Archive for the ‘injecting drugs’ Category

Is Heroin the New Opana?

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From CDC data released 3/15

From CDC data released 3/15

The Center for Disease Control and Prevention (CDC) released new data last month showing a rapid rise in heroin overdose deaths. While total overdose deaths from opioids remained level for the past few years, deaths involving heroin escalated sharply.

The rate has tripled since 2010, and nearly quadrupled since 2000. Males have a four times higher rate than females with the highest rate seen in white males aged 18 to 44. All areas of the country had increased heroin overdose death rates, but the highest were seen in the Midwest, with the Northeast right behind them. The South, for a change, had the lowest rate of heroin deaths, after the West.

Those of us treating patients at OTPs knew heroin was moving into areas where pain pills once dominated, but I had no idea deaths had tripled in three years. That is appalling even to me, and I see appalling things all of the time. I can’t stress enough how bad this is.

Why is this happening? I’ve read and heard various opinions:

 Some people speculate that since marijuana became legal, that crop is less profitable to Mexican farmers, who switched to growing opium poppies. This is just a theory, though the timing supports the premise. I don’t know how it can be proved, short of taking surveys of Mexican farmers, which seems problematic and unlikely to happen.

 As we implemented measures to reduce the availability of prescription opioids, the price increased. Heroin is now cheaper than pain pills in many areas, and heroin’s purity has increased. Many addicts who can’t afford pain pills switch to heroin to prevent withdrawal. NIDA (National Institute for Drug Addiction) estimates one in fifteen people who use prescription opioids for non-medical reasons will try heroin at some point in their addiction.

Maybe that’s why the South still has the lowest heroin overdose death rates: we still have plenty of prescription opioid pain pills on the black market.

 With the increased purity, heroin can be snorted instead of injected. Many people start using heroin by snorting, feeling that’s safer than injection. It probably is safer, but addiction being what it is, many of these people end up injecting heroin at some point.

 Heroin has become more socially acceptable. In the past, heroin was considered a hard-core drug that was used by inner city minorities. Now that rural and suburban young adults are using heroin, it may have lost some of its reputation as a hazardous drug.

Most experts in the field agree that much of the increase in heroin use is an unintended consequence of decreasing the amount of illicit prescription opioids on the street. But we are doing the right thing by making prescription opioids less available. Physicians are less likely to overprescribe and that’s essential to the health of our nation.

Now it’s critical that we provide all opioid addicts with quick access to effective treatment, no matter where they live.

The face of heroin addiction has changed. It is no longer only inner-city minorities who are using and dying from heroin; now Midwestern young men from the suburbs and rural areas are the most likely to be using and dying from heroin.

In the past, when drug addiction was seen as a problem of the poor and down-trodden (in other words, inner-city minorities), the general public didn’t get too excited. But when addiction affected people in the middle classes, there was a public outcry. The Harrison Act of 1914 was passed due to public demand for stronger drug laws.

I think the same thing will happen now. Suburban parents will organize and demand solutions from elected officials for this wave of heroin addiction. Indeed, I think that’s already started to happen.

Let’s make sure a big part of the solution is effective treatment.

Let’s make treatment as easy to get as heroin.

Case Study of an Opioid-addicted Patient: New England Journal of Medicine

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A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).

The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.

But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”

Huzzah!

But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.

As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.

A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”

I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.

This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.

After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.

In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”

Can I get an “Amen!”?

The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.

This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.

At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.

This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.

I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.

During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.

Project Lazarus in the Huffington Post

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In a nice article in the Huffington Post, Project Lazarus, located in Wilkes County, NC, was highlighted as an example of how a community can take action to prevent drug overdose deaths. Please check it out at: http://www.huffingtonpost.com/2014/03/05/project-lazarus_n_4889620.html?1394071210

Many people think Project Lazarus provides naloxone kits to reverse overdoses, and this is true, but they do much more than that. Project Lazarus has sponsored educational programs for doctors to learn to be more cautious when prescribing opioids, has sponsored medication take back days where old prescription meds can safely be disposed, and has worked with agencies and organizations across North Carolina and the nation to better inform doctors, law enforcement, and elected officials about what works to prevent drug overdose deaths.

Project Lazarus helped pass a Good Samaritan law North Carolina (see my post of April 20, 2013). Under this new law, a person who calls 911 to save another person’s life – or their own – won’t be prosecuted for minor drug possession, since they were trying to do the right thing and save a life by calling 911.

The Huffington Post article describes how the opioid overdose death rate has been falling in Wilkes County, while the overdose death rate in other parts of the country has been steadily rising. They credit Project Lazarus for this reduction in overdose deaths.

While I’m sure Project Lazarus has played a huge role in reducing overdose deaths not only in Wilkes County and the state of North Carolina, other factors have helped. Being an opioid addiction treatment provider, of course I believe availability of addiction treatment reduced deaths too.

Project Lazarus also supported the opening of an opioid treatment program in 2011, Mountain Health Solutions. Started by Dr. Elizabeth Stanton, this program initially offered only buprenorphine. As it grew, it became obvious some patients needed methadone treatment, so option became available by late 2011. Mountain Health Solutions was eventually purchased by CRC Health in 2012, and has continued to grow. Located in a small town, we have nearly four hundred patients.

I am honored to be the medical director at this program. It’s one on the best programs I’ve seen, and we work hard to keep improving our quality of care. Our program has done outreach -particularly in the medical community- to try to reduce the stigma of medication-assisted treatment. If you read my blog, you know this can be both a joy and a challenge.

Initially, Project Lazarus paid for an intranasal naloxone kit for every patient entering our opioid treatment program. Now since our patient census has risen, Project Lazarus still pays half of the $50 cost of the kits. The opioid treatment program pays the other half, out of a $33 admission charge for new patients. I feel lucky to be able to partner with Project Lazarus, as I’ve seen these kits save lives.

I know of four occasions when a naloxone kit saved a person’s life. Three of these four times, that person saved wasn’t even in treatment for opioid addiction.

Most recently, a parent used a kit to reverse an opioid overdose in a child who accidently ingested the parent’s medication. The parent called 911 and while waiting for EMS to arrive, used one of the two vials in the kit. The child partially woke, and started breathing better. Then EMS arrived and took the child to the hospital. This child survived a potentially fatal overdose and is back to normal with no lasting damage, thanks in part to that naloxone kit and a parent who knew how to use it.

Naloxone kits can be obtained much more cheaply, but contain Narcan vials, a more dilute form of naloxone that is meant to be injected. Those kits, which cost a few dollars, contain a syringe and needle instead of the Project Lazarus kit for nasal administration. Trying to inject naloxone into a vein is technically much more difficult than spraying the more concentrated form of naloxone up into the nose.

And unfortunately, a kit containing a needle and syringe would meet resistance from the public. I can imagine all sorts of angry phone calls to our opioid treatment program: “My son came to you people to get off the needle and you GAVE him a needle and syringe??” Politically, the public would more likely oppose distribution of a naloxone kit with a needle than a kit for intranasal use.

Fifty dollars for an intranasal naloxone kit to save a life is a pittance in the overall picture. Some insurance companies will cover these kits, as will Medicaid, but most of our patients have no insurance. They pay for their buprenorphine/methadone treatment out of their own pocket. Fifty dollars is a big sum for these patients.

I am blessed to work for an opioid treatment program that gets financial help from Project Lazarus for these kits. And I am very blessed to work for a for-profit company, CRC Health, which is willing to bear half the cost of the kits, since this comes out of their profits. Most opioid treatment programs do charge patients an admission fee, but unlike Mountain Health Solutions, don’t put that money towards buying a naloxone kits for their patients.

This is an example of the success that can happen when agencies work together toward a common goal.

Warning Warning Warning

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If you are still using heroin, or know someone using heroin, please heed this caution. SAMHSA (Substance Abuse and Mental Health Services Administration) sent out a notification last week, warning people that a deadly form of heroin is causing deaths in the Northeast.

Since the first of the year, thirty-none overdose deaths occurred in Pittsburgh and Rhode Island from heroin contaminate with fentanyl. Fentanyl is a powerful opioid, and kills opioid addicts accustomed to using heroin alone. Trends like these can spread rapidly, so if you are reading this and know someone who uses IV heroin, warn them about this deadly heroin.

When I first read SAMHSA’s notification, I wondered if I should put the warning on my blog. Being realistic, I know some addicts will think, “How can I get some of that? It sounds like good stuff!” That’s the insanity of addiction…people are dying from a variety of heroin and other addicts want to try the deadly substance, believing they can use without harm.

In the interest of harm reduction, I’m going to describe precautions that addicts, still in active addiction, can take to reduce the risk of overdose death. This information can be accessed at: http://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf

1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.
Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.
2. Get a naloxone kit. I’ve blogged about how one patient saved his sister with a naloxone kit. These are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/
3. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Your addict friends probably can tell you which pharmacies are the most understanding.
Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.
4. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
5. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The New England overdose deaths described by SAMHSA may have been avoided if the addicts had used smaller tester shots instead of shooting up the usual amount.
6. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
7. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
8. Opioid overdoses are much more likely to occur in an addict who hasn’t used or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
9. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
10. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can.

To people who believe I’m giving addicts permission to use, I’d like to remind them that addicts don’t care if someone gives them permission or not. If an addict wants to use, what other people think matters little. But giving people information about how to inject more safely may help keep the addict alive until she wants to get help.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org

Heroin Invades New England

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Last week the New York Times ran an article on heroin, describing how it’s infiltrated not only big cities, but also New England’s smaller towns and suburbs. http://www.nytimes.com/2013/07/19/us/heroin-in-new-england-more-abundant-and-deadly.html?pagewanted=all&_r=0
This Colombian heroin has a higher purity than users have seen in the past, meaning it can be snorted for an opioid high. Addicts who wouldn’t consider using a needle are willing to snort this heroin. And addiction being what it is, some of these addicts do eventually inject the drug.

In Maine, New Hampshire, Vermont, and Massachusetts, heroin is causing increased numbers of overdose deaths. Some experts say heroin is now being used by pain pill addicts. Since regulations around opioid prescribing have tightened, fewer (and more expensive) prescription opioid pills are diverted to the black market. Low-priced, high-grade heroin has been released into this void, creating ideal conditions for rampant heroin use. This Times article quoted law enforcement officials as saying they are seeing triple the number of overdose deaths from heroin this year as compared to several years ago.

Wow, I thought when I read the article. This is a bad situation, and it’s been brewing for years. Maine was one of the first states to see a sharp increase in opioid addiction and opioid overdose deaths around ten years ago. So of course, their conscientious state officials did the right thing, and worked together to assure evidence-based addiction treatment would be available for all who ….…oh wait. No.

No, that’s NOT what Maine’s state legislature did. In fact, they did the opposite. Duh.

Last year, Maine passed a law last year limiting Medicaid payment for treatment with methadone or buprenorphine. Against this backdrop of addiction and death, state officials decided to limit payment of treatment to two years of maintenance with either buprenorphine or methadone, and even made it retroactive to the date the patient started. After addiction medicine specialists decried the stupidity, not to mention the illegality of this, government officials backed off somewhat from their two-year limit. But the Maine legislature cut coverage and funding for opioid addiction treatment with buprenorphine and methadone in order to save money.

As I never seem to get tired of repeating: Medication-assisted treatment of opioid addiction with buprenorphine and methadone is one of the most heavily evidenced -based treatment in all of medicine.

Earlier this year, the American Society of Addiction Medicine, better known as ASAM, issued a public policy statement regarding pharmacological therapies for opioid addiction, which can be read in its entirety here: http://asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2013/04/25/pharmacological-therapies-for-opioid-use-disorders

ASAM’s statement says limitation of coverage for opioid addiction will cost lives. It will disrupt families and communities. It warns against limits on duration of treatment, number of times of treatment, and any other limit imposed by non-physicians on the medical care of patients with opioid addiction.

ASAM is a society of the most highly educated and experienced physicians who work in the field of Addiction Medicine. In other words, these are the best brains in the country when it comes to treatment of opioid addiction that exists in our nation. One would think that federal, state, and local governments would pay attention to what they had to say. One would think insurance plans would do the same.

The federal Mental Health Parity and Addiction Equity Act, passed in 2008, was intended to entitle patients with mental illness and substance abuse issues the same medical coverage as patients with other illnesses. Clearly the Act is being violated in Maine and other states, but so far the federal government hasn’t enforced the law.

I rarely advocate for the involvement of lawyers into any situation, as they can complicate the simplest of situations. However, here’s a situation ripe for picking. It’s going to take legal action by patients who have been denied federally mandated medical coverage to get the attention of insurance payers. This is against the law. This includes federal and state coverage as well as private insurance, because all have put some limits on coverage of the treatment of addiction.

It’s important to try to educate state legislators and to let them know you are watching to see if they are doing the right thing. But when they don’t do the right thing, maybe it’s time to call in the lawyers.

On the Horizon: Heroin Vaccine

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In a May issue of the Proceedings of the National Academy of Sciences, scientists at the Scripps Research Institute in California reported their success using a heroin vaccine in rats. The lead author of the study, Joel Schlosburg, works with Dr. George Koob, renowned and accomplished scientist who heads the team at Scripps.

This vaccine is still only in the animal phase of study. Scientists have developed a vaccine that stimulates the rat body immune system to recognize heroin and its metabolic byproducts. The immune system sees these substances as pathogens which must be got rid of, and manufactures antibodies against the compounds. After the antibodies bind to the heroin and its active metabolites, it gets further metabolized into harmless compounds that are eliminated from the body without ever crossing the blood brain barrier. In other words, the vaccine binding prevents this powerfully reinforcing opioid from ever getting into the pleasure centers of the brain to cause euphoria, or a “high.”

The first studies in rats are promising. This vaccine is postulated as a way to prevent heroin overdoses, since vaccinated addicts will no longer get euphoria from the drug. However, similar studies have been done with cocaine, and some human subjects could over-ride that vaccine by taking more cocaine, and were still able to get high. Dr. Koob says that with this new heroin vaccine, it would take a very large amount of heroin to over-ride the vaccine, or to cause an overdose. The rats in this heroin vaccine study didn’t try to load themselves with more heroin, a positive sign.

The vaccine wouldn’t affect opioid medications like methadone or buprenorphine, and so the heroin vaccine could theoretically be used along with these standard opioid addiction treatments.

Researchers took pains to make clear this vaccine is not a magic bullet. Once a vaccinated addict is subjected to cues associated with past heroin use, like being back in an old neighborhood, craving will still occur and the vaccinated addict may still use heroin in response to that craving, despite a lack of euphoria once it is used.

Also, it won’t be effective on most opioids contained in prescription pain pills. This means other opioids can still be useful if a vaccine-treated patient needs pain control… but it also means a vaccine-treated patient could still get high from non-heroin opioids. My fear is that a heroin addict would just switch to misusing prescription opioids.

Even with the vaccine, addicts still must have the psychosocial aspects of treatment in order to overcome addiction. It should be used as a part of a comprehensive treatment program.

Human trials may begin as early as the end of this year.

Schlosburg et.al., “Dynamic vaccine blocks relapse to compulsive intake of heroin,” Proceedings of the National Academy of Sciences of the United States of America, 2013 110 (22) 8751-8752.

Needle Fixation

I’m reading an interesting book that covers different aspects of injection drug use: the history of “recreational” drug injection, pharmacological aspects of injecting, social aspects, health complications, infectious transmissions, and something called “needle fixation.” The authors define needle fixation as “the habit of injecting compulsively,” where the process of injecting becomes as important or more important than the drugs. (1)

That chapter was particularly interesting. I’ve heard patients talk about how they are addicted not only to the drugs, but also to the ritual of drawing their drug up into the needle, and the act of injecting it. This chapter says not all addicts who inject develop this sort of intense relationship with the act of injecting. The authors wrote  a list of questions meant to assess the degree of needle fixation.

For each question, the addict can answer “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree,” or “strongly agree.” The more answers under the “agree” or “strongly agree,” the worse the needle fixation, except for questions 6 and 11, which are scored in the opposite direction.

Here are the questions:

  1. I inject water if I have no injectable drugs available.
  2. I enjoy the pain I experience when injecting myself or when injected by others.
  3. I think that I would find it more difficult to give up the act of injecting than to give up my preferred drug.
  4. I find the thought of injecting a partner sexually arousing.
  5. I am attracted to the needle because of the association with pain.
  6. If I could get the same rush without the hassle of using the needle I would give up injecting.
  7. I find the thought of being injected by a partner sexually arousing.
  8. Injecting water has a calming effect on me.
  9. I flush blood in and out of the syringe barrel before/after injecting the drug.
  10. I find injecting sexually arousing.
  11. If someone invented a method of taking drugs that gave me a better rush than the needle, I would give up injecting and use this.
  12. I continue to flush blood in and out of the syringe barrel even if there are blood clots.
  13. The act of injecting has become a substitution for sex for me.
  14. The preparation and process of the injection is more important to me than the drug rush.

The higher the score, the worse the needle fixation.

Apparently there’s sometimes a sexual aspect of injecting, or injecting your partner, about which I was clueless. The above questions indicate such a relationship. The authors of that section of the book talk about the symbolism of the needle (phallus), and the sadomasochistic side of the pain of the needle and the pleasure that follows with the drug intoxication. Part of me wondered about that last part.

I really wanted details about how I can help addicts on methadone or buprenorphine to lose the obsession and compulsion to use a needle. Unfortunately, the authors say no specific therapy or counseling technique has been proven to be superior to others. They do state the obvious, that the dose of maintenance medication (methadone or buprenorphine) should be high enough to prevent physical withdrawal.

Hopefully I can use this information to ask better questions, and get a better understanding about why people inject, particularly after they’re in treatment. Acknowledging the compulsion to continue using needles even when not in withdrawal will at least bring the issue into the open. Maybe it will help to know that other people have had this compulsion, and with counseling and time have been able to overcome it.

1. Pates et. al., editors, Injecting Illicit Drugs, (Mauldin, MA, Blackwell Publishing, 2005) pp 47-58.