the pros and cons of medication-assisted treatment. I tried hard to base this book on available research and not my own opinions, though I do state some of my opinions in the book. My book also has summaries of the major studies done using medication-assisted treatments, so that if you need resources to prove why methadone works, you’ll have them. OK. I’m done blathering. Order it on EBay and you’ll save some money.
  3.      Motivational Interviewing by William Miller and Stephen Rollnick. This is a book all addiction counselors should have… and read. I’ve learned so much about how to interact with people as they consider if, how, and when to make changes in their lives by reading this book. The authors demonstrate how the Stages of Change model easily fits with this style of counseling. There are some solid examples of how to incorporate MI techniques.
  4.      Cognitive Therapy of Substance Abuse, by Aaron Beck et. al. This is a venerable text describing cognitive therapy as it applies to substance abuse. The book is relatively concise, but it’s still dense reading. Get out your underliner because you’ll want to find some parts to read again. The dialogues in the book that serve as examples are instructive. This book has been around for some time, as texts go, since it was published in 2001.
  5.     Narcotics Anonymous Basic Text, by Narcotics Anonymous World Service. Now in its sixth edition, this is one of the books that serve as a foundation for 12-step recovery in Narcotics Anonymous. If you are a counselor who’s in recovery, you’ve probably already read it. If you’re not, you need to get it, read it, and be able to talk intelligently about the 12-step recovery program of this 12-step group. The AA “Big Book,” which is AA’s version of a basic text, has much of the original old-time words and phrases, and speaks mostly of alcohol. For these reasons, some addicts won’t like the Big Book as well as the NA Basic Text. However, the Big Book does have a certain poetry that will appeal to others. (….trudge the road of happy destiny…) You can order it at http://na.org or go to that site and download it as a pdf.
  6.  The Treatment of Opioid Dependence, by Eric Strain and Maxine Stitzer. Written in 2005, this is an update to a similar title written in the 1990’s. This book reviews the core studies underpinning our current treatment recommendations for patients in medication-assisted treatment of opioid addiction. I don’t know why more people haven’t read this book, because it’s relatively easy to understand. Don’t make the mistake of assuming it will be too advanced for you. Get it and read it.
  7. Addiction and Change: How Addictions Develop and Addicted People Recover, by Carlo DiClemente. This book describes the paths people follow as they become addicted and as they recover. It’s focused on the transtheoretical model of the stages of change, so named because it can be used with many counseling theories. I think this is a practical book, and easier to understand than some texts.
  8.  Diagnosis Made Easier: Principles and Techniques for Mental Health Technicians, by James Morrison M.D. This is an improvement of his earlier book, DMS IV Made Easy, written in 1992. At any work site, addictions counselors will have to be familiar with the criteria used to diagnose mental illnesses. Since around 30 – 50% of addicts have another co-occurring mental illness, you need to be familiar with the criteria used to diagnose not just addiction, but these other illnesses as well. And this book makes learning relatively painless. It’s practical and easy to read, and based on common sense. It contains many case examples, which keep it interesting.
  9. The American Disease: Origins of Narcotic Control, by David Musto. This book has been updated and is on its third edition, but so much has happened since this last edition in 1999 that the author needs to write an update. This is an interesting book, and it moves fairly quickly. This information puts our present opioid problem into the context of the last century or so. As an alternative, you can read Dark Paradise: A History of Opiate Addiction in America, by David Courtwright in 2001. I included this book, but be warned it’s heavier reading. This author is an historian, so maybe his writing style didn’t resonate with me as much. Still, he has much good information. You can’t go wrong with either book. You could also read The Fix by Michael Massing, which is another book about the history of addiction and its treatment in the U.S… This last book doesn’t focus on just opioid addiction, but still gives all the pertinent history. This book is written by a journalist and will keep your interest. It was written in 2000.
  10.  Hooked: Five Addicts Challenge Our Misguided Drug Rehab System, by Lonnie Shavelson. This book, written by a journalist, follows five addicts through the labyrinth of addiction treatment. You’ll see the idiotic obstructions addicts seeking help are asked to negotiate in our present healthcare system. I was angry as I read the book, seeing obvious simple solutions that couldn’t be enacted for one administrative reason or another. Let this book make you angry enough to demand change from our system. Be an advocate for addicts seeking treatment.

 Have I left out any? Let me know which book have helped you be a better counselor or therapist.

The Pain Management Movement

 In the late 1990’s, organizations like the American Pain Society and the American Academy of Pain Management declared that doctors in the U.S. were doing a lousy job of treating pain, and were under-prescribing opioid pain medications, due to a misguided fear of causing addiction. As a result, there was a national push to treat pain more aggressively. Some states even passed pain initiatives, mandating treatment for pain. Lawsuits were brought against doctors who didn’t adequately treat pain. The Joint Commission on the Accreditation of Healthcare Organizations (JACHO), the organization that inspects hospitals to assess their quality of care, made the patient’s level of pain the “fifth vital sign,” after body temperature, blood pressure, heart rate, and respiratory rate. Pain management specialists encouraged more liberal prescribing of pain medication. These experts told their primary care colleagues that the chance of developing addiction from opioids prescribed for pain was about one percent.

With these limited facts, the pain management movement was off and running. Many pain management specialists, some of whom were paid speakers for the drug companies that manufactured powerful opioid pain medications, spoke at seminars about the relative safety of opioids, used long term for chronic pain. Pain management specialists taught these views to small town family practice and general medicine doctors, who were relatively inexperienced in the treatment of either pain or addiction.

The problem was…the specialists were wrong.

These specialists, in their well-intentioned enthusiasm to relieve suffering, used flawed data when reciting the risk for addiction. The one percent figure came from a study looking at patients treated in the hospital for acute pain, which is quite different from treating outpatients with chronic non cancer pain. (1) In other words, they compared apples to oranges.

To many addiction specialists, an addiction risk of only one percent seemed improbable, since the general population has an addiction risk estimated from six to twelve percent. Surely, being prescribed pain pills would not lessen the risk for addiction. Yet the one percent figure was often cited by many pain management professionals, as well as by the representatives of the drug companies selling strong opioids. 

Some pain management specialists even took a scolding tone when they spoke of some primary care physicians’ reluctance to prescribe strong opioids. They often muddied the waters, and grouped patients with cancer pain, acute pain, and chronic non-cancer pain together, and spoke of them as one group. This can feel insulting to doctors who, though reluctant to prescribe opioids endlessly for a patient with chronic non cancer pain, are adamant about treating end-of-life cancer pain aggressively with opioids. No compassionate physician limits opioids for patients with cancer pain or with acute, short term pain. However, chronic non-cancer pain is different, with different outcomes than acute pain or cancer pain.

 We didn’t learn from history, or we would have learned that when many people have access to opioids, many will develop addiction.  We are scientifically more advanced than one hundred years ago, but we still have the same reward pathway in the brain. The human organism hasn’t changed physiologically. The present epidemic of opioid addiction is reminiscent of the early part of the twentieth century, just after the Bayer drug company released heroin, which for a short period of time was sold without a prescription, before physicians recognized that over prescription of opioids caused iatrogenic addiction.

 Few pain patients intended to become addicted. Some addicted people blame their doctors for causing their opioid addiction, but most doctors were conscientiously trying to treat the pain reported by their patient, and the pain management experts had told these doctors the risk of addiction was so low they didn’t have to worry about it.

Certainly many patients made bad choices to misuse their medications, either from curiosity or peer influence, pushing them farther over the line into addiction. Patients need to recognize their own contribution to their addiction. But with opioid addiction, as the disease progresses, the addict loses the power of choice that he once had. If the addict is fortunate enough to have a moment of clarity, before the disease progresses too far, he may be able to stop on his own, without treatment.

 By their very nature, opioids produce pleasure. Any time doctors prescribe something that causes pleasure, we should expect addiction to occur. Some people, for whatever reason, feel more pleasure than others when they take opioids, and seem to be at higher risk for addiction. As discussed in previous chapters, genetics, environment, and individual factors all influence this risk.

Opioids treat pain – both physical and emotional. Many of the neuronal pathways in the brain for sensing and experiencing pain are the same for both physical and psychological pain. For example, the brain pathways activated when you drop a hammer on your toe are much the same as when you have to tell your spouse you spent the rent money while gambling. Opioids make both types of pain better. Chronic pain patients with psychological illnesses are at increased risk for inappropriate use of their pain medications.

 In a recent study, the rate of developing true opioid addiction in patients taking opioids for chronic pain was found to be increased fourfold over the risk of non-medicated people. (2) Instead of a one percent incidence, as estimated by pain medicine specialists in the past, it now appears eighteen to forty-five percent of patients maintained long-term on opioids develop true addiction, not mere physical dependency. (3) If this information had been available in the late 1990’s, doctors may have taken more precautions when they prescribed strong opioids for chronic pain.

 Researchers have identified the risk factors for addiction among patients who take opioids long-term (more than three months) for chronic pain. Studies now show that a personal past history of addiction is the strongest predictor of future problems with addiction, as would be expected.  A patient with a family history of addiction is also at increased risk for addiction, as are patients with psychiatric illness of any kind, and younger patients. (4)

However, at the height of the pain control movement, there were no good studies of the addiction risk when opioids were used for more than three months. The little information that did exist was misused, resulting in an incredible underestimation of the risk of addiction in patients with chronic pain, who were treated with opioid medications for more than three months.

 With the momentum of the movement for better control of pain, both acute and chronic, the number of prescriptions for opioid pain pills increased dramatically. In the years from 1997 through 2006, prescription sales of hydrocodone increased 244%, while oxycodone increased 732% during that same time period. Prescription sales for methadone increased a staggering 1177%. (5)

It’s not just patients who are at risk for abuse and addiction. The increased amount of opioids being prescribed meant there was more opioid available to be diverted to the black market. When an addicting drug is made more available, it will be misused more often.

  1. Porter and Jick, New England Journal of Medicine, 302 (2) (Jan. 10, 1980) p. 123.
  2. Michael F. Fleming, Stacey L. Balousek, Cynthia L. Klessig, et al. “Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy,” Journal of Pain, 207; Vol. 8, issue 7: 573-582.
  3. 7. Steven Passik M.D., Journal of Pain and Symptom Management, Vol. 21 No. 5, (May 2001), pp.359 – 360.
  4. Chou, R, Fanciullo, G, Fine, P, et. al., “Opioid Treatment Guidelines: Clinical guidelines for the use of Chronic Opioid Therapy in chronic, non-cancer pain.” The Journal of Pain, 2009, Vol. 10, No. 2. pp. 113-130

5. Andrea Trescott, MD, Stanford Helm, MD, el. al., “Opioids in the Management of Chronic Non-cancer Pain: An Update of American Society of the Interventional Pain Physicians’ Guidelines,” Pain Physician 2008: Opioids Special Issue: 11:S5 – S 62.

The Narcotic Farm: A Bit of History

We don’t have to keep re-inventing the wheel.

We can investigate the success rates of addiction treatment methods used over the past century, see what worked, and what didn’t work. We can use programs of proven benefit or we can continue to spend money on programs repeatedly shown to have little benefit.

From 1935 until 1962, drug addicts were treated at a unique facility, part jail and part treatment hospital. Initially named the United States Narcotic Farm, it was later changed to the U.S. Public Health Service Narcotics Hospital. Even after this name change, most people still called it the Narcotic Farm.

This facility was located on twelve acres of Kentucky farmland. The facility was created by the Public Health Service and the Bureau of Prisons, meant to serve a dual purpose. It was a treatment hospital, where drug addicts could voluntarily be admitted for treatment of their addiction, and it was also a federal prison, where drug offenders were sent to serve their sentences. About two thirds of the inpatients were prisoners and the other third were addicts, voluntarily seeking help for opioid addiction. Both types of patients were treated side by side. For over forty years, it was the main drug addiction treatment center in the United States, along with a similar facility in Ft. Worth, Texas, which opened in 1937.

            The Narcotic Farm was a massive institution for its time. It had fifteen-hundred beds, and housed tens of thousands of patients over its forty years of operation. It was located in a rural area of Kentucky, which gave it space for numerous operations to engage the prisoners – now called patients – in all types of job training. (1)

             The Narcotic Farm really was a farm. Besides growing many types of vegetables, there was a working dairy, and livestock including pigs and chickens. These operations provided food for the patients and staff of the facility and provided work for the patients. The patients provided the labor to keep the farm going and it was hoped they would simultaneously learn useful trades. In addition to farming, they learned skills in sewing, auto repair, carpentry, and other trades. Besides teaching new job skills, it was hoped that fresh air, sunshine, and wholesome work would be beneficial to the addicts. (1)

            For its time, the Narcotic Farm was surprisingly progressive in its willingness to try multiple new treatments. For the forty years it operated, many different treatments were tried for opioid addicts. It offered individual and group talk therapies, job training, psychiatric analysis, treatment for physical medical issues, Alcoholics Anonymous meetings, art therapy, shock therapy, music therapy, and even hydrotherapy, with flow baths to soothe the nerves. Despite these options, the Farm apparently retained many of the characteristics of a prison, with barred windows and strict security procedures. (1)

             The Narcotic Farm had its own research division, the Addiction Research Center (ARC), which became the forerunner of today’s National Institute on Drug Abuse (NIDA). The Narcotic Farm did pioneering work, using methadone to assist patients through withdrawal, and helped establish the doses used to treat opioid addiction. Methadone was used only short term, for the management of withdrawal symptoms, and not for maintenance dosing at the Narcotic Farm. The Farm also trained a dedicated group of doctors and nurses, who were pioneers in the field of addiction treatment. It provided new information on the nature of addiction.

             Admission to the Narcotic Farm allowed an opioid addict some time to go through opioid withdrawal, eat regular meals, work in one of the farm’s many industries, and have some form of counseling. However, after leaving the hospital, the addicts were entirely released from care and supervision, with no assistance to help re-enter their communities. Most times, they returned to their same living situation and old circumstances encouraged relapse back to drug use and addiction. As a result, two follow up studies of the addicts treated at the Narcotic Farm showed a ninety-three percent and ninety-seven percent relapse rate within six months, with most of the relapses occurring almost immediately upon returning home. Many addicts cycled through the Public Health Hospital multiple times. (1)       

            The Narcotic Farm was eventually turned over to the Bureau of Prisons in 1974, as the treatment for addiction was de-centralized. Since the studies found high relapse rates for addicts returning to their previous communities, it was hoped by moving treatment centers into communities, these addicts could have ongoing support after they left inpatient treatment.

  1. Nancy P. Campbell, The Narcotic Farm: The rise and fall of America’s first prison for drug addicts, (New York, Abrams, 2008)

 

This is an excerpt from my new book, “Pain Pill Addiction: Prescription for Hope.” 

Available at http://prescriptionforhope.com

 and on Amazon and Ebay

and many bookstores