People with opioid dependence in recovery show ‘re-regulation’ of reward systems

Within a few months after drug withdrawal, patients in recovery from dependence on prescription pain medications may show signs that the body’s natural reward systems are normalizing, reports a study in the Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

The study by Scott C. Bunce, PhD, of Penn State University College of Medicine, Hershey, and colleagues provides evidence of “physiological re-regulation” of disrupted brain and hormonal responses to pleasurable stimuli – both drug- and nondrug-related.

Signs of Reward System Disruption After Drug Withdrawal…

The pilot study included two groups of seven patients in residential treatment for dependence on opioid pain medications. One group had recently gone through medically assisted opioid withdrawal–within the past one to two weeks. The other group was in extended care, and had been drug-free for two to three months. A group of normal controls were studied for comparison.

The researchers performed several tests to assess changes in the “brain reward system” during early recovery. After drug withdrawal, many people with opioid dependence have “persistent changes in the reward and memory circuits”–they may experience heightened “rewards” or “pleasure” in response to drugs and related stimuli, but greatly reduced responses to naturally pleasurable stimuli (such as good food, or friendship).

Dr Bunce explains, “This is thought to occur because opiates are potent stimulators of the brain’s reward system; over time, the brain adapts to the high level of stimulation provided by opiates, and naturally rewarding stimuli can’t measure up.” Such dysregulation of the natural reward system may contribute to the high risk of relapse during recovery.

The test results showed several significant differences in the reward system between groups. A test of startle reflexes showed that patients with recent drug withdrawal had reduced pleasure responses to “natural reward” stimuli–for example, pictures of appetizing foods or people having fun.

In brain activity studies, patients with recent drug withdrawal showed heightened responses to drug-related cues, such as pictures of pills. In the extended-care patients, these increased responses to drug cues — in a region of the brain called the prefrontal cortex, involved in attention and self-control — were significantly reduced.

…May Lead to New Objective Measures of Recovery

Patients who had recently withdrawn from opiates also had high levels of the stress hormone cortisol (adrenaline). In the patients who had been drug-free for a few months, cortisol levels were somewhat reduced, although not quite as low as in healthy controls. The recently withdrawn group also had pronounced sleep disturbances, while sleep in the extended care group was similar to controls.

All of these changes — brain and hormonal responses to drug cues and natural rewards, as well as sleep disturbances — were correlated with abstinence time. The more days since the patient used drugs, the lower the abnormal responses.

The study supports past research showing dysregulation of the reward system during early recovery from opioid dependence. It also provides evidence that these responses may become re-regulated during several weeks in residential treatment — a period of “clinically documented” abstinence from opioids.

That’s a potentially important step forward in addiction medicine research, Dr Bunce believes. “It shows that if the patient remains in treatment and off drugs for several months, the body’s natural reward systems may have the capacity to return toward normal, making it easier for them to remain drug-free outside the treatment setting.” With further study, tests of the natural reward system might provide useful, objective markers of recovery — clinical tests that help to evaluate how the patient’s recovery is proceeding.

Such tests might help in managing the difficult problem of prescription opioid dependence — an ongoing epidemic associated with a high risk of relapse after drug withdrawal. Dr Bunce and colleagues are conducting a follow-up study, funded by the National Institute on Drug Abuse, to determine whether measures of the brain’s reward system, sleep and the stress response system indicate the capacity for re-regulation and the patient’s risk of relapse during recovery.

Helping an Addicted Loved One

David Lisonbee, twintowntreatmentcenters.com

How do you help arrest a loved one’s decent down the destructive path of alcoholism and addiction? Is this the best time to address these problems? Can you pretend that everything is fine and that everyone is happy? Are you motivated by a benevolent care for your family or is self-defense or evening the playing field the goal? Are you acting from a place of concern and love, or are you reacting from the fear and pain of past injuries?

First take a look at yourself. Gauge your readiness for the task. Evaluate the present likelihood of success. Be realistic since all of these motives, both constructive and destructive are likely and legitimate.

I hope that this note provides you some helpful thoughts and strategies. It is normal to resent the very person you are striving so hard to help. Their behavior has harmed you and others for a very long time. Your anger, fear, and anxiety stem from constant anticipation of threat from the person who needs your help. You may have once relied upon for help yourself. Now they cannot be trusted. They have become unpredictable and unreliable. Repeated traumas have reinforced beliefs, ideas, feelings and behaviors that push your emotions out of control. You must protect yourself before becoming useful to anyone.

Even though the causes of addiction are innate and biological, continued regression versus recovery boils down to personal choice. The practicing addict is immersed in a world of immediate rewards and the avoidance of pain and emotional turmoil. Their reactions to you are constantly colored by their psychological and physical relationship with a chemical. That chemical has become centered and all-important in their life.

You can blame yourself. You can blame them. You can blame the chemical. Blame simply magnifies pain- your pain, their pain, our pain.

Set ground-rules or boundaries for yourself and keep them. If you react out of resentment or pain, you have become ineffective or destructive. Stop yourself and retreat.

Remember that you can only control your behavior. When you attempt to control others including addicts, you are acting to increase your pain, anger, resentment and fear. You set yourself up for failure. The futility of your actions result in worsening results. Stop!

Aggravating old problems and creating new ones does not improve the situation for anyone though this may feel natural at this point in your relationship.

Denial and rationalization are defenses which serve to maintain the status quo. Change is uncomfortable and creates fear, fear of the unknown. Accepting the reality of a situation is first stage of recovery. You must accept that you may lose your addicted loved one before you set out to help them. They must somehow arrive at the reality of their problem. Arousing their defenses defeats the purpose and blocks progress.

Rather than entangling the person’s drug or alcohol use/ inebriation, conduct any and all conversations while they are sober. During the holidays or weekends, these conversations will necessarily be made well before events and usually early in the day.

Draw a line in the sand that if the person drinks or uses, you will not associate with them during their use or while they appear under the influence. If you find them using or under the influence at your place, ask them to leave. If you are elsewhere, you leave. Make the agreement simple and hold to it.

When the loved one wants to engage or reengage in a relationship with you, set the expectation that they have to be sober and doing something to maintain that sobriety. Don’t step into the trap of accepting quick-fixes and temporary reprieves. If your loved one comes to realize that their relationship with you is important, they will allow you to hold onto your expectations.

Raising your voice, making threats, recalling shaming events are likely to arouse defensiveness in the addict and motivate even more chemical use. The chemical is used to avoid such situations and the emotions encountered from them. Set ground-rules about what you will tolerate and hold to them. Place accountability and responsibility back on the addicted loved one. Parenting creates childish behavior. Anger creates fights. Guilt creates shame.

Rather than submitting to the well-known and self-defeating habit of looking to blame, notice what is happening inside, and remember the routine and its consequences. Realize that your insides don’t feel well and seek more constructive remedies. Step away from the situation, go to an Alanon/ Coda meeting, talk with someone, write it down, change your focus, listen to different ways of viewing or thinking about the situation, but take action for yourself. Do what is uncomfortable- take the long-term solution. Take care of yourself and your loved one will do what they need to do.

Balancing work, home, leisure, recreation and physical exercise are essential toward maintaining resilience and to build energy from which action can be taken. Isolation, boredom, fatigue, frustration, anger are often results of encountering addiction in a loved-one. Realize when stress becomes greater than stress reducing activities. Seek social support, exercise, meditation, healthy diet, supportive social relationships, spiritual practices, rest…

Find a mutual support group, a treatment center, a professional therapist or an interventionist. Accepting the help of another contains potent medicine. Collaboration creates unity and connection. Addiction is the lonely disease for all effected.

Risk of Opioid Overdose, Addiction Outweighs Benefits in Many Cases: Neurologists

By Join Together Staff

September 30th, 2014

The risk of death, overdose and addiction from prescription opioids outweighs the benefits in treating headache, chronic low back pain and other non-cancer conditions, according to a new position paper from the American Academy of Neurology.

The doctors’ group says research shows that half of patients who take opioids for at least three months are still on them five years later, HealthDay reports.

“Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction,” the statement noted.

“More than 100,000 people have died from prescription opioid use since policies changed in the late 1990s to allow much more liberal long-term use,” Dr. Gary Franklin of the University of Washington in Seattle said in an academy news release. “There have been more deaths from prescription opioids in the most vulnerable young to middle-aged groups than from firearms and car accidents,” he added. “Doctors, states, institutions and patients need to work together to stop this epidemic.”

The group advises doctors to consult with a pain management specialist if a patient’s daily opioid dose reaches 80 milligrams to 120 milligrams, especially if the patient isn’t showing a major reduction in pain levels and improvement in physical function. The statement outlines a number of steps doctors can take to prescribe opioids more safely and effectively. These include creating an opioid treatment agreement, screening for current or past drug abuse, screening for depression and using random urine drug screenings

Treatment centers: 12-step and MAT should coexist

The polarization of the treatment field between medication-assisted treatment (MAT) and 12-step drugfree treatment is gradually dissolving, according to experts interviewed by ADAW last week. “The problem is that some people view it as either/or,” said Philip L. Herschman, Ph.D., chief clinical officer of CRC Health Group. “Either it’s MAT and nothing else, or it’s 12-step and nothing else.”

At many treatment programs, including CRC and the Hazelden Betty Ford Foundation (the nation’s largest for-profit and not-for-profit treatment chains), it’s not either/or — it’s both. And the National Institute on Alcohol Abuse and Alcoholism (NIAAA) supports both as well.

Buprenorphine, methadone and Vivitrol are all proven medications that work, but not necessarily with the same patient, said Herschman. But other psychosocial treatments are necessary as well, including cognitive behavioral therapy (CBT).

“There are multiple evidencebased treatments, MAT being justone of them,” said Marvin Seppala, M.D., chief medical officer of the Hazelden Betty Ford Foundation. But MAT is an important one, especially because of the high overdose rate for opioid addiction. “If you neglect the literature and the science of addiction, you still have to look at the death rate,” he said. Hazelden added buprenorphine because so many patients overdosed after being discharged from treatment there (see ADAW, November 12, 2012).

“We try to differentiate between three different groups” for patients with opioid addiction, said Seppala — one treated with naltrexone (Vivitrol), one with buprenorphine and one drug-free.

The medications for alcoholism aren’t as good, and there are no medications for other drugs of abuse, noted Seppala.

Role of AA

“Hazelden is founded on the use of the 12 steps; it is one of the absolute tenets of treatment here,” said Seppala. “We are going to continue to emphasize the use of AA, CA and NA.”

Interestingly, Hazelden is “having really good outcomes on the people who refused medications but who stick around in our psychosocial therapy,” said Seppala. “the people on the medications are doing well.”

Physicians can’t predict who should be on medication and who shouldn’t, or who should be on what medication, said Seppala. “We’re trying to walk down the middle. What do you do with a 19-yearold who just started on oxycodone six months ago?” he asked.

But regardless of age, every patient who comes into a program should be informed that medications exist and may help, said Seppala. “I’m a psychiatrist and I was trained to give information — on what might work and on the risks,” he said.

There is adequate evidence to support the use of 12-step programs for people with addiction, said Seppala. Some critics claim that 12-step does not include a “manual” that has been proven by clinical trials (with the impossible placebo group) to work.

But even with CBT, the best therapists do not stick to a “manual,” said Seppala. “An experienced psychotherapist may have been trained according to a distinct model, but over time they realize it doesn’t work for everyone, and they alter their practice for different patients,” he said.

A good addiction treatment program should have a training system that helps their clinicians have a foundation in evidence-based practice,  said Seppala. “But to say ‘We’re going to use CBT and you have to do it with a manual’ — that’s nonsensical,” he said.

CBT alone isn’t adequate, and 12-step alone isn’t adequate, said Seppala. “It’s true that I can suggest that people go to 90 meetings in 90 days, and some of them will stay sober,” he said. “But we need to individualize treatment.”

Hazelden has a “stigma management” program to help patients who are on buprenorphine, because there is such a lack of understanding of MAT.

Alcoholics Anonymous and similar 12-step groups are “supports as part of a complete treatment plan for recovery,” said CRC’s Herschman. As a support system, AA is part of the treatment “that happens after an acute episode of treatment,” he said. “But in and of itself, AA is not treatment.”

‘Sobriety’ first

But David Lisonbee, president and CEO of Twin Town Treatment Centers in Los Alamitos, California, thinks that some programs are too reliant on pharmaceuticals. “We as treatment providers have allied with our clients and the interests of our clients, and our preferences and our goals have to do with long-term recovery and sobriety, which in heclassic terms means you’re coping with a minimum of assistance,” he said. Some people, he said, feel that the profit motive is behind the designation of buprenorphine as a maintenance medication instead of a detoxification agent (it can be used as either).

Many providers now accept that for some patients — the long-term heroin addict, for example — maintenance medication is appropriate, said Lisonbee. “Where we balk at maintenance is if it’s an occasional user or a young adult who has dipped into his parent’s medicine cabinet,” he said. “That person is suited to long-term sobriety.”

But, he acknowledged, the field is changing. “The field used to balk at antidepressants, but over the past 10 to 15 years antidepressants have been a treatment of choice when there’s a coexisting affective disorder,” said Lisonbee.

Evidence base for AA

There is evidence for the effectiveness of 12-step facilitation (AA) in Project MATCH, the NIAAA-funded comparison of CBT, motivational enhancement therapy and AA. That study concluded in 2001 but has been used for other studies showing the evidence of the effectiveness of AA (see ADAW, June 17, 2014).

“Excessive drinking is a heterogeneous disorder,” said Raye Z. Litten, Ph.D., associate director of the NIAAA Division of Treatment and Recovery Research. “That’s why one philosophy doesn’t work for everyone — but we think AA can work for some people.”

More studies have been done recently on AA, said Litten. “People do attend [AA], they stick with it, and they have improvements in drinking outcomes.”

“I’m happy to hear that they’re putting more of a menu of reatments” in addiction treatment centers, said Litten, referring to MAT. “If one medication doesn’t work, another one might.”

Litten recalled that last year at the ASAM annual meeting there was a special symposium on integrating AA and 12-step recovery into treatment.“There’s more going on here than meets the eye,” he told ADAW. “Some people have worked hard and found medication works in some people, and they are frustrated that more people aren’t using it,” said Litten. “But that doesn’t mean you should bash AA.” There are more than 50,000 AA groups in the United States, noted Litten. “Where else can you go for help that’s free and confidential?” Litten said.

Litten noted there is a stark difference between methadone and buprenorphine, the agonists used to treat opioid addiction, and acamprosate and naltrexone, which are medications approved to treat alcoholism. “Everyone who gets methadone or buprenorphine will have an effect from those medications,” said Litten. “But the alcohol medications don’t work for everyone.”

Still, it’s important to have the full toolbox to offer to patients. And Lisonbee agreed. “We are getting there,” said Lisonbee. “But we don’t want our treatment providers to be in it for the profit. We don’t want people to submit to a treatment industry that makes more dollars. We want to be client advocates.”

Alcoholism Drug Abuse Weekly, Vol. 26 Number 8, Feb 24, 2014, Allison Insinger

 

 

 

Susan Musetti, MFT accepts Twin Town Clinical Director Position/ Ethical Standards Restated!

Doing the right thing is not easy but it is what we’re about

Media coverage of addiction treatment leads the public and some professionals to conclude that service providers will take inappropriate measures to increase revenues.

Twin Town distinguishes itself by:

• Refusing to accept/ pay referral fees or contract with referral mills (internet websites) to increase rates of patient enrollment. The patient and family geographic location, and the clinical needs expressed by the patient and their family are always considered when forming disposition/ referral plans.

• Refusing to mislead patients and their families with statements such as, “We’ll take your insurance and we will accept payment arrangements for the unpaid balance”. In situations where the patient and their family are misled at enrollment, they are later shocked by bills which may exceed tens of thousands of dollars. The reality all along was that the insurance would have only paid for only a few days of residential or out-of-network treatment.

• Refusing to contract with the patient or family for a “flat case-rate” for the entire course of treatment. Under flat case rate agreements refunds are frequently refused and the unused funds are pocketed.

Twin Town sets ethical and quality standards that in many ways exceed the norm:
 Twin Town provides only cost-effective treatment which is quality monitored.
 Before admission, we provide full financial and service disclosure, and we secure voluntary informed consent. We avoid surprises.
 Our staff seeks to protect the dignity and confidentiality of each client patient and their family members.
 Documentation and billings for outpatient treatment goes towards the provision of outpatient treatment. Twin Town does not provide residential treatment- outpatient treatment is billed and is what is offered.
 Clinical relationships with current and/or prior caregivers are respected and protected. Twin Town will not transfer clients from care of therapists, counselors, psychiatrists and/or physicians. Twin Town COORDINATES care with community professionals rather than setting up competitive or fragmented systems of care.
Substance Use Disorder Services, Department of Healthcare Services and the Joint Commission certify and accredit the services rendered by Twin Town Treatment Centers. Twin Town contracts with most insurance, managed care companies and employee assistance programs.
Commercial media coverage of addiction treatment leads the public and some professionals to conclude that treatment entails residential room and board.
“Treatment” was once synonymous with twenty-eight or more days “in rehab”- away from home, family and job. Clinical outcome research, cost-effectiveness studies, competitive pricing, and purchaser/ consumer demand for choice have challenged the old paradigms. No conclusive or credible finding has changed the receding tide of residential treatment admissions and lengths of stays.

“Treatment on an outpatient basis allows a more valid assessment of environmental, cognitive and emotional antecedents of drinking episodes and drinking urges on the part of the patient, and allows the patient to test new coping strategies while still within a supportive counseling relationship. These conditions would be expected to foster greater generalization of learning in treatment to the patient’s natural environment” (Annis, 1986, p. 183).

Outpatient treatment mobilizes available supports (family, family doctor, and mutual support organizations) rather than creating temporary and artificial supports that will be removed once the residential experience ends. Indigenous recovery supports are identified and activated during the course of outpatient treatment. The transition from active treatment into aftercare is much less abrupt and gains are generalized. Clinical changes, recovery supportive resources and relationships are likely to be maintained.

Outpatient treatment provides a much greater “take-home” advantage.

“Compared to those receiving no treatment, those receiving nonresidential treatment took longer to fail or recidivate. However, those receiving residential treatment did not differ from those who received no treatment in time to failure. In the treatment-only model, nonresidential treatment participants took longer to fail than their matched residential treatment counterparts” (Krebs et al. 2009).

Longer durations and greater intensity of treatment episodes have been tied to more successful treatment outcomes. Regardless of whether the treatment is provided in residential or outpatient settings, if the patient is satisfied and remains involved with treatment, their outcome will likely be better than shorter or sporadic episodes of care (Hser, et al.).

Do outpatient services of “full-service” treatment programs provide only steps into and out of the more lucrative residential level of care if financial resources exist?

Residential treatment will produce better profit/ development margins if critical business volumes can be achieved. The higher operating costs, administrative time, and professional oversight of residential components draw decision-makers to focus on their residential treatment at the expense of their less complex and less lucrative outpatient services. It is clear to the margin-oriented administrator that short-term financial gains will be best made from a residential model if only the beds can be filled.

If your principal stakeholder is the consumer or payer of care, cost-effectiveness must take priority. Outpatient treatment, whenever clinically feasible, is the primary access point for both private and public addiction treatment. When higher acuity conditions warrant intensive supervision at the beginning of a treatment episode, “step-down” outpatient treatment provides the necessary duration of care and the sober adaptation to a normative living environment.

In our time of cost cutting and efficiency planning, outpatient treatment coordinated with detoxification, residential stabilization, medical and mental health care, and sober living answers clinical and fiscal problems. Coupled with sober living accommodations, outpatient treatment emerges as the cost-effective and accessible venue of care for many who are in need of recovery and who require a sober living condition and structure.

Bibliography:

“Subjects benefited equally from outpatient and residential aftercare, regardless of the severity of their drug/alcohol problem.” Differential effectiveness of residential versus outpatient aftercare for parolees from prison-based therapeutic community treatment programs. William M Burdon1, Jeff Dang2, Michael L Prendergast1, Nena P Messina1 and David Farabee 1, *Corresponding author: William M Burdon wburdon@ucla.edu, 1University of California, Los Angeles, Integrated Substance Abuse Program, Substance Abuse Treatment, Prevention, and Policy 2007, 2:16 doi:10.1186/1747-597X-2-16

“Previous reviews have concluded that there was no evidence for the superiority of inpatient over outpatient treatment of alcohol abuse, although particular types of patients might be more effectively treated in inpatient settings. We consider the implications of our findings for future research, especially the need to examine the conceptual rationales put forward by proponents of inpatient and outpatient treatment, i.e. mediators and moderators of setting effects.” The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects, JOHN W. FINNEY, ANNETTE C. HAHN, RUDOLF H. MOOS Article first published online: 24 JAN 2006 DOI: 10.1046/j.1360-0443.1996.911217733.x Addiction Volume 91, Issue 12, pages 1773–1796, December 1996

National studies indicate significant reductions in recidivism following outpatient treatment
Pre-treatment Post-treatment, Drug Abuse Reporting Program (DARP), National Treatment Improvement Evaluation Study (NTIES), Treatment Outcome Prospective Study (TOPS)

Outpatient treatment more effective than residential treatment for drug-involved probationers (Krebs et al., 2009) and during reentry and can reduce likelihood of re-incarceration by 63% (Burdon et al., 2004)

Greater benefits for the cost for outpatient treatment in non-offender samples (CALDATA, French et al., 2000, 2002)

Aftercare services among drug-involved offenders can significantly reduce substance use and re-arrest (Butzin et al., 2006)

Aftercare services provide $4.4 – $9 return for every dollar invested (Roman & Chafing, 2006)

17% of Unemployed Workers Have Substance Use Disorder: Survey

17% of Unemployed Workers Have Substance Use Disorder: Survey

By Join Together Staff | December 2, 2013

Jobs_Blog

A government survey finds 17 percent of unemployed workers have a substance use disorder, compared with 9 percent of full-time workers, CNNMoney reports.

The findings, from the National Survey on Drug Use and Health, are self-reported, so the rate of substance use disorders among the unemployed may be even higher, the article notes. The survey included addictions to alcohol, illegal drugs and misused prescription drugs.

An study released earlier this year concluded it is more likely unemployment leads people to substance abuse, rather than drug and alcohol use leading to unemployment. Researchers from theFederal Reserve Bank of St. Louis noted, “During episodes of large increases in unemployment, the number of drug users can increase dramatically.”

A University of Miami researcher who published a study in Industrial Relations earlier this year on alcohol and unemployment says as people become unemployed, they have less income and are less able to afford drugs and alcohol. At the same time, they have more time to drink and use drugs. “Among those who are unemployed, the leisure effect is dominating the income effect,” researcher Michael French told CNN Money. “We find that when the unemployment rate increases, all else equal, drinking increases.”

Is Suboxone a Wonder Drug that Helps Heroin Addicts Get Clean–Or Just Another Way to Stay High?

Suboxone

Pablo Iglesias

Is Suboxone a Wonder Drug that Helps Heroin Addicts Get Clean–Or Just Another Way to Stay High?

By Anna Merlan Wednesday, Oct 23 2013

Five months ago, Chris resolved that it was finally time to get clean.

Suboxone is “not being used in the context we’ve seen it to kick a habit or even to replace a narcotic dependence. It’s just a way to control your habit a little bit better.”

Sort of.

The 34-year-old Brooklyn real estate broker (who declined to be identified by his real name; “Chris” is a pseudonym) had begun using heroin and quit once before, in his late teens. But family problems and a few tough months caused him to relapse, and soon he was snorting the drug two or three times a week.

After nearly a year of using, the days between doses started to get dicey, and Chris got worried. On the off days, he says, “I was never myself. I was irritable, exhausted, had no motivation or desire to do things I once enjoyed doing. I wasn’t happy.”

So, in between bags of heroin, Chris scoredSuboxone, a prescription painkiller used to treat opiate addiction. He’d use it when he was making a halfhearted attempt to get sober, or when he just didn’t want to feel bad between bags. Thanks to its main ingredient, buprenorphine hydrochloride, Suboxone eliminated the agonizing heroin withdrawal, the “three days of complete hell” he had to go through every time he tried not to use.

Chris didn’t get Suboxone through a doctor, at first. He didn’t have to. It was easier and quicker to buy the drug from a friend who had a prescription and lots of leftovers, which he was willing to sell to Chris for $5 a pop. “Subs,” as people often shorthand the drug, come in paper-thin strips, a lot like theListerine kind, that melt under the tongue. Chris’s friend took half of a two-milligram strip each day and sold the extras to Chris.

Eventually, Chris decided he was spending too much money on the subs. He found a physician willing to prescribe him 24 milligrams a day—a “totally ridiculous” dose, he says, far too much for one person to take. (According to the drug’s manufacturer, U.K.–based Reckitt Benckiser, the recommended maintenance dose is anywhere from four to 24 milligrams.) He takes one or two strips each day, two to four milligrams, and sells the rest on Craigslist.

“I don’t work with everyone,” Chris says. “I’m probably more cautious than most.” He tries to weed out law enforcement by asking for Facebook or LinkedIn profiles to back up the buyer’s identity. “I’m not a full-blown addict. I do have a job. I have a lot to lose.” Besides, he adds, “I’d rather sell to someone who wants to get clean, rather than someone who just wants it in between their heroin binges. I’d rather help someone.”

Other dealers up and down the East Coast who sell buprenorphine take the same tack in their Craigslist sales, positioning themselves as stops on the road to recovery.

“If you’re trying to kick your diesel habit, then TEXT me asap!” writes one dealer. “Heroin is overwhelming here in New Jersey, so please do the right thing and get on Subutex asap!”

“Not LE here,” writes another dealer in Soho, using the shorthand for “law enforcement.” “Just a guy with a few extras and looking to help someone in need. Please be real about getting clean.”

“No bs and no le,” echoes a poster in upstate Montgomery County. “I’m just trying to help someone who needs to be off of pain medication.”

The technical term for what Chris and other dealers are doing is “diversion,” and it is, as you might guess, illegal. Selling your meds is a class C felony in New York, carrying a minimum of one year and a maximum of 10 in prison.

In the case of Suboxone and its generic equivalents, diversion is also increasingly common. Suboxone has been on the market in the U.S. since the late 1990s. Over the past two years, sales have skyrocketed, corresponding to a rise in heroin and (especially) painkiller addiction. The number of pain-pill prescriptions hovered around 209.5 million in 2010; the National Institute on Drug Abuse estimates that 5 million people in the U.S. abuse painkillers.

It’s hardly surprising that a drug that can help people get off opiates has become a runaway success. According to IMS Health, a company that collects data about the drugs U.S. doctors prescribe, Suboxone reached $1.4 billion in sales in the first quarter of 2012—nearly 10 times the figure from 2006. Seven years ago, Suboxone was the 198th-most commonly prescribed drug in the U.S. Today, it ranks 26th. In 2012, doctors wrote 9.3 million prescriptions for buprenorphine. From January to March of this year, they wrote 2.5 million more. A majority were for Suboxone, which controls about 70 percent of the buprenorphine market.

As the legal market for the drug expands, so does the black market pooling underneath. If Chris is too picky, Craigslist drug seekers can do business with 24-year-old Luis, who teams up with a friend with a prescription to sell the drug. Luis, who calls himself a “distributor,” is homeless and says he’s selling Suboxone to finance his move out of the shelters. That, and a desire to help folks.

“People thank me,” he says earnestly. “I’m not doing a bad thing. I’m not selling drugs.”

In her line of work, Bridget Brennan sees—and busts—a lot of drug dealers. She’s immensely skeptical of the notion that anyone buying Suboxone on the street is taking it to get clean.

“To me, that seems highly unlikely,” she says. “You don’t need health insurance to go to a treatment center.”

Brennan is New York City’s Special Narcotics Prosecutor, and her office is responsible for prosecuting drug crimes. It was created by the city’s five district attorneys in the 1980s as a way to respond to a new epidemic of heroin and a corresponding citywide increase in violent crimes.

Brennan doesn’t seem surprised, or especially concerned, to learn that people are using Craigslist to sell their detox meds. She notes that Craigslist drug sales have transpired on and off for years. “Our focus is on more of the major suppliers,” she says. “But we do monitor Craigslist, and we do periodic sweeps there.”

Brennan says that, in her experience, most dealers carry Suboxone as a way to keep their clientele happy; in recent years, her office has busted several drug rings that stock it alongside heroin, Xanax, and Percocet. Addicts buy Suboxone when they can’t afford their drug of choice, or when they have a pressing social engagement that requires them not to turn up totally high.

“It’s not being used in the context we’ve seen it to kick a habit or even to replace a narcotic dependence,” she asserts. “What I’ve seen is not a real commitment to getting clean, it’s just a way to control your habit a little bit better.”

Mike Laverde agrees. He’s a former heroin addict himself, now nine years sober and an intervention specialist with a Chicago company called Family First Intervention. Like Brennan, he sees black-market Suboxone users as just another subspecies of addict.

“They think they can take the Suboxone and come off drugs themselves,” he says. “But they can’t. The problem in the drugs department is them.” Without actual treatment, Laverde says, addicts are very likely to fall back into dependence on their drug of choice. That practice—toggling back and forth between the drug you like and the drug that helps you avoid withdrawal—is known as “bridging.”

“People cycle on and off, absolutely,” says Jose Sanchez, a substance-use counselor at the nonprofit Lower East Side Harm Reduction Center. His clients, Sanchez explains, tell him they carefully plan out their drug use. “They’ll stop taking the Suboxone for a couple days, so that by the third day they’ll be able to feel that zing of the opiate, whether it’s heroin orOxycontin.”

It’s unlikely they’ll ever really get clean that way, he adds. “It certainly could work. But I think to be successful, you need every bit of support you can get”—i.e., counseling and a doctor’s supervision.

When someone self-medicates with Suboxone, Sanchez says, “You really can’t judge how well the medicine’s working for you. All you know is you feel good that day, and the next day you want to feel just as good.”

If you wanted to kick an opiate habit the aboveground way, you might visit a doctor likeDana Jane Saltzman, an internist who’s also one of the 1,600 doctors in New York State authorized to prescribe Suboxone. Her practice is hidden away in midtown, in a nondescript, five-story building not far from the marquee lights of the Ambassador Theater. She keeps two websites, one for her regular practice, and the other,NYCSuboxone.com, for people looking to get clean.

Saltzman’s building is a little down at the heels, but her clientele is anything but. Most of her Suboxone patients, she says, are Wall Street guys, “masters of the universe types” who find themselves with a pain-pill addiction and a pressing need to get sober without cutting into their 100-hour workweeks.

“I see a lot of young men, very high-functioning, very ambitious and upwardly mobile,” Saltzman says. Many of them are prescribed Oxycontin after they sustain sports injuries: shoulders, backs, knees. A client came to see her several weeks ago who’d been on the painkiller for two years before he realized he’d become dependent.

Buprenorphine is popular with Saltzman’s patients and other opiate addicts for one basic reason: It too is an opiate.

“It hits and stimulates the same receptors in the brain that are affected by heroin ormethadone,” explains Adam Bisaga. He’s a professor of clinical psychiatry at Columbia University and an addiction researcher at the New York State Psychiatric Institute.

Like other opiates, buprenorphine binds to certain receptors in the brain. It’s “stickier” than drugs like heroin, binding to those receptors faster and holding on longer: Morphine has a half-life of about two hours; buprenorphine’s is anywhere from 24 to 60 hours.

Buprenorphine is also a partial opioid agonist. It doesn’t fill up the brain’s receptors as completely as heroin or painkillers do, making its effects much more muted than the intense euphoria heroin offers.

“It stimulates the receptors, but only to 50 percent,” Bisaga explains. “At some point there’s a ceiling, and no matter how much you take, you’ll never get across that. It’s like an electronic block on your gas pedal in a sports car.”

To further limit its effects, Suboxone contains naloxone, an opiate blocker. The most famous naloxone-containing drug is Narcan, which can treat people during an overdose, and which has no known potential for abuse. Subutex, a Reckitt Benckiser-manufactured formulation that’s pure buprenorphine, is more potent—and in greater demand on the black market. Saltzman says she won’t prescribe it unless a patient has a proven allergy to naloxone.

Suboxone’s older cousin, methadone, is a full agonist, meaning that its effects, along with its getting-high and overdose potential, are that much stronger. But Suboxone offers users a powerful feature methadone can’t match: It’s designed to be taken at home, whereas by law methadone is required to be distributed at a clinic. (In New York, methadone patients can get take-home doses, but they’re tightly controlled; to get a six-day supply, a patient has to have been in treatment for at least three years.)

“You have to go to the clinic every day, and that has a little bit of a reputation,” Bisaga says. “Many people don’t like the idea.”

Buprenorphine was introduced as a treatment for opiate addiction in Belgium in 1983, in the form of little orange tablets that were placed under the tongue. Four years later, it was being used in France. Reckitt Benckiser won approval to distribute Suboxone in the U.S. in 1994, although it wasn’t released here until 2003. At the time, the Food and Drug Administration granted it “orphan” status, which is awarded to drugs that are meant to treat “rare diseases or conditions” and aren’t expected to be profitable. Orphan drugs qualify for generous tax credits, and the FDA can’t rescind the designation once it’s granted.

Suboxone retained orphan status until 2009, when the patent for the tablets expired. Several U.S. drugmakers promptly set to work making generic versions, two of which went on the market this past February. That month, analysts projected Reckitt’s annual pharmaceuticals profit would take as much as a 4 percent hit.

By 2006, Suboxone’s abuse potential had become pretty clear: A study of French buprenorphine users found that a lot of them were crushing up their tablets and injecting them. According to the European Opiate Addiction Treatment Association, the same problem soon turned up in EnglandIrelandScotlandNew Zealand, Australia, Finland, and the Czech Republic. (A recent report in the daily Prague Post estimates that Subutex accounts for 70 to 80 percent of all drugs sold on the street.)

Also in 2006, the federal Substance Abuse and Mental Health Services Administration(SAMHSA) found the same issue cropping up in the U.S., noting that buprenorphine abuse appeared to be “concentrated unevenly in Northeastern and Southeastern regions.”

Seeing buprenorphine cross the Atlantic came as no surprise to Bisaga. “It’s a problem with every drug we have,” he says. “It was just a matter of time.”

Introduce a drug, and soon people will find a way to use it to get high.

According to SAMHSA figures, emergency-room visits involving buprenorphine use “increased substantially, from 3,161 in 2005 to 30,135 visits in 2010, as availability of the drug increased.” More than half of the people seen at the ER reported that they were using the drug “non-medically.”

The researchers who studied French buprenorphine injectors wrote that it seems “pharmacologically impossible” for anyone to get high from the drug. And yet, they say, the addicts did report feeling a “rush” after injecting it, which the researchers chalked up to the placebo effect.

The question for drug- and policy-makers alike is how to short-circuit any new drug’s potential for getting you high. Adding naloxone to buprenorphine hydrochloride is one way to limit abuse, Bisaga says. Another was to pull the tablets off the market and replace them with a film designed to be impossible to abuse. (According to several pharmacies theVoice contacted, brand-name Suboxone tablets are still available, at least in New York, though Reckitt Benckiser had notified the FDA in February 2012 that it would voluntarily discontinue the tablets. The company said at the time that the pills would be off the market by March 2012 at the latest. Reckitt Benckiser did not respond to several requests for comment for this story.)

People still try very hard to make the most of their Suboxone; Internet forums are full of tips and tricks about how to get high off the strips. Some users recommend melting them in water and injecting them, or offer instructions on how to “snort” them. Others insist the would-be stoners are wasting their time, that “bupe” won’t ever get you lifted.

Bisaga begs to differ. “People who are not in treatment, not taking it every day, can get high.” If you take it consistently and correctly, as part of a treatment plan, you probably won’t feel any euphoric effects, he says. But taken more sporadically, it’s possible: “You wouldn’t get as high as with heroin. It’s not such a powerful, instant, intense euphoria. But you’d still feel somewhat affected.”

Some patients in treatment report that the drug has mood-lifting properties. “People often feel good on Suboxone,” notes Saltzman, the Suboxone specialist. “Many people say they feel better than they have in their lives.”

Saltzman has seen the rise of Suboxone abuse firsthand. She has had a license to prescribe it since 2000; in the past few years, the number of patients she suspects are diverting the drug is increasing.

“There’s a constant wave of diversionary tactics in here,” she says. “It’s constant and unending. It’s just piling up.”

She tries to weed out the drug-seekers from the people who are genuinely eager to get sober. She requires patients to attend group therapy and one-on-one sessions with a counselor, and she encourages them to enroll in a 12-step program like Narcotics Anonymous. She also drug-tests them every time they come in to have their prescription refilled.

“If someone doesn’t want to give a urine sample, that’s always a bad sign,” she says. “That may mean their last prescription was sold on the street.”

Saltzman is quick to add that most of her patients—including the ones who relapse or sell their prescriptions—genuinely want to get better. She acknowledges, too, that her treatment is too expensive for many: $400 for the initial visit and $250 for every visit thereafter. The medication itself is covered by insurance, but the office visits aren’t.

That’s by design, Saltzman says. Otherwise “we’d have lines out the door. It would be a whole different thing. Making people pay is about getting their full attention. It’s very intense work, and it’s not at all like primary care.” (By law, Suboxone doctors can only treat a maximum of 100 patients.) A couple of low-cost clinics in the city don’t charge for the initial visit, but most Suboxone doctors’ rates are as steep as Saltzman’s.

As for the price of the drug itself, at a CVS pharmacy, the estimated price for an uninsured person to get 30 days’ worth of Suboxone tablets is $295. At Duane Reade, it’s $315. At Rite Aid, it’s $283. Insurance brings down the price substantially: United Healthcare’s rate is $60 ($25 for the generic). Blue Cross Blue Shield‘s is about $40; Aetna‘s, $75.

Chris, the real estate broker and Craigslist dealer, routinely gets e-mails from people who say the price is what prevents them from procuring the drug legally.

“im interested in yr add,” a recent would-be buyer wrote. “recently lost insurance, and the cost of a doctor/script is just too much fr me right now. very serious about getting off, without getting too sick to work. Im a professional honest guy with a family you can look me up on facebook, just search [redacted] in new york, there is a drawing of a rabbit as my main photo. Please keep it discreet and profess. and i will do the same.”

Motive and legality aside, how harmful is “bridging” with Suboxone? Every dose of buprenorphine is a dose of heroin (or the like) not taken. And a person is far less likely to die from using buprenorphine. According to Joshua Lee, a professor at New York University Medical Center and an attending physician at Bellevue Hospital, buprenorphine has “less overdose potential” than methadone. In particular, it’s less likely to cause “respiratory depression”—the physical state when breathing becomes so shallow as to no longer provide the body with oxygen.

“As doctors prescribing it, we’re very concerned with this,” Lee says of black-market use. “And we discourage people from doing that. But from a public-health, harm-reduction standpoint, we acknowledge that diversion of buprenorphine seems different than diversion of oxycodone, say, or Xanax.”

“So many people who cannot afford the medications from legitimate sources are basically buying it on the street to treat themselves,” offers Bisaga, the Columbia professor and addiction researcher. “I don’t think these people are doing it to get high—although certainly there are people like that. I think most of them are just trying to get treated at low cost, which is obviously a tragedy. Most developed countries in the world have free treatment for drug addicts and this is no longer an issue.”

A few months after he began selling his prescription on Craigslist, Chris has decided to stop for good. “I pulled all my ads down,” he says.

Chris is muscular and pale, and he looks exhausted. He’s wearing a V-neck sweater and jeans, and carrying a shoulder bag that looks like something a doctor making house calls might use. He says he saw “many, many” people in the few months he was selling—including attorneys, fellow real estate brokers, and even one addiction counselor.

Chris says he got himself off Suboxone, a process he describes as “brutal.” He did it by transitioning to the painkiller Percocet, then weaning himself off that.

The experience of detoxing left Chris with mixed feelings about Suboxone. “On the one hand, it is a good thing,” he says. “It keeps people from stealing and robbing and overdosing. But it really just masks the issue: the addiction. From heroin withdrawals, you move onto Suboxone, and then you have to go through those withdrawals. It’s something that’s going to happen, but a lot of us choose to prolong it.”

In the longer term, he adds, the drug also made him feel “like total shit.”

“My girl always says I couldn’t even formulate sentences,” he explains. “I was not articulate. I couldn’t fuck her, excuse my language. I was just totally like a zombie. And then my feet were constantly uncomfortable. I couldn’t sleep without it. My eyeballs would turn into like these huge dishes, big pupils like Mickey Mouse.”

To his dismay, Chris realized that he initially felt even worse when trying to pull back on the Suboxone than when he experienced heroin withdrawal. “You’re exhausted for a very long time. It takes forever to get out of your system,” he says.

He believes now that his doctor didn’t adequately warn him that the detox drug had the potential to be addictive, nor about its “sticky” properties. “The doctor I was seeing—it was literally five or 10 minutes—he sits there and gives his typical speech about how bad drugs are, et cetera, and then he writes a scrip, and I’m gone. He gets paid, I go fill it, and that’s it.”

Saltzman says some Suboxone doctors operate as little more than drug mills. “I had one of them get arrested right in front of me on 57th Street the other day,” she says. In part, she goes on, the problem may have to do with how Suboxone doctors get their licenses. Ten years ago, in order to be able to prescribe the drug, she was required to complete a two-day class at Mount Sinai Hospital. These days, she says, “it’s an Internet course that takes a couple of hours.”

Chris also was disturbed to hear his doctor tell him that he might have to use buprenorphine for the rest of his life. “It made me feel like a loser,” he says.

Adam Bisaga takes a different view. “This is the push that they hear from [12-step programs],” the Columbia professor says. “That recovery with medication is something inferior. That you’re not truly in recovery until you take nothing. It’s not science. It’s just ideology from a 12-step movement that makes them vulnerable to relapse.” (Responds a spokesman for Narcotics Anonymous: “The experience of NA members is that being clean means complete abstinence from all mood- and mind-altering drugs. That said, NA welcomes everyone. Ultimately, we’re not in the business of telling people blanket statements about whether they’re clean or not.”)

“On the other hand,” Bisaga adds, “you do hear the stories of the pharmaceutical industry pushing people to stay on as much medication as possible. Depending on where you stand in this conversation, you can hear arguments on both sides. We rely on science and effective treatments, and we’d like patients to make informed decisions on their future.”

Saltzman says some of her patients are, for all practical purposes, on the drug permanently, but she doesn’t encourage it. “I don’t like that idea. It’s not a healthy way to live,” she says. “To me it speaks to someone not wanting to look at themselves.”

Chris gazes out a window and rubs his legs, which sometimes still hurt. “At some point,” he says, “you have to pay the piper. There’s no easy way out with opiate addiction.”

Asked how long he’s been clean, he smiles, looking both proud and more tired. “Two weeks,” he says.

amerlan@villagevoice.com

Rehab center earns honors for work with disabled

http://www.ocregister.com/articles/disabled-530421-twin-schlesinger.html

Published: Oct. 10, 2013 Updated: 8:29 a.m.

Rehab center earns honors for work with disabled

8 Photos »

By ASHER KLEIN / ORANGE COUNTY REGISTER

A Los Alamitos-based drug and alcohol treatment center was given two awards by Cal State Long Beach’s Disabled Student Services for its work with the disabled.

Members of Twin Town Treatment Centers were recognized for “Outstanding Achievement in Disability Advancements” and “Outstanding Achievement in Motivation for the Disabled” on Tuesday. The organization was recommended by its own employee, Rob Schlesinger, for making the place accessible to him.

Debbie

Debbie Muehl, left, senior counselor at Twin Town Treatment Centers, Inc., receives an award for Outstanding Achievement in Disability Advancements for her office from David Sanfilippo, director of disabled student services at California State University, Long Beach and Rob

ANIBAL ORTIZ, ORANGE COUNTY REGISTER

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Schlesinger has cerebral palsy, which though it hasn’t stopped him from counseling others, or Twin …

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Number of People Seeking Addiction Treatment Could Double Under New Health Law

By Join Together Staff | September 12, 2013 |

Addiction_Treatment

 

The number of people seeking addiction treatment could double under the Affordable Care Act, the Associated Press reports. Under the new law, four million people with drug and alcohol problems will become eligible for insurance coverage. The surge of new patients is likely to strain the substance abuse treatment system, the AP notes.

How many new patients will seek addiction treatment will depend in part on how many states decide to expand their Medicaid programs.

“There is no illness currently being treated that will be more affected by the Affordable Care Act than addiction,” Tom McLellan, CEO of the nonprofit Treatment Research Institute, told the AP. “That’s because we have a system of treatment that was built for a time when they didn’t understand that addiction was an illness.”

The new law designates addiction treatment as an “essential health benefit” for most commercial insurance plans, meaning the plans must cover it.

Substance abuse treatment is to a large extent publicly funded, and run by counselors who have limited medical training, according to the article. Programs are already running over capacity in many places, and have been hit by government budget cuts. The increase in patients could result in long waiting lists, treatment agencies warn.

According to the 2012 National Survey on Drug Use and Health, 23.1 million people ages 12 and older needed treatment for an illicit drug or alcohol use problem last year, but only 2.5 million received treatment at a specialty facility. About one-quarter of those who need treatment but do not receive it lack insurance, according to the article.

CDC state data shows high costs due to excessive alcohol use

 

Costs mainly due to binge drinking

Excessive alcohol use causes a large economic burden to states and the District of Columbia, according to a new study released by the Centers for Disease Control and Prevention. Excessive alcohol use cost states and D.C. a median of $2.9 billion in 2006, ranging from $420 million in North Dakota to $32 billion in California. This means the median cost per state for each alcoholic drink consumed was about $1.91.

Binge drinking, which is defined as consuming five or more drinks on an occasion for men or four or more drinks on an occasion for women, was responsible for more than 70 percent of excessive alcohol use related costs in all states and D.C. The District of Columbia had the highest per-person cost ($1,662), while Utah had the highest cost per drink ($2.74). Furthermore, about $2 of every $5 in state costs were paid by government, ranging from 37 percent of the costs in Mississippi to 45 percent of the total costs in Utah.

Study authors found that costs due to excessive drinking largely resulted from losses in workplace productivity, health care expenses, and other costs due to a combination of criminal justice expenses, motor vehicle crash costs, and property damage. Across all states and D.C., excessive drinking costs due to productivity losses ranged from 61 percent in Wyoming to 82 percent in D.C., and the share of costs due to health care expenses ranged from 8 percent in Texas to 16 percent in Vermont.

“Excessive alcohol use has devastating impacts on individuals, families, communities, and the economy,” said CDC Director Dr. Tom Frieden, M.D., M.P.H.  “In addition to injury, illness, disease, and death, it costs our society billions of dollars through reduced work productivity, increased criminal justice expenses, and higher healthcare costs.   Effective prevention programs can support people in making wise choices about drinking alcohol.”

Economic cost estimates for states and D.C. were based on a previous CDC study that found that excessive drinking cost the United States $223.5 billion in 2006. Costs were assessed across 26 cost categories using data from several sources, including the Alcohol-Related Disease Impact Application, the National Epidemiologic Survey on Alcohol-Related Conditions, and the National Survey on Drug Use and Health.

Researchers believe that the study’s findings are underestimated because it did not consider a number of other costs, such as those due to pain and suffering by the excessive drinker or others who were affected by the drinking.

“It is striking to see most of the costs of excessive drinking in states and D.C. are due to binge drinking, which is reported by about 18 percent of U.S. adults,” said Robert D. Brewer, M.D., M.S.P.H., Alcohol Program Lead at CDC and one of the authors of the report. “Fortunately, theCommunity Guide includes a number of effective strategies that states and localities can use to prevent binge drinking and the costs related to it.”

Excessive alcohol consumption is responsible for an average of 80,000 deaths and 2.3 million years of potential life lost in the United States each year.  Binge drinking is responsible for over half of these deaths and two-thirds of the years of life lost.

The study, “State Costs of Excessive Alcohol Consumption, 2006,” will be available today athttp://www.ajpmonline.org/ and in the October 2013 digital issue of the American Journal of Preventive Medicine.  For more information about the prevention of excessive alcohol use, visithttp://www.cdc.gov/alcohol/.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

CDC works 24/7 saving lives and protecting people from health threats to have a more secure nation.  Whether these threats are chronic or acute, manmade or natural, human error or deliberate attack, global or domestic, CDC is the U.S. health protection agency. 

http://www.cdc.gov/media/releases/2013/p0813-excessive-alcohol-use.html