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.
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.
•••
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.
The skyrocketing use and abuse of prescription narcotics in Las Vegas is accompanied by a similarly startling increase in the number of fatal overdoses, a Sun analysis has found.
Fatal overdoses involving prescription painkillers more than quadrupled in a decade and now exceed those involving illicit drugs, according to data compiled by the Clark County coroner’s office.
The trend reflects the extraordinarily high use of narcotic painkillers by Nevadans. The Sun reported Sunday that its analysis of Drug Enforcement Administration data shows that Nevadans per person use more hydrocodone — the potent ingredient in the drugs Vicodin, Lortab and Norco — than residents of any other state. Nevadans rank fourth nationally in per person consumption of methadone, morphine and oxycodone, the main ingredient in OxyContin.
The increased use and availability of the drugs are primary factors in the rise of addiction, illegal distribution and fatal overdoses, experts say.
In 1997, there were 57 fatal overdoses in Clark County in which prescription narcotics were a contributing factor, a rate of about five per 100,000 people. In 2007, 258 people died in Clark County from overdoses of prescription narcotics, a rate of 13 per 100,000 people.
In contrast, the number of deaths caused by illicit drugs has plateaued. Street drugs such as cocaine, methamphetamine and heroin were involved in a combined 197 fatal overdoses in 2007.
Deaths involving prescription narcotics exceeded or rivaled those caused by firearms (321) and motor vehicle accidents (234) in Clark County in 2007.
Clark County Coroner Mike Murphy called the prescription drug deaths a “dire situation.”
Doctors who specialize in pain management, and pharmaceutical companies that make the drugs, emphasize that many people are helped by prescription narcotics while acknowledging that a small percentage may become addicted.
Prescription drug overdoses draw national attention when the victims include such celebrities as Heath Ledger and Anna Nicole Smith, but aside from the sensational anecdotes, little is reported about the overall toll of overdoses.
Poisoning, usually caused by unintentional drug overdose, is the second leading cause of injury death in the United States, surpassing firearms in 2004, according to the National Center for Health Statistics.
Prescription narcotics deaths accounted for 56 percent of poisoning deaths nationally in 2005, according to the Centers for Disease Control and Prevention, and their absolute number increased by 84 percent from 1999 to 2005.
Some regional data compiled by medical examiners further illustrate the problem:
• In King County, Washington (Seattle), prescription opiates killed 148 people in 2006, a 572 percent increase since 1997.
• In Virginia, prescription narcotics took 399 lives in 2006, compared with 146 deaths from cocaine and amphetamines.
• In Oklahoma, of 603 drug-related deaths in 2006, more than half, 327, were attributed to hydrocodone, methadone or oxycodone.
• In Florida, people who died of drug overdoses in 2007 had prescription drugs in their systems more often than illicit drugs.
No prescribed narcotic is involved in more deaths among Nevadans than methadone. The long-acting painkiller was named in a third of the 1,771 prescription drug overdoses in Clark County from 1991 to 2007, according to the Clark County coroner’s office. The number of deaths involving methadone climbed from three in 1993 to 20 in 1998 and 105 in 2007. (Cocaine was a factor in 116 Clark County deaths in 2007.)
Methadone, widely used to wean addicts off other drugs, has grown in popularity as a painkiller in recent years. Several doctors said it’s preferred by insurance companies because it’s inexpensive — though insurers dispute this, saying there are many low-cost generic narcotics so there would be no reason to favor methadone.
But methadone is a challenging drug to prescribe because it stays in a person’s system for five to 11 days, even after its effects have worn off, said Las Vegas pain specialist Dr. Jim Marx. That means a patient could take multiple doses of methadone over time to keep pain in check, allowing potentially lethal amounts of the drug to build up in the body. In comparison, hydrocodone leaves the body within hours.
“It’s trickier to prescribe because of its persistence,” Marx said.
Methadone deaths have increased more than those involving any other narcotic, the Centers for Disease Control and Prevention reports.
Its data show Nevada had almost four methadone deaths per 100,000 people from 1999 to 2005, the fourth-highest rate in the United States, behind Maine, Utah and Washington.
The CDC said it’s hard to determine whether the increase in opioid-related deaths is due to prescribing practices, a failure by patients to take drugs properly, or illegal abuse.
CDC medical epidemiologist Leonard Paulozzi told Congress in March the drug overdose deaths correspond to the rapidly rising rates of prescription narcotic use reported by the Drug Enforcement Administration, and the overdose deaths are expected to continue.
Statistics through 2005 “probably underestimate the present magnitude of the problem,” Paulozzi said.
•••
There are many ways to get prescription narcotics illegally, said Matt Alberto, deputy chief of investigations for the Nevada Public Safety Department, the state’s lead prescription drug policing agency.
Unscrupulous doctors sell prescriptions for cash. Abusers shop for doctors who prescribe narcotic painkillers without asking many questions. Children fish around in their parents’ medicine cabinets. Patients forge prescriptions. Pharmacy workers, clinic workers and hospital employees steal the drugs.
The most notorious criminal case of a doctor in Las Vegas illegally providing narcotic drugs involves Dr. Harriston Bass Jr., who, according to evidence at his trial, made house calls to prescribe and distribute prescription narcotics.
Bass drove to patients’ homes, conducted 10-minute exams and then sold the patients two or three bottles of 100 pills each — even though he had no license to distribute controlled substances, according to testimony at his trial. He also wrote prescriptions for patients to fill at pharmacies.
Among his patients was Gina Micali, who received about 300 hydrocodone tablets from Bass every other month, plus a prescription for another 180 and one refill. On each visit she also received the muscle relaxant Soma and the anxiety medication Xanax, plus prescriptions for each. In pills and prescriptions, Bass sold Micali a total of about 1,400 pills per visit, said Conrad Hafen, the chief deputy attorney general, who prosecuted the case.
On Oct. 5, 2005, Micali, 38, died after ingesting too many painkillers she got from Bass.
Hafen told the jury that when police searched Bass’ home, they found $150,000 in cash and large quantities of hydrocodone in bottles labeled with the name of his company — DOCS-24-7 — and a wholesale prescription drug company in Illinois.
Alberto said the Illinois company offered no good explanation for why it was selling drugs to a doctor who didn’t have clearance from the Drug Enforcement Administration.
In March, Bass was convicted of second-degree murder in Micali’s death and was found guilty on more than 50 drug-related charges. He was sentenced to 25 years to life in prison.
A more typical case of illegally diverting prescription painkillers involves Stephanie Ortiz, a former pharmacy technician at four Smith’s grocery stores in Las Vegas. She admitted to the pharmacy board that she gave unauthorized refills of Lortab — a painkiller made with hydrocodone — and free drugs to friends posing as patients. Ortiz filled out refill requests but never faxed or phoned them to physicians for approval, the complaint against her says. She admitted illegally diverting 10,680 doses of the painkiller.
In a letter she wrote admitting her guilt, Ortiz says she started giving the purloined drugs to people she knew, and then got text messages and phone calls saying a random person would come by for another pickup. In exchange for the drugs, Ortiz said, she received VIP tables at nightclubs and access to hotel rooms on busy weekends.
Authorities say young people are cavalier with prescription drugs, sharing them among themselves or sneaking them from their parents and passing them around to their friends. Such a transaction ended in death two years ago this week in Mesquite.
According to an affidavit filed by the Nevada Public Safety Department, Brett Sawyer, 19, was found dead in his bedroom on July 8, 2006. Hidden in a gym bag by his bed was an empty bottle of hydrocodone pills prescribed by a dentist in St. George, Utah, to one of his friends.
Sawyer’s family told investigators he was a drug user. “Brett was the type — if one aspirin worked, three would work better,” his mother said.
Police learned that Sawyer was addicted to OxyContin and often obtained drugs from Cody Morris, who was also an addict and dealt the drugs to his friends.
On July 7, 2006, Morris sold Sawyer three 80 mg OxyContin pills — what some call the Cadillac of prescription narcotics — for $45 each. Morris said he warned Sawyer not to take more than one at a time and to avoid mixing them with alcohol.
Sawyer was dead the next day.
Morris pleaded guilty to manslaughter and was sentenced to three years’ probation.
Alberto, the investigator, said it’s as common for drug dealers to sell prescription narcotics as it is methamphetamine or cocaine — and more profitable. An ounce of methamphetamine might sell wholesale in Las Vegas for $700, he said, but the same weight in OxyContin pills would be $3,000. He guessed the illegal abuse of prescription painkillers could account for 10 percent of the state’s total use.
Alberto laments that policymakers and the public are focused on street drugs, and virtually ignore the dangers in people’s medicine cabinets. Narcotics investigators for Metro Police do not investigate prescription drug dealing and deal with the drugs only on a reactive basis, a spokesman said.
Yet prescription narcotics are becoming more popular than marijuana for new abusers. The 2006 National Survey on Drug Use and Health found that among new drug abusers, 2.2 million people chose prescription painkillers and 2.1 million preferred marijuana.
Nothing stimulates the brain with pleasure more than drugs. But doctors disagree about the threat of drug addiction. People at risk of becoming addicted to them range from 3 percent to 18 percent of the population, depending on the study or the expert.
Prescription narcotics can change the brain’s chemistry, creating a physical and psychological dependence that compels addicts to forgo career, children, money, sleep, sex and all-around well-being in pursuit of the drug of choice.
Officials with the Nevada Substance Abuse Prevention and Treatment Agency say the rise in prescription narcotic addiction in the state cannot be quantified because of the way records are kept. Nationally, a 2006 Substance Abuse and Mental Health Services Administration survey showed that an estimated 5.2 million people 12 and older took narcotic painkillers for nonmedical purposes 30 days before the survey, up from about 4.4 million in 2002.
People seem to think that because the drugs are commercially manufactured and approved by the Food and Drug Administration, their abuse is less risky than that of illicit drugs, said Steve Pasierb, president of the Partnership for a Drug-Free America.
“This is a deadly behavior,” Pasierb said of the drug abuse. “When prescription drugs are abused in the same way as illegal street drugs, they’re every bit as addictive and they’re every bit as deadly.”
Methadone Deaths Shoot Up Jan 24, 2008
WASHINGTON (CNN) — Methadone-related deaths have skyrocketed, fueled by a jump in theft and misuse of the addiction treatment drug, according to a Justice Department report released Wednesday
The report said methadone-related deaths jumped from 786 in 1999 to 3,849 in 2004. By contrast, during the same period, deaths related to cocaine increased 43 percent from 3,822 to 5,461.
The National Drug Intelligence Center, an arm of the Department of Justice, says it published the assessment because of its concern over the sharp increases stemming from the diversion and methadone abuse. The center, which analyzes and dispenses strategic drug intelligence, noted methadone is safe and effective when prescribed and used correctly to treat opiate addiction, but is deadly when misused –"particularly in combination with other prescription drugs, alcohol, or illicit drugs."
The report said physicians dispensed the drug more frequently in the management of pain during the years studied.
"Methadone thefts from manufacturers, distributors and retailers have increased the amount of methadone available for abuse," the report said.
"Diversion from pain management facilities, hospitals, pharmacies, general practitioners, family and friends, and to a lesser extent narcotics treatment programs, increased availability, primarily at the retail level," the study said.
The study said Florida had by far the most methadone deaths during the past three years of the study — 2002 to 2004. Four hundred deaths occurred in Florida during 2004. North Carolina was second with 245 deaths, followed by California, New York, Washington, Texas, Virginia and Kentucky. Officials say the problem continues to get worse, with the Florida Department of Law Enforcement reporting as many as 716 methadone deaths in 2006.