Archive for the ‘Uncategorized’ Category

5 Year Blog Anniversary

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I never imagined my blog would be going strong after five years. Initially, I started it to promote I book that a wrote. The book did OK, but the blog has been so much more interesting and rewarding. I hope I’ve helped educate my readers, because they surely have educated me. I have a much better idea what’s going on out there in “addiction land.” My patients educate me about local trends, but blog commenters give a more universal view.

Thanks for reading and let’s continue our education of each other.

Goblins of Addiction

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Time for some whimsy…

Misery and Deceit, two goblins who worked for the Emperor of Wretchedness, were talking in a dark alley. Hopeless, another goblin, had just left them and was shuffling down the street, trailing the stench of sulfur.

“Idiot,” said Misery, speaking about Hopeless. “He couldn’t stop his human from getting help for addiction. What an incompetent. Doesn’t he realize that addiction must continue so we can make these humans miserable? Addiction is a key method to keep people in our Kingdom of Wretchedness”

The other goblin, Deceit, fancied himself a guru to the younger and less experienced dark spirits like Misery, Despair, and Hopeless. He smiled as he thought about how much wiser he was than the others. After all, he had been the original dark spirit to help lead most humans to addiction. He promised these humans that drugs would allow them feel good all of the time. He promised freedom from the usual ups and downs of a normal human life. Many times, they believed him.

“Well, now, Misery, when you’ve been around as long as I have…” Deceit started.

“Yeah yeah. Whatever. But what advice can we give the poor fellow?” Misery really didn’t feel like listening to the bombastic Deceit blather on again, and cut him off with a question.

“There are things to be done. After all, his human, Joe, entered treatment at a methadone clinic. As you know, in his part of the country, many people have bad opinions about that kind of treatment. Especially if they know nothing about it.” Deceit began laughing, but the laugh ended with a phlegm-producing cough. Ironically, Deceit was strongly addicted to cigarettes, though he kept saying he could quit when he wanted.

“I’ll call on poor Hopeless, and give him some advice. That would be gracious of me.” Deceit said. In his mind, Deceit finished the sentence with, “And he would owe me a big favor.” The dark spirits kept careful tallies of who owed a favor to whom, and often fought bitterly about this.

“All right, great. I’ve gotta go.” Misery was sick of this conversation, and wanted to get away. Misery was never happy with where he was, and always wanted to be somewhere else, which made it difficult to have a conversation with him.

Later that week, Deceit knocked on Hopeless’s door. It was smudged with some dirty substance. Hopeless believed cleaning house was hopeless, as it only got dirty again. Deceit’s knuckles were black with the stuff. As he was wiping the filth off his hand, Hopeless answered the door. It looked as if he’d been crying, as his eyes were red and there was mucus sliding from his nose. “Hello Deceit. Come on it. I’ve been feeling down this week after my failure with my human, Joe. Sometimes I feel like I’ll never get anything right. And of course I’ll be blamed for it all.” Hopeless sighed dramatically as he said this last part, feeling very sorry for himself.

“I’ve come to help you. I have much sound advice to give you, so let’s sit and talk for a while.”

“OK. But I doubt it will work.”

Deceit ground his teeth at Hopeless’s predictable self-pity. Of all the dark spirits, Deceit thought Hopeless was the least pleasant to be around.

“It will work,” Deceit said more emphatically than he felt. “The key is to use the people around your human to discourage him in his recovery.”

“For example, Joe’s wife is happy that Joe is no longer spending $100 a day for pain pills off the street, and she’s happy he’s no longer snorting them. But she won’t be happy if you can convince her that methadone is a dangerous drug. Suggest she look on the internet. She’s sure to find negative and untrue information. But keep her off legitimate websites. You don’t want her to learn any of the benefits of methadone. Keep her on the more emotional sites, where people write about their beliefs, and not actual facts. And be careful she doesn’t understand the distinction between methadone bought on the street and methadone dosed each day as prescribed by a doctor. Try to get her to hysterically demand of Joe that he “get off that stuff.”

“Or you can use his friends. Have them call him a weakling for wanting to quit drugs, and
how foolish he is to go to the clinic. Tell him that the clinic only wants his money. Be careful not to remind Joe that all medical treatments cost money. Convince him his addiction treatment should be free. After all, he is giving up drugs. Maybe you can even get him to thinking people should pay him to give up his drugs.”

Hopeless began to mewl about the impossibility of such things, but Deceit cut him off again.

“You can get an addict to believe all kinds of outrageous nonsense. Oh, and keep him from remembering that some of these same so-called friends have sold him pain pills. We don’t want Joe to perceive that these people want to keep a good customer.”

“Get him to go to a family doctor who’s uneducated about methadone treatment. Even if he’s seen for an unrelated medical problem, these docs sometimes will give deadly advice to such patients. Some of these doctors tell their patients to get off methadone as soon as possible.”

“What, his doctor wants him dead? Surely not.”

“Oh no, but many of them aren’t well-educated about the treatment of addiction. So if you can get Joe in with one of these doctors, we have the delight of watching a medical professional, who should know better, give bad advice to one of our humans. If Joe follows that advice, it will be easier for us to steer him back into addiction again. And then if Joe relapses, and tells his doctor about it, the doc is likely to shame him for relapsing. You see how funny it gets to be? He wouldn’t have relapsed but for the doctor’s bad advice….” Deceit trailed off, smiling at fond memories of previously amusing times.

“I don’t know. Joe doesn’t seem to be listening to me, or his old friends. He used to be easy to lead with a suggestion or two. Now he wants to stand up for himself. He says he feels good and isn’t using drugs for the first time in years. It feels hopeless to try to convince him he’s doing a bad thing.” Hopeless shook his head and squinted at the floor.

Again, Deceit felt a great surge of annoyance at Hopeless’s attitude. “Then you must undermine his confidence. Have you had no training in that sort of interference? Tell lies, and plenty of them, before he gains even more confidence. His mind must be turned against him. I’ll get one of my friends to come and help you. His name is Denial, and he’s an expert at convincing such humans that their lives in addiction really weren’t that bad. How about I send him over here later today so you two can make a plan?”

“You can send your friend Denial, but I doubt there’s much that can be done…”

Shortly after this somewhat unsatisfying end of their conversation, Deceit waddled home. (He was very fat, having fed on the misery of humans for millennia). He knew this was not a hopeless situation, because he’d seen many recovering addicts, patients of methadone clinics, who had been shamed into stopping their treatment. It was entertaining to watch a person, leading a normal life but for dosing each day with methadone, slide back down into the darkness of active addiction once he left treatment. Quite often, goblins of the underworld used the twisted fears and inaccurate beliefs of the people who said they loved the addict to aid in the addict’s downfall.

Entertainment in the underworld didn’t get any better than this!

(…inspired by The Screwtape Letters by C.S. Lewis)

Harm Reduction

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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

Just for Fun

Holiday 2014

I’d like to wish all my readers a Happy Thanksgiving, whether you are in the U.S. or in another country.

To celebrate at my opioid treatment program, we all decided to dress up as either Pilgrims or Native Americans. You can see from the picture above that no one actually came as a Pilgrim (although a few said they were dressed as descendants of Pilgrims). I guess everyone had clothing more suitable to be a Native American.

I participated a little reluctantly, but I’m glad I did. This is a fun group of people that I work with. To a person, they are dedicated to helping their patients recovery from addiction and achieve their goals. They are passionate about their work, and even though they come from very different backgrounds, work together well as a team. I am honored and blessed to be able to work with them.

I am so thankful for my co-workers and the wonderful patients that we serve.

I’ve said it before…I have the best job in the world.

NSDUH Data Released

NSDUH Data on Heroin Use

NSDUH Data on Heroin Use

Each fall, the National Survey on Drug Use in Households releases data from their yearly survey, and data from 2013 is now being released. It’s a gradual process, with more information released as data is analyzed and compared to years past.

The NSDUH report compiles data collected about drug and alcohol use in the nation and in individual states. This annual survey of around 70,000 people in the U.S. over age 12 also collects data on mental health in the U.S. This research information is collected from phone calls to individual households and is the primary source of data on the abuse of drug including alcohol in the U.S. Data can be compared to past years to look at drug use trends, among other information.

Since this survey is conducted on household members, some scientists say the data underestimates drug use since its methods exclude populations living in institutions such as prisons, hospitals and mental institutions. Such populations are known to have the highest rates of drug use and addiction. But the annual NSDUH report is still one of the best sources of information we have at present. This data can be evaluated for new trends of drug use and abuse, and can help direct funding toward problem areas. Researchers use this data to assess and monitor drug use, as well as the consequences.

Data from 2013 shows that around 9.4% of U.S. citizens use illicit drugs at least monthly. This includes marijuana, cocaine, heroin, hallucinogens, and misused prescription medication. This rate of use hasn’t changed much over the past two years, but it’s a little higher than it was ten years ago.

Of the people who used illicit drugs at least monthly, two thirds used marijuana as their only illicit drug. Marijuana, not surprisingly, is still the most frequently used illicit drugs in the nation. This percentage of people using marijuana has been slowly but steadily increasing over the past ten years. Interestingly, the number of people surveyed who said they were daily or near-daily users of marijuana increased from 5.1 million in 2007 to 8.1 million in 2013.

I do not see this as a good thing, but my blog is dedicated to opioid addiction and its treatment, so I’ll let you make up your own minds about marijuana.

I was happy to see that non-medical use of all prescription medication continued to drop, though slowly, down to 2.5% of the population. Non-medical use of prescription opioids specifically has also shown a slight drop from 2009 to 2013. I hope this means people (and their doctors) are beginning to understand the dangers of illicit opioid use. Tranquilizer use also has shown a slow decline over the past three years, a trend I hope will continue.

Of the group of people who said they were non-medical users of opioids, over half still said they obtained their drug from friends or family, for free. Around 11% bought their drug from a friend or family member, and 21% got the drug from one doctor. Only 4.3% said they got their prescription opioid pills from a drug dealer or a stranger, and only .1% bought them off the internet.

This data tells us – again this year – that the main suppliers of illicit opioids aren’t drug dealers on the corner or dealers over the internet. Main suppliers are friends and family members of the user.

Why is this still a thing people do?? This has got to stop. Sharing medication, controlled substance or not, is dangerous – not to mention illegal. Sharing medication causes harm. You aren’t helping anyone by sharing.

The youngest age group surveyed, aged 12 to 17, showed a drop in the non-medical use of prescription opioids over the last decade, from 3.2% in 2003 to 1.7% in this 2013 survey. That’s reason to hope that youngsters now either have less opioids available to them or that they know how damaging opioid addiction can be. I hope this drop forecasts an overall drop in the number of people addicted to opioids in the coming years.

Now for the bad news: NSDUH shows that heroin use continues to rise, from around 373,000 people in 2007 to 681,000 people in 2013. That’s not quite a doubling over the past six years, but pretty close. That strongly correlates with what I see at my work; people addicted to opioid pain pills tell me it’s harder to find opioids, and also more expensive. Mexican drug cartels have seen this, and moved in to supply heroin as an alternative to opioid pain pills.

It’s an unintended and unfortunate consequence of efforts to limit illicit prescription opioid use.

This 2013 survey showed that there were an estimated 2.8 million new users of illicit drugs in people over age 12. Over 70% of these new illicit drug users started with marijuana. Only about 13% of new users started with non-medical use of opioid pain pills, and this is a lower percentage than in past NSDUH surveys.

This NSDUH data will be released in other reports as more analysis is done on this information.

Kratom: Useful for Drug Addiction?

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I had a blog comment from a reader who advocated for kratom as a cure for opioid addiction, and thought it would be a good topic to cover with a full blog post.

Kratom (also called ketum or kratum) is a tree in the genus Mitrogyna, which is related to the coffee tree, and found in Southeast Asia. Kratom leaves have been used for thousands of years by natives of the area to produce stimulant and opioid effects. Fresh leaves can be chewed, or broken up to make a drink, or steeped in hot water to make a tea. Dried leaves can be smoked by users, who say low doses of kratom cause a stimulant effect. Higher doses are said to cause sedation.

Kratom’s active ingredient is mitragynine, an opioid agonist. Mitragynine activates the mu opioid receptor in the human brain to cause an opioid-like effect. Like other opioids, this compound in the kratom tree relieves pain and causes euphoria. Some rat studies demonstrated more potent analgesia from mitragynine than morphine. It’s structurally different than other opioids, and unlikely to show as an opioid on drug testing.

Because of its opioid-like effects, kratom can be used recreationally for the high it produces.
If you google “buy kratom,” more than a million websites appear, offering to sell all sorts of varieties of kratom, and extolling its properties of, “Pain relief, Energy, Prolonged Sexual Intimacy, and Mood Support.” You can buy capsules, dried leaves, and plant extracts. Because of this recreational use, governmental agencies in the U.S. have been reluctant to fund studies on this drug.

Users and marketers of kratom say it’s an herbal pain medication that’s safe and effective.
Sadly, many people accept the idea that “herbal” and “natural” means “safe.” Not so at all. Some of the world’s most potent poisons are found in nature. Hemlock, belladonna, and cyanide leap to mind. And there’s no way to know what exactly you are buying on the internet. It may be kratom, ….or it may be nightshade.

Assuming a person does buy real kratom off the internet – is it harmful? Probably about as harmful as other opioids, though rat studies did show less respiratory depression than other opioids. That may be due to kratom’s activity at the kappa opioid receptor. This drug also has adrenergic and serotonergic activity, so it has a complicated method of action. The increased adrenergic effect of the drug may give users a feeling of energy, like the other stimulants cocaine and amphetamines. This property has led some people to say kratom could be a treatment for methamphetamine addiction.

Chronic and continued use of the kratom leaf can cause opioid dependence, with opioid-type physical withdrawal symptoms when stopped. However, at least one case report showed less physical withdrawal than expected when a heavy user suddenly stopped kratom after having a seizure. [1] There’s talk on internets sites of using kratom as a treatment for opioid addiction, but no scientific literature or human trials have been done.

Mitragynine from the kratom tree has intriguing possibilities for use in the medical world, but we won’t know unless scientific studies are done. Until then, it would be dangerous and irresponsible to recommend use of this product, especially if it’s bought off the internet with no way to know what you are buying.

I hope researchers will explore this drug to see if it has potential to help patients with opioid addiction. For now, there’s not enough evidence to be able to recommend kratom’s use for any purpose.

Even if the compound mitragynine in kratom shows efficacy in clinical trials as a pain reliever or opioid addiction treatment, it shouldn’t be ingested in unprocessed plant form. We don’t have people in pain chew on an opium poppy seed pod, or heart patients chew on the foxglove plant to get their digitalis, and doctors won’t recommend use of kratom in the plant form. Let’s purify the drug in kratom, mitragynine, study it, and produce it as a medication in standardized doses with quality control if it’s found to be effective.

1. http://www.scientificamerican.com/article/should-kratom-be-legal/

Criminally Pregnant

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I usually don’t post a new entry so soon after the last, but this topic is time-sensitive.

I’m getting tired of writing about Tennessee’s crazy politicians but this time their insanity is so egregious that I can’t let it pass without comment.

The Tennessee house and senate passed a bill that allows a woman to be criminally charged if her baby is born drug dependent. If their Governor Haslam signs this bill, it will become law.

As we know, Tennessee has a terrible opioid addiction problem with one of the highest overdose death rates in the nation. Opioid addiction afflicts men and women in nearly equal numbers, and most of those women are in their child-bearing years. Thus, Tennessee has many pregnant women who have the disease of drug addiction.

Naturally, hospitals have seen a growing number of infants born with opioid withdrawal. Small rural hospitals may not have physicians who are educated about how to treat these babies. It’s a frightening situation, and the response is fear-based: make drug use during pregnancy a crime.
Politicians promote draconian laws that will punish these women, who are probably the most vilified segment of society, and gain favor with voters who don’t understand the underlying issues.

So now Tennessee has a law that makes getting pregnant a crime, if you have the disease of addiction. (By the way, there are other illnesses that can harm the fetus if the mom becomes pregnant, but we have no laws making pregnancy illegal for those patients.)

Supporters of this new insane law probably say it should encourage pregnant addicts to get help before their babies are born. That could be true, if Tennessee had adequate treatment programs in place. As we know, methadone and buprenorphine are the best treatments for opioid-addicted pregnant women, yet under this law, this gold-standard of treatment may also be considered illegal.

So should pregnant moms “just say no” and stop using opioids? We know that going through opioid withdrawal while pregnant is associated with bad outcomes for mom and fetus, what with increased risks of preterm labor, placental abruption, and low birth weights. Over the last fifty years, multiple studies repeatedly show better outcomes when you maintain the mom of a stable dose of methadone, or more recently buprenorphine, during the pregnancy.

If this bill is signed into law by Tennessee’s governor, we can predict what will happen.

After all, what would you do, if you are a pregnant addict and know you will be prosecuted if anyone discovers you’re drug user? You avoid prenatal care. Maybe you get an abortion, even if you really want a baby, because you don’t want to go to jail. Maybe you try to stop using opioids on your own, go into withdrawal, and have one of the complications we know to be common in such a situation. Maybe you have preterm labor at 30 weeks and your baby ends up in the intensive care unit for many months. Worse, maybe your baby doesn’t make it. Or your baby does make it, but is taken away from you at birth, because authorities say an addict can’t care for a baby. Your baby enters the foster care system, with its pitfalls.

In short, this law discourages medical care in the very population of women who can benefit the most from medical care and treatment of addiction!

But wait…this law says the woman can be charged if the baby is born dependent. What about pregnant women who smoke? The infants are technically dependent on nicotine, so that meets this law’s criteria. These women can also be criminally charged. Probably Tennessee would have to build a new jail just for those women, and of course Tennessee’s taxpayers would be happy to pay for their incarceration, right?

In the past, laws against drug use in pregnancy have been unevenly implemented. If you look at the cases that have been prosecuted, nearly all involved poor, non-white mothers. Maybe that’s because law enforcement knows that people of higher socioeconomic status can afford hire a lawyer to defend themselves against these ridiculous laws, which always get struck down on appeal, though that can take years.

Policies that inflict criminal penalties on pregnant women with the treatable disease of addiction cause harm to everyone. Hospitals have higher costs when a mom with no prenatal care arrives on their door step ready to deliver, with much higher rates of perinatal complications. Taxpayers end up paying the high costs of incarceration for these women. But most of all, the babies and their moms are harmed.

Let Governor Haslam know how you feel by writing to him: bill.haslam@tn.gov or call at: (615-741-2001)

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