Summer House
Drug dependence is a universal public health problem of which opioid dependence, notably involving heroin and morphine are a major component. In Europe alone, there are an estimated 1.1 million intravenous drug users and the number is estimated to be at least 3 times that many in North America. The majority of these individuals remain untreated. Opioid dependence is a chronic relapsing medical condition that requires long-term treatment and patient support. In addition, many of these intravenous drug users share syringes and needles, a practice that can lead to the transmission of serious blood-borne infections including human immunodeficiency virus (HIV), hepatitis B and hepatitis C.
Currently opiate dependence treatments like methadone can be dispensed only in a few centers that focus in addiction treatment. There are not enough addiction treatment clinics to assist all patients seeking treatment. Suboxone is the first narcotic drug available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed by a physician. Hopefully, this advance in therapeutics will provide more patients the opportunity to access treatment.
Suboxone (buprenorphine with naloxone) is currently available for the maintenance treatment of opioid addiction. The intention of adding naloxone to the formulation is to deter intravenous misuse and reduce the symptoms of opiate dependence. Suboxone treatment is intended for use in adults and adolescents more than 16 years of age who have agreed to be treated for addiction.
Once detoxification of the individual is completed, Suboxone is used during the maintenance phase of treatment. Suboxone has recently become the drug of choice instead of methadone in the treatment of opiate addiction. Suboxone use is less rigidly controlled than methadone because it has a lower potential for abuse and is less dangerous in an overdose. As patients progress on therapy, the physician may write a prescription for a take-home supply of the medication.
Suboxone Prescription
Only those physicians who have approval from the Drug Enforcement Agency (DEA) are able to start in-office treatment and provide prescriptions for ongoing medication. The Center for Substance Abuse Treatment (CSAT) maintains an active database to help patients locate qualified doctors.
Route of Administration
Suboxone is available as a tablet which is always administered sublingually. The pill is placed underneath the tongue until it is fully dissolved. Swallowing or sucking on the pill does not offer any therapeutic benefit. When placed underneath the tongue, the pill dissolves and is absorbed in 10 -20 minutes.
Suboxone treatment is generally done under medical supervision. During the induction phase, one is taught how to properly take the medications and dose adjustments are done during the phase. One is usually started on the smallest dose until the best therapeutic effect is obtained. Once the ideal dose is obtained, the individual is seen once in a while and prescriptions can generally be available from the same physician.
Suboxone is available as 2 and 8 mg tablets. Most anecdotal reports indicate that the response to the 2 mg dose is suboptimal. The majority of individuals report benefit at higher doses of 8-16 mg. The aim of the maintenance treatment is to rid the drug craving and decrease the anxiety. The dose is usually adjusted until the drug craving features are diminished.
Since Buprenorphine is a Schedule III drug, the physician is only allowed to prescribe 5 refills in 6 months.
Maintenance therapy
Although Suboxone can be used for detoxification, its intended use is for maintenance. The ideal candidate for maintenance therapy with Suboxone is an older individual who has previously been on drugs but now has a job and wants a stable lifestyle. The individual previously has failed detoxification and wants to live a simple life without the daily cravings of his previous addiction. The majority of past drug users immediately adjust to Suboxone as the cravings disappear immediately and a smoother life style are accessible.
Suboxone Control
Because of the great potential for abuse, FDA works closely with the drug manufacturer, Reckitt-Benckiser, and other agencies to develop an in-depth risk-management plan. The FDA receives quarterly reports from the manufacturer and pharmacies and maintains a comprehensive surveillance program. This monitoring allows for early detection of abuse of the drug. The major components of the risk-management program are preventive measures and surveillance. Preventive measures instituted include drug education, tailored distribution, Schedule III control under the Controlled Substances Act (CSA), child resistant packaging and supervised dose induction. The program regularly monitors local pharmacies and web sites. Numerous other agencies also monitor the abuse of Suboxone and these include:
-Drug Abuse Warning Network (DAWN). This agency run by the Substance Abuse and Mental Health Services Administration (SAMHSA) gathers data from emergency rooms related to the illicit use of drugs or non-medical use of a legal drug.
-Community Epidemiology Working Group (CEWG). This agency monitors the use of buprenorphine.
-National Institute of Drug Abuse (NIDA). NIDA frequently sends newsletters to physicians about the addictive drugs and to report it if necessary.
Side Effects
The most common reported side effect of Suboxone includes:
- Cold or flu-like symptoms
- Headaches
- sweating
- insomnia
- Nausea
- Mood swings
- Pain
- restlessness
Like other opioids, Suboxone have been associated with respiratory depression (difficulty breathing) especially when combined with other depressants.
Cautions
Intravenous use of Suboxone usually in combination with benzodiazepines or other CNS depressants has been associated with significant respiratory depression and death. Suboxone has the potential for abuse and produces dependence of the opioid type with a milder withdrawal syndrome than full agonists. There are no adequate and well-controlled studies of Suboxone use in pregnancy. Due caution should be exercised when driving cars or operating machinery.
Alcoholism Treatment Programs and Interventions Jul 09, 2008
Close to a million Americans are treated for alcoholism on a daily basis. For the past 3 decades, the majority of treatments have been empirical and the success of the treatments has never been verified by clinical trials. The numerous methods developed in the treatment of alcohol addiction include the use of medications, psychological, social, behavioral methods and self help groups- all designed to help achieve abstinence from alcohol.
The initial approaches to alcohol treatment were all based on self help and over the years the 12-step self help program has become the gold standard. Other treatments include brief interventions by visiting the primary care physician or trained nurses. Behavioral and psychosocial support therapies have evolved over years and generally involve long term therapy. Over the last 2 decades, motivational enhancement therapy and involvement of the non-drinking spouse have evolved and produced good results.
Of course, over the past 4 decades, pharmacological approaches to alcoholism treatment have made some progress, but the ideal drug still remains to be discovered.
Alcoholism Treatment
The majority of individuals with alcohol dependence initially always deny that they have a problem and are reluctant to undergo therapy. Agreeing to undergo alcohol treatment usually occurs after the individual encounters health, family, employment or legal problems. Depending on the situation of the individual, various treatments are available to help with alcohol dependence. The initial part of the treatment involves evaluation, a brief intervention and either an in/outpatient program or counseling.
Principles of Alcohol Dependence Treatment
Before alcohol treatment can begin, one has to determine if the individual is alcohol dependent. For some who drink socially and are in control over their drinking, treatment may simply require reduction of drinking<. For those who have no control over their drinking, the best treatment is abstinence.
To maintain abstinence, the best approach is to be included with alcohol abuse therapists. These specialists can help develop specific-tailor made treatment plans, which may include objectives, behavioral modification skills, use of self-help manuals, counseling and follow-up care at a treatment center.
Non Drug Residential treatment programs
There are numerous non-drug residential alcoholism treatment institutions and include therapy to maintain abstinence, individual and group therapy, participation in alcoholism support groups (such as Alcoholics Anonymous), educational seminars, spousal involvement, work assignments, physical and non physical activity therapy. Most of these residential programs have professional counselors and staff involved in the treatment of alcohol dependence.
All individuals undergo a complete physical and medical assessment prior to therapy. The essence of all residential programs is to commence detoxification and treatment of withdrawal symptoms that may occur. Hard-hitting psychological counseling and psychiatric treatment is offered to individuals, couples and their families. The principal emphasis of all residential programs is on recognition of the problem and motivation for abstinence. Individuals who are unable to fulfill this basic criteria usually do not succeed with therapy.
Psychological, Behavioural and Social therapy
Numerous behavioral approaches to alcohol dependence treatment include psychological therapy. The primary component of these therapies is motivational enhancement therapy. This therapy is designed to help the individual become more responsible and develop a change in his lifestyle.
Various forms of counseling are available and may involve cognitive behavior therapy to help cope with distorted/abnormal thoughts and help develop a sense of control over these thoughts and feelings.
The majority of pychological therapies often involve the non-alcoholic spouse as most studies show that couple participation increases the likelihood of abstinence from alcohol. Behavioral –marital therapy is a combination of an approach to drinking treatment while strengthening the marital relationship through sharing, teaching and communication skills
Self-Help Programs
The most common self help group in the treatment of alcohol dependence is Alcoholics Anonymous (AA). This is one of the most common and easily available group in any community.
Alcoholics usually get involved with AA before seeking professional help, as a part of it, or as aftercare following professional treatment. Although anecdotal data on the success of AA are plentiful, results indicate that inpatient treatment, a combination of professional treatment and AA, will achieve better results for more people than AA alone. The reason why AA has been beneficial as a treatment for alcohol addiction includes isolating the individual from his social network of alcoholic friends, providing psychological/social support, teaching coping skills and structured behavior treatment.
Physician intervention
Some indivuals receive counseling from primary care physicians and trained nursing professionals. This consists of numerous office visits and counseling. The majority of these brief interventions help those with acute alcoholic crises. Following the brief intervention, all individuals are recommended to enter specialized treatment programs if the alcohol consumption continues.
Drug Treatments
Disulfiram (Antabuse) is an alcohol-sensitizing drug which has been around for at least 40 years. It was the first drug used for aversion therapy. It provides a strong deterrent to alcohol. It is not a cure and does not decrease the craving for alcohol. If taken before an alcoholic drink, it causes a severe reaction that includes nausea, vomiting, facial flushing and headaches. The drug is rarely used today as the severe reaction is not tolerated and most alcoholics are reluctant to take it.
Naltrexone (ReVia), is an antagonist of morphine and has been found to decrease the urge to drink. As is the case with all addiction disorders, however, naltrexone is only effective if taken on a regular basis.
Acamprosate (Campral) is a drug that decreases alcohol cravings and helps maintain abstinence from alcohol. Unlike disulfiram, naltrexone and acamprosate have fewer side effects and do not produce serious nausea and vomiting if alcohol is consumed.
Recently, the Food and Drug Administration (FDA) approved the first injectable drug to treat alcohol dependence. Vivitrol, a drug similar to naltrexone is administered by an intramuscular injection in the buttocks monthly. It has been shown to decrease the urge to drink by blocking neuro receptors/transmitters that may be coupled with alcohol dependence. Vivitrol has no effect on the withdrawal symptoms due to alcohol. The drug is recommended for use by alcoholics who are undergoing psychosocial therapy and have not consumed any alcohol in the recent past. The drug is also available as a pill, but it has been found that the injectable formulation is easier for individuals recovering from alcohol dependence and only has to be administered once a month.
Even though some drugs may reduce alcohol drinking, it is highly recommended that individuals enter in aftercare programs and prop up groups to help prevent relapse and encourage motivational behavioral and life style changes.
Conclusion
Research supports the idea of using drugs as an adjunct to the psychosocial/behavioral therapy for alcohol abuse and dependence. However, additional clinical trials are needed to identify those patients who will most likely benefit from such an approach, to determine the most appropriate medications for different individuals, to develop optimal dosing formulas, and to develop strategies for improving patient compliance with medication protocols.
With continued research on the effect of alcohol on the brain and behavior, hopefully this will lead to the magic pill. Drugs to decrease alcohol craving are around but specific medications are still missing. In the meantime, the combination of drug therapy and the use of behavioral therapies are the best hope for recovery of the individual -and the lives of loved ones-who suffer from alcohol abuse and dependence.
Addicts Seek Solace in Delray Beach Jul 09, 2008
Miami Herald — Most everybody in this neighborhood coffee haunt has been hooked on something. The high school dropout with beauty-pageant looks has been fending off a heroin habit for two decades. The former football player says he is clean now after years of popping pain pills. Santa Claus succumbed to alcohol.
Nineteen of the fallen are here tonight for therapy and healing, for a second — or a third or fourth — chance, hoping to reclaim a piece of their lives. They form a circle in the pebble garden behind KoffeeOkee, which is owned by Harold and Dawn Jonas, former users who now help others kick drug and alcohol habits and answer the question: What now?
A resort on the Atlantic in Palm Beach County, Delray Beach has another, less obvious civic profile: Florida’s sobriety capital. Like Hazelden in Minnesota and Utah’s Cirque Lodge and the communities that surround them, it is a place to dry out, clean up. Its recovery community is spirited and multilayered, a dense mesh of dozens of treatment facilities, counseling centers and residential housing that gives addicts a wide-reaching chance for recovery and permanent lifestyle change.
This is where people start over. And sometimes stay.
”You want to be here if you are struggling with an addiction,” says Anna O’Connell, 43, who has been in and out of detox for crack cocaine, heroin and alcohol over the past 20 years and attends therapy sessions at KoffeeOkee. “This is the closest thing to family; this is where you feel safe.”
Treatment for addictions that the medical community now accepts as chronic diseases ranges from private $10,000-a-month treatment centers to free coffee, counseling and karaoke at java houses such as this one, which hosts formal therapy sessions twice a week and informal gatherings even more often.
MANY, FROM ALL OVER
The size of South Florida’s recovery community is difficult to estimate because only one layer — facilities with residential treatment beds — is licensed by the state. Delray Beach alone offers more than 1,200 beds in transitional houses — a second layer — according to the South County Recovery Residence Association in Delray, which monitors halfway residences.
Every week in Delray, about 5,000 addicts attend 12-step meetings that stretch from 7 a.m. to 11 p.m. At Crossroads Club, a squat stucco complex off Lake Ida Road, about 700 people walk through the doors every day to attend 120 meetings aimed at a swath of needs, from treatment for cocaine addiction to obsessive cluttering, says Susan Miller, executive director, a recovering alcoholic.
Addicts arrive from as far away as Oregon and Rhode Island and from as nearby as South Beach. They face daunting odds: Relapse rates range from 40 to 90 percent, depending on the client’s dedication and will power, sustained treatment, and follow-up care, according to the National Institute on Drug Abuse.
”My parents sent me here to try to turn my life around,” Rani Canosa, 21, a pretty, petite college dropout offers one Monday night at KoffeeOkee. “Alcohol made me feel good. I would be really, really happy, then really, really sad, then just miserable.”
Canosa, from a Baltimore suburb, started drinking seriously as an 18-year-old freshman in college. Soon she could consume a 12-pack of beer and a half-bottle of vodka in a two-hour stretch.
She had tried treatment centers in Maryland and Pennsylvania but returned home only to relapse once she was back among friends and familiar haunts.
Canosa has been in Delray Beach since Aug. 29, out of treatment at the Wellness Resource Center in nearby Boca Raton since Feb. 5. She lives in a halfway house and works as a barista at KoffeeOkee.
”The truth is, if I was home, I would be drunk or looking to get drunk,” she says softly, never making eye contact. “I actually want to be here.”
COLLECTIVE STRUGGLE
But what distinguishes this vibrant recovery community from similar places elsewhere, is a growing sober social infrastructure, an informal network of places for people to mingle without the colossal temptations of drugs and alcohol.
”Delray Beach is a microcosm of the various layers of the recovery process,” says Howard Lerner, clinical director of the Addiction Treatment Program at South Miami Hospital. “Those struggling belong to a fraternity.”
Here, even in the midst of fighting for sobriety, addicts can go dancing at popular clubs that hold sober nights, sing karaoke at a sober coffee house, listen to live music at a sober juke joint, call in to recovery radio shows, roar into the sunset with a sober motorcycle club and pray at a Bible study just for them.
”The struggle with an addiction can be forever,” says Harold Jonas, a mental health counselor. “So all we really want is for people to be healthy and to laugh and have hope and be part of the world, not just the recovery community.”
The collective sobriety struggle here is no longer anonymous. Recovering addicts live among ”normies” and often work on Atlantic Avenue, the city’s glittering ribbon of sidewalk cafes and boutiques and galleries.
”When you are on this journey, it’s incredibly important to feel like you are not alone, to see and be around people just like you,” says nattily-dressed Jonah Yolman, now 22 months on the clean side of a wicked crack-cocaine addiction.
Yolman, 29, sitting in a Starbucks on Atlantic Avenue, quietly acknowledges two people ordering coffee who are in one of the dozens of 12-step anonymous programs. He talks casually about the familiar identifying signs of people in recovery: the relentless smoking and coffee drinking, the trails of cigarette butts and empty coffee cups and candy wrappers. And the most obvious sign: people tightly clutching books with dark covers, their 12-step guides.
”We are everywhere, living and working in this city,” says Yolman, a counselor at a local treatment facility who promotes two sober nights at area clubs. He and a partner are also launching a similar sober club night in August at a South Beach club (sobernightlife.com).
“People come here and enjoy the weather, the beaches, low-key atmosphere and try to start over.”
NATIONAL REPUTATION
In some ways, Delray’s recovery community draws its inspiration from a small, rural town in Minnesota that over the years became a magnet for recovering addicts, from marquee rock stars like Eric Clapton to the anonymous souls who came looking for peace and order.
Since 1949, addicts have famously flocked to Hazelden, which started as a farmhouse retreat in Center City for men working their way through programs based on the 12-step principles.
Over the years, teams of doctors, counselors and chaplains developed a holistic approach to rehab now emulated worldwide.
More than three decades ago, Delray’s first sober houses opened for people making the transition from residential care to independent living. The houses — a yellow clapboard with a sweeping porch on one street, a peach bungalow with a white-picket fence on another — are sprinkled within neighborhoods, around public squares, near churches.
Rents range from $125 to $175 weekly for a room and access to kitchens and family areas. Most landlords require random drug tests, and some perform bed checks or monitor whether their clients have reported to work.
Two years ago, Crossroads Centre in Antigua, a drug-treatment program founded by Eric Clapton, opened in the city. And in February, Lecreshia Hall, a Boca Raton psychiatrist, started Hallway of Life Recovery Center, a faith-based, 28-bed transitional facility for women, on a quiet residential street near downtown.
”When I did the research to find the best place to open, Delray Beach kept coming up,” says Hall, who leads Bible study on Tuesdays. “The idea of our center is to teach our clients how they can use the Bible to help in recovery.”
But Delray Beach’s national reputation as a recovery community has been unsettling for some residents.
”We don’t mind taking care of the people living here, but we don’t particularly like people coming from all over the country or the world to recover,” says City Manager David Harden. “But it’s a fact of life, and so we have tried to be supportive of the community.”
Harden says Delray Beach gives money each year to the Drug Abuse Foundation of Palm Beach County, the county’s oldest chemical-dependency treatment and prevention center. The Commission also sold city property to Crossroads Club several years ago, allowing the center to expand.
Over the years, residents have complained to city officials about the lack of security and control at some sober houses. Owners need only a landlord permit to run them, a reality that makes strict regulation difficult.
Jonas, who heads the South County association and runs the coffee shop, says problems stem mostly from unscrupulous landlords who hope to turn quick profits at the expense of fragile tenants and the surrounding neighborhood.
”You got some of these operators who don’t manage the property or the tenants, then they put the people out and leave them homeless,” Jonas says. “There are some operators we would all be better off without.”
FINDING SOLACE
Jonas came to Florida 20 years ago full of reasons to give up. But with the help of his father, who put him in a West Palm Beach treatment center, he cleaned up and stayed put.
A slight guy with a thick mustache and a thicker Philadelphia accent, Jonas sits in the lounge of his coffee shop one afternoon rattling off his story with sobriety’s detachment and confidence.
Pot by 13. Then acid and speed and cocaine. Graduation to alcohol. Bottomed out in the injection world of cocaine and heroin.
Jonas entered rehab in 1987. He married Dawn, a recovering cocaine addict (they met in a 12-step group), and went back to school, earning an online master’s degree in counseling psychology from Antioch University and a doctorate in addiction studies from International University in St. Kitts.
”You come out of a situation like that broken and with very little to hold on to,” Jonas says. ‘You come out of treatment and you say, `Now what?’ ”
So Jonas and his wife — who recently celebrated her 22nd clean year — began working to answer this huge question, working to help define what life after treatment really means.
In 2000, they launched sober.com, a Web clearinghouse for 30,000 recovery programs nationwide. And for 10 years, he operated a recovery residence in Delray Beach. She runs a home for women in recovery.
Two years ago, they opened KoffeeOkee, in many ways ground zero for the recovery community. Inside is a cozy mix of velvet wingback chairs and bistro tables and a small cafe offering every coffee, tea and juice imaginable but absolutely no alcohol. The walls are covered with bulletin boards offering testimonials, treatment and housing ads, and calendars outlining the month’s sober activities.
A piano sits in the corner with a dried white rose on top, a delicate memorial to Valerie, a drug counselor who died a year ago.
Of an overdose.
The Painful Truth About Painkillers Jul 08, 2008
Las Vegas Sun — Nevadans consume about twice the national average of several prescription painkillers, making us among the most narcotic-addled populations in the United States, a Sun analysis has found.
The consequences are deadly. More people in Clark County die of prescription narcotics overdoses than of overdoses of illicit drugs or from vehicle accidents. In 2006, Nevadans were the No. 1 users per capita of hydrocodone — better-known by the brand names Vicodin or Lortab.
We took enough of the drug to equal 48 Vicodin pills for every man, woman and child in the state for a year.
And the numbers are climbing. From 1997 to 2006, the most recent year for which data are available, the per capita rate of hydrocodone used in Nevada jumped by 273 percent.
Nevadans are turning to other narcotic painkillers at an even faster rate.
The per capita use of oxycodone, best-known by the brand name OxyContin, climbed sevenfold from 1997 to 2006, while methadone use jumped 12-fold.
Nevada is ranked fourth in the nation for methadone, morphine and oxycodone use per person, the Sun analysis found.
Following crack cocaine in the 1980s and methamphetamine in the past decade, prescription narcotics are “the next big drug epidemic,” said Matt Alberto, deputy chief of investigations for the Nevada Public Safety Department, the lead prescription drug policing agency in the state.
Emergency room physician Dr. Edwin “Flip” Homansky, medical director of the Valley Health System and a member of the Nevada State Board of Health, said the dramatic rise in prescription narcotic use should be examined.
“When you see increases like that, it’s a warning sign to all of us,” he said, referring to the Sun’s analysis.
The Sun reached its findings after analyzing several thousand pages of Drug Enforcement Administration reports on the state-by-state distribution of controlled substances to pharmacies and health care practitioners. (The DEA monitors the production and distribution of prescription narcotics, which fall into the highest category of regulation for prescription drugs.) After breaking down the data by state populations to reach per capita figures, the Sun determined the highest per person consumption of each prescription narcotic, as well as how consumption has changed over time.
Nevada leads a national trend in the growing use of narcotic painkillers. The National Institute on Drug Abuse reports the number of opiate prescriptions escalated from about 40 million in 1991 to 180 million in 2007 — a 350 percent increase at a time when the nation’s population increased by 19 percent.
A few doctors are doing most of the prescribing. A Sun analysis of a Nevada Pharmacy Board database that tracked all the prescriptions for controlled substances in the state, not just narcotics, showed that in 2007, 1 percent of medical practitioners in the database prescribed 51 percent of controlled substances in the database, and 5 percent of them prescribed 88 percent of the drugs.
No identifying information was made available to the Sun, but experts presume that the heaviest prescribers are pain management and cancer specialists.
Although analyzing individual prescribing habits could hint at who might be overprescribing narcotic painkillers, scrutinizing the database with that intent is banned by statute. Pharmacy board officials said that’s to allow doctors to make judgments and prescribe medicine without fear, which could compromise patient care. The database can be examined by police as part of an active investigation, but authorities can’t use it to go fishing for doctors who can be criminally prosecuted for overprescribing narcotic painkillers.
Assemblywoman Sheila Leslie, D-Reno, said it’s important to understand the factors surrounding the rise in prescription narcotic use and abuse, so legislators may need to “take a closer look” at the law that prevents analyzing the state’s highest prescribers.
Narcotic painkillers are derived from opium, a drug made from poppies that has been used medicinally for thousands of years. Opiate use was common in the United States in the 19th century, and by the early 1900s, when it was recognized that doctors were overprescribing opiates and addiction was a problem, their use was regulated and the drugs fell out of favor. They were mainly prescribed to cancer or terminal patients until the 1990s, when their use was expanded to people with chronic pain. Now we’re in a prescription narcotics boom.
The increasing use of prescription narcotic painkillers in America illustrates the evolving understanding and treatment of pain.
Among the chief challenges to doctors who prescribe potentially addictive painkillers is that pain can be described only subjectively, by the patient. It can’t be measured clinically, like blood pressure or pulse rate.
As a result, pain treatment is both an art and a science. Is the doctor to believe the patient is in pain, or is the doctor being conned by an addict or a drug dealer on the hunt for painkillers? Even the best pain management specialist will say he can’t always tell the difference.
The lines separating prescription narcotic dependence, abuse and addiction are blurry, making it difficult to say whether the skyrocketing drug use is a welcome relief, an epidemic, or something in between.
And experts disagree on how to interpret the growing use of narcotic painkillers. Law enforcement complains about the illegal activity, addiction specialists decry that more people are becoming hooked on drugs, and pain management specialists talk about the benefits of narcotics.
Research on narcotics’ effectiveness in treating pain is inconclusive. In fact, there’s some evidence they can increase pain.
Alarmed experts from all fields agree the rising rate of prescription narcotic use shows no sign of abating.
•••
The use of narcotics to treat pain got a tremendous boost in 1995 from the American Pain Society. Its corporate members include the pharmaceutical companies Purdue, maker of OxyContin; Abbott, maker of Vicodin and UCB, and Watson, maker of the hydrocodone drugs Lortab and Norco.
The society set guidelines saying proper pain management includes urging patients to report unrelieved pain. At the time studies had shown that cancer patients were suffering needlessly because they were not being given enough painkillers.
In January 1999, the Veterans Affairs Department, citing the American Pain Society’s statement that pain is one of the main reasons people consult a doctor, launched a campaign known as “Pain is the Fifth Vital Sign.”
The initiative encouraged health care providers to monitor a patient’s reported level of pain — a subjective symptom — as they did the four measurable vital signs: blood pressure, breathing rate, pulse and temperature. Health care providers asked patients to rank pain on a scale of 1 to 10, and were then urged to treat it.
Dr. Mel Pohl, a Las Vegas addiction recovery specialist, criticizes the pharmaceutical industry’s role in making pain the fifth vital sign.
“The rationale was that we don’t want people to suffer,” Pohl said. “In the best case that’s what it was about. In the worst case, somebody was working this out with the (financial) bottom line in mind. Probably both factors are part of it.”
Soon after, the methods advocated by Veterans Affairs were endorsed by the Joint Commission, the agency that monitors and regulates hospitals. Every hospital is now expected to measure pain in a similar manner.
Dr. Jim Marx, a Las Vegas addiction medicine and pain management specialist, praised the advances, saying doctors now realize they can safely treat patients for pain. This allows patients such as blue-collar workers in Las Vegas to continue in their jobs, he said.
The advent of direct-to-consumer marketing by pharmaceutical companies has also contributed to the rise of prescription narcotics. In 1997, the Food and Drug Administration allowed drug companies to hype their brand-name medicines directly to consumers, which has helped remove any stigma attached to their use. Doctors say patients are now demanding drugs by name.
Homansky, the emergency room doctor, recalled the case of a tourist who said she’d left her bottle of hydrocodone pills at home and needed more. After Homansky recommended a nonnarcotic treatment, she stormed out of the hospital, cursing the staff along the way.
“We’ve had people who get physically abusive, verbally abusive and expect that we’re just there to provide them whatever they want,” Homansky said.
The pharmaceutical companies also market their narcotic painkillers by unleashing cadres of sales representatives on doctors and hosting dinners where physicians offer testimonials about the companies’ medicines.
“There’s a lot of money in the drug industry and they push really hard,” one pain doctor said.
No one can say with certainty why so many narcotic painkillers are used in Nevada, but experts make several educated guesses. The lifestyle of night life and partying leads to more drug-seeking and abuse, doctors said. Also, pain is a complicated symptom of multiple diseases that’s intensified by psychological distress. Las Vegas is a transient place where many people are without social and family support and where the nation’s highest rate of suicide shows a population with mental health problems, doctors said.
The city’s physician shortage also likely plays a role, several experts said. Doctors stressed for time may treat the symptomatic pain rather than explore the problem that’s causing the pain. And once the treatment begins it may continue under the logic that it’s what the patient is accustomed to.
Doctors may further be predisposed to cave in to patients’ requests for narcotics because of how they are reimbursed by insurance companies: by the number of patients they see, not the time spent with each. This may lead providers to take the path of least resistance by writing a prescription. Pohl, the addiction recovery specialist, said it takes doctors “five minutes to say yes and 45 minutes to say no” to a patient’s demand for drugs.
•••
Larry Pinson was browsing in a shop recently when a greeting card caught his eye: “The best part of getting sick is Vicodin,” the card read. “So make sure you save me some, and don’t tell your doctor!”
When greeting cards joke about illegal narcotic abuse, Pinson said, “We’ve got a problem.”
The United States makes up less than 5 percent of the world’s population, but is supplied 99 percent of its hydrocodone and 71 percent of its oxycodone, according to the National Institute on Drug Abuse.
As executive director of the Nevada Pharmacy Board, Pinson presides over the licensing of thousands of pharmacists, pharmacies, technicians and wholesalers, plus about 7,000 doctors, nurse practitioners and dentists who prescribe the drugs and about 180 drug distributors.
About a decade ago the board became aware of the emerging practice of “doctor shopping,” the illegal practice of conniving patients’ visiting multiple providers to get drugs, either to feed an addiction or to sell.
So the Nevada Pharmacy Board created a database that would list every prescription written in the state for certain controlled substances, with the name of the provider and the patient, and the date of the transaction. The monitoring program would help catch patients who might be “doctor shopping.” Regulators from about three dozen other states have followed Nevada’s lead.
A growing number of health care practitioners are using the online database to track their patients’ use of prescriptions. In 1997, the first year of its existence, the database was used 480 times. The number grew exponentially to 65,372 reports in 2007, nearly double from the previous year.
The database flags patients who make a certain number of visits to doctors within an allotted time frame, though officials will not say exactly what type of patient behavior triggers the system, for fear addicts will adjust their behavior accordingly. The database then alerts the doctors to patients who may be shopping for drugs.
Pain management specialists in Las Vegas say the prescription monitoring program is one of many safeguards they use to ensure patients are not abusing painkillers.
“Our attitude is that when a patient leaves our office with a month’s worth of medication, it’s the equivalent of leaving the office with a loaded gun,” said Dr. Michael McKenna, a Harvard- and Stanford-trained pain specialist in Las Vegas.
Among the precautions pain specialists can take to guard against abuse are requiring contracts with patients that discourage doctor shopping, urine tests to verify drug use and monthly visits to track prescriptions and lessen the number of pills a patient has at a given time.
But not every provider takes these precautions.
Jennifer Hilton says that after she had a tooth filled, her dentist handed her a prescription for Vicodin even though she was not complaining about pain. She bristled at the unsolicited prescription because she’s a program coordinator for an inpatient drug addiction program for adolescent girls that’s run by Westcare, a Las Vegas nonprofit that specializes in substance abuse treatment.
Hilton admonished her dentist to ask whether his patients have addiction problems before handing them Vicodin prescriptions.
She said the dentist replied that patients should inform him if they have a drug problem.
“I’m sure some of my clients would have loved to have him as a dentist,” Hilton said, incredulous.
Las Vegas medical professionals repeatedly fail to take addiction seriously, Hilton said. On every clinic visit her teenage drug addicts hand doctors a medical feedback sheet that says: “This person is in a residential treatment facility. Please do not prescribe them anything of a narcotic or addictive nature.”
Still, about one in three kids returns with a narcotic painkiller prescription.
Las Vegas doctors say they are aware of physicians who prescribe whatever drug patients desire, so they will return. It’s good for business.
One drug addict told the Sun addicts share information about the doctors who are quick to write prescriptions.
“If you want (the drugs), you know where to go,” the woman said.
She said a few doctors ran her name through the Nevada Pharmacy Board’s database, recognized her as a doctor shopper and refused to give her drugs. But they never helped her or talked to her about treatment options, she said. Instead they sent her on her way.
The woman, who did not want to be identified, said she is trying to quit drugs and is detoxifying at home. Her only hope is her own motivation to get clean. Her only support is from fellow addicts in her 12-step program.
“I could go to the doctor tomorrow and mess it all up,” she said.
Dr. Jerry Jones, a Las Vegas obstetrician-gynecologist who is president of the Clark County Medical Society, said there may be a few unethical doctors who are overprescribing narcotics. “Most primary care doctors are extremely cautious and conservative about their narcotics prescriptions,” Jones said.
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Experts struggle to explain the notably high use of narcotic painkillers in Nevada. Two popular explanations are based on myths or outdated assumptions propagated in the medical community.
Every medical professional interviewed by the Sun cited what each said was Nevada’s aging population — assuming older people need more drugs because they suffer from more cancer or painful chronic conditions.
But U.S. Census figures show that Nevada is actually the 11th-youngest state in the country.
National experts said the same thing, and indeed the median U.S. age — reflecting aging Baby Boomers — rose from 35 in 1997 to 37 in 2007, according to Census figures. But the population aged 65 and older decreased in the same time frame from 12.6 percent to 12.4 percent.
The other common explanation for the high rate of narcotic use was that pain is undertreated in the United States and that Nevada doctors are prescribing more, as they should. But data suggesting the undertreatment of pain are dated and don’t reflect the exponential growth of prescription narcotic use in the past decade.
James Zacny, a psychopharmacologist at the University of Chicago who studies opiates, said the undertreatment of pain is no longer a concern for most patient populations. “I’ve heard the pendulum has swung the other way,” he said. “Now there’s some concern about overprescribing.”
The tragic irony is that painkillers may not work as well as people think. Many doctors say they’re not ideal for long-term use for chronic pain. And some studies show, paradoxically, that they can increase pain. McKenna said the research is relatively new, but shows that some patients actually improve when the medication is withdrawn.
“Pain is very complicated,” McKenna said. “But throwing opiates alone at pain is probably not the best approach.”
Washington Post – When it comes to treatment, the experts think alcoholism needs to catch up to depression.
Three decades ago, long before the dawn of the Prozac Era, depression was a disease rarely treated in its mild form, reluctantly treated with drugs and usually treated by experts only. Today, signs of depression are actively sought, drugs are prescribed early and often, and most cases are handled by nonpsychiatrists.
With alcohol abuse, however, most physicians don’t go looking for trouble and don’t recognize it until it’s breathing in their face. Over-drinking patients often don’t think of looking for help even if they know they are heading in the wrong direction. And society as a rule looks at alcohol treatment as a last-chance, 90-degree corner taken only at high speed.
Simplify screening
All this will change if American physicians adopt the new guidelines for "Helping Patients Who Drink Too Much" promulgated by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.
The idea is to simplify the screening for excessive alcohol use in general medical practice and to convince clinicians and patients that early intervention for drinking that hasn’t yet wreaked havoc is both possible and useful.
"We’re trying to increase the accessibility and attractiveness of treatment to a much broader spectrum of people," said Mark L. Willenbring, a psychiatrist who directs the Division of Treatment and Recovery Research at NIAAA.
Those especially targeted in the guidelines are heavy drinkers who are not yet physically dependent on alcohol but are at risk for becoming so.
"We know that that group responds very, very well to what we call facilitated self-change and brief motivational counseling. We could make that very widely available without much cost," Willenbring said.
A big part of the new strategy is to make primary care physicians — people without specialized training in addiction medicine — think about alcohol abuse the way many now think about depression, anxiety and obsessive-compulsive disorder. Which is to say, they need to think of it as something common, diagnosable and within their capacity to treat. The guidelines make this easy: The screening tool for alcohol problems consists of a single question. For men: How many days in the past year have you had five or more drinks? For women: How many days in the past year have you had four or more drinks?
"Most doctors don’t know how to make the diagnosis and don’t really try to do anything about it until it is so easy to diagnose that all you have to do is glance at the patient," said Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania who has been treating alcoholics for 38 years.
"It used to be said that you can’t treat somebody until they are down and out. But when they are down and out, they are really hard to treat," O’Brien said.
Willenbring concurs.
"I think there is a belief that people with more moderate levels of dependence don’t know they have a problem. I think they do. But they don’t think rehab is the model of treatment for them — and I don’t, either."
The sort of therapy both advocate does not involve magic bullets or easy answers or effortless behavior change. But it does enlist pills that help a little, quite a bit of talk and lots of self-discipline.
And what does it get a person?
Perhaps not surprisingly, there’s evidence that getting control of a drinking problem early can improve one’s health, completely apart from the social, psychological and familial benefits it brings.
Looking at death rates
A study published two years ago looked at the experience of 628 men and women who entered alcoholism treatment (either in residential rehab or as outpatients) in their mid-30s and were followed for 16 years.
Over that period, 121 died, or 1.2 percent a year. The average age of death was 48. But the chance of dying was significantly lower in people who after the first year were abstinent or had no drinking-related problems or symptoms.
So how successful is treatment, or at least how successful has it been?
Researchers in 2000 analyzed seven studies, one going back to the late 1970s, in which more than 8,000 people were treated for alcoholism in various ways, including with drugs. After a single course of treatment, one-fourth were abstinent for at least a year and one-tenth dramatically decreased their drinking. The rest, about two-thirds of the subjects, drank less often and in quantities averaging less than half of what they consumed before treatment. Mortality in the first year was 1.5 percent.
Some of those patients had a four-week stay in "rehab," but most did not. A long treatment-center admission as the optimal strategy to stop a serious drinking problem is much more the model of the 1980s than the 2000s. The newer one emphasizes outpatient treatment — occasionally after a brief hospital stay for acute detoxification, if necessary — with care provided by non-specialists in many cases.
How often contemporary treatment succeeds was also explored in a complicated clinical trial of about 1,400 alcohol-dependent men and women, average age 44 and consuming 12 drinks a day, that was published in the Journal of the American Medical Association in 2006.
The researchers randomly assigned the patients to nine groups. Four of the groups got nine sessions, conducted by a doctor or nurse and lasting at least 20 minutes, that reviewed the health consequences of excessive drinking, encouraged abstinence and attendance at Alcoholics Anonymous meetings, and urged adherence to the study medicines. Four of the groups also got intensive counseling by alcohol-addiction experts — up to 20 hour-long sessions.
Drug therapy
Some of the patients were assigned to take a drug for three months: either naltrexone, which blocks opiate receptors in the brain that are involved in alcohol’s "reward pathways," or acamprosate, which works through so-called GABA receptors to decrease the anxiety and restlessness that can come with abstinence. Some got placebo pills.
A year later, there were no big differences among any of the groups, although there were some interesting small ones. (This was true even with what the researchers considered the placebo group, the people who received specialized alcohol counseling but no time with a physician and no pills.)
People who met regularly with a doctor or nurse and then got either naltrexone or the intensive counseling did equally well; about 66 percent were abstinent. People who had those sessions and got placebos did less well; 59 percent were abstinent. Those who got intensive counseling but no pills, neither active ones nor placebos, had an intermediate outcome, with 62 percent abstinent.
Unlike some other studies, this one showed no benefit from acamprosate. But that may not be the last word.
Interesting findings
A clinical trial not yet published showed the drug worked only when started during a period of abstinence, not while a person was still drinking. And last month researchers reported more evidence that GABA receptors play a role in alcohol addiction. Laboratory rats that got the drug gabapentin, which enhances the action of GABA, drank less — but only if they were already chronically exposed to alcohol. Those that used alcohol only occasionally did not show such an effect, suggesting the pre-existing state was crucial to the response.
Abstinence, in almost all practitioners’ minds, is always the goal. But its absence doesn’t signal abject failure.
"It is a fiction that the typical change process is a sudden transformation," Willenbring said. "The more common is a change process that lasts years and is characterized by lengthening periods of sobriety and shorter relapses until they are gone."
In that way, alcohol abuse is like depression. In another way, too.
"Recovery from depression requires effort. The same is true for alcohol dependence," he said.
And in both cases, he thinks they’re really worth the effort.
The two drugs, along with a dummy pill called a placebo, were tested for 22 months among 126 patients in Malaysia who had emerged from a detoxification and counselling programme, it said.
Buprenorphine, which is marketed as Temgesic or Buprenex, was twice as effective as naltrexone (branded as Revia, Depade or Vivitrol) and the placebo in terms of days of abstinence from heroin and a full-fledged relapse to the narcotic.
Indeed, buprenorphine proved to be so superior that the trial was halted early, as it would have been unethical to continue it to its scheduled end.
The study, led by Yale University’s Richard Schottenfeld, gives support for placing buprenorphine alongside methadone, and both of them over naltrexone, as pharmacological treatments for helping addicts stay off heroin.
The three drugs belong to a class called opioid antagonists.
These treatments are increasingly used to help ease heroin dependence but remain prohibited in some countries, amid suspicions that they are liable to be abused or simply substitute one addiction for another.
The study is important because it gives the first assessment of the relative effectiveness of two of the opioid antagonists.
Heroin and other illicit opiates were once a problem mainly confined to developed countries, but in the past few decades have spread to developing economies and nations of the former Soviet bloc.
China, India, Indonesia, Iran, Malaysia, Pakistan and Russia are among the countries where expansion of heroin use has risen fastest, according to a 2004 World Health Organisation (WHO) paper.