The Best Laid Plans

Mac Miller – 26 year old rapper – died of an apparent overdose last week. One more beautiful young person lost in the prime of life. Friends and fans have unanimously said he was one of the sweetest guys they’d ever known with a great sense of humor. Miller spoke openly about his struggles with addiction over the years: “It just eats at your mind, doing drugs every single day, every second. It’s rough on your body.”

August 31st is International Overdose Awareness Day. I think we are all very aware of the enormous and continuing-to-rise number of drug––mostly opioid––overdose deaths. It is clear from conversations with many of the famous and not-famous users, like our son, that they have every intention of controlling their addiction and no intention of overdosing. But something goes wrong…

Dr. Jana Burson, an addiction treatment physician in North Carolina, has a great blog (https://janaburson.wordpress.com/) with insights gathered from her patients, many of whom are long-term opiate abusers. “I’m not gonna overdose. I know my limits.” Dr. Burson writes in August 2017: “I really hate hearing these words. Usually patients say this in response to my concerns about their pattern of drug use while I’m prescribing methadone or buprenorphine. But many patients feel they are the experts. They can’t imagine making a deadly mistake with their drug use. But I’ve heard this phrase from people who are now dead from overdoses.”

She recently cited a study in Australia 2013, where overdose deaths have risen steadily since 2007. In that country, unlike the U.S., heroin use is declining while prescription opioid misuse is rising. This study looked at non-fatal overdoses in very experienced people who inject drugs––an average of 21 years of IV drug use––half of whom were in a MAT (Medication Assisted Treatment) drug program.

Most of these overdoses happened in private homes––many the subjects said they were impaired by alcohol or benzodiazepines. Over a third of the subjects had used fentanyl, a very powerful illicit opioid, leading up to the overdose. The authors of the study concluded that these experienced drug users were aware of common risks for overdose, yet drug intoxication from sedatives such as alcohol or benzodiazepines may have clouded the user’s thinking when injecting opioids. They also found that unexpected availability of drugs contributed to overdoses.

This was our son’s story: It was his first night after 6 months in sober living––but it was not his first night using again. He had been on Percocet for oral surgery (a huge mistake) a month before he overdosed and then had returned to IV heroin use the week before his overdose. He had been drinking with friends the first night in his new apartment––his decision making abilities were impaired. We are not sure exactly how much heroin he injected, and since it was Black Tar heroin from Mexico, the strength is absolutely unpredictable. What we do know from the autopsy is that he had many times more heroin in his body than a fatal dose. His was an overdose that he would not survive. Was this his last conscious thought: “I’m not gonna overdose. I know my limits.”?

Epidemic Worsens, Hope Wains

In a March 6, 2018 public health report on NPR, Rob Stein reported the grim news on recent CDC statistics: across America, overdoses from opioids increased by an average of 30% in 2017––some areas were as high as 109% while others remained stable at 20%––occurring in every region and every age group of men and women. The latest data could underestimate the overdoses, because many people who overdose never end up in the emergency room (like our son) so are not accounted for.

“We think that the number of people addicted to opioids is relatively stable. But the substances are more dangerous than five years ago,” acting CDC Director Anne Schuchat says. “The margin of error for taking one of these substances is small now and people may not know what they have, due to availability of newer, highly potent illegal opioids, such as fentanyl.”

Sadly, 20 years on in the opioid epidemic, things are still worsening and government policies are doing nothing to help. Declaring it a “health emergency” but failing to fund quality public health care and the long-term recovery expenses that are essential for opiate recovery is creating a false sense of well-being when there is none.

“Emergency room staff need better training to make sure people with substance-use disorder get follow-up addiction treatment,” says Jessica Hulsey Nickel, president and CEO of the Addiction Policy Forum. “Too often, addicts are simply revived and sent home without follow-up care, only to overdose again. We can use this near-death experience—use it as moment to change that person’s life.”

These overdose deaths have contributed significantly to life expectancy in the US dropping for the second year in a row. This is alarming public health officials since life expectancy gives us insight into the health of a nation––the last time we had a drop was during the AIDS epidemic.

In another study about “Deaths of Despair”, Anne Case & Angus Deaton, economists at Princeton University, report “It’s also a crisis in which people are killing themselves in much larger numbers—whites especially. Deaths from alcohol have been rising as well––we think of it all being signs that something is really wrong and it is happening nationwide…The decline of well-paying jobs, security and good benefits may be fueling a sense of frustration and hopelessness,” Case says. “That may be one reason fewer people are getting married and having children outside of marriages.They have a much more fragile existence than they would have had a generation ago. As a result, these deaths are related to the fact that people don’t have the stability and a hope for the future that they might have had in the past.”

Hope for the future––something we all need––something that is increasingly hard to find in our fragmented society. Many, many voices are calling us to return to the basics for sustained human health and growth: real community, true spirituality, public and private integrity, simplicity of lifestyle, and sincere and tangible love for each other: love is a verb

https://www.npr.org/sections/health-shots/2018/03/06/590923149/jump-in-overdoses-shows-opioid-epidemic-has-worsened

https://www.npr.org/sections/health-shots/2017/12/21/572080314/life-expectancy-drops-again-as-opioid-deaths-surge-in-u-s

SAFETY NETS

On August 7, 2018, Rolling Stone reported that Demi Lovato was given Narcan (naloxone) by paramedics in response to a drug overdose after 6 years of sobriety.“I want to thank God for keeping me alive and well,” she said. Yes, God – He works through people and available medications. After 2 weeks in the hospital, she entered rehab. I imagine she has health insurance for hospital expenses and the rehab costs should be no question considering her career.

But how many other Americans battling addiction are not insured – or under-insured – or insured without mental health or rehab coverage, as our son was? And how many can afford the costs of detox, rehab, medications, and long-term recovery programs? Here are some average costs:
Outpatient detox: $1500
Inpatient rehab: 30 days, up to $30,000 / 60-90 days, up to $90,000 or more
Medication: Methadone $5,000 yr / Suboxone $200-600 mo
Sober Living Homes: $500-$2000 mo

Opioid addiction needs detox, rehab, medication, and then – as has been proven time and time again – at least a year of sober living and perhaps a lifetime of medication – along with a 12-step community. Where is a student or an unemployed or under-insured addict supposed to go when there are no safety nets in our society?

The New York Times August 8, 2018 article “Too Little Too Late: Bankruptcy Booms Among Older Americans” – another group for whom safety nets have disappeared. In a study from the Consumer Bankruptcy Project, “A three-decade shift of financial risk has occurred from government and employers to individuals – who are bearing an ever-greater responsibility for their own financial well-being as the social safety net shrinks…older Americans turn to what little is left – bankruptcy court.”

We, as a society, should be ashamed of this. Are we so independently minded and lacking in empathy that we cannot accept the need to collectively care for the weak among us – those in need – with social safety nets? In previous generations, families took care of their own – from birth until death. But as modern society has shifted from rural and communal to urban and individualistic, there is a need for we as a society to have safety nets in place.

Our daughter and family live in Australia. They are the beneficiaries of one of the best single-pay health systems in the world. When we tell friends about it, the response is, “They have socialized medicine, right? They can’t get medical care when they need it and people die on the streets.” As the conversation continues, we hear they are a socialist country and lack freedoms we enjoy. None of this is true. They enjoy a very good standard of living and pay higher taxes – taxes that provide a safety net for each and every citizen.

As the opioid epidemic continues to take the lives of so many, leaving families destroyed, we need to not only acknowledge that addiction is a disease that can be treated with medication, rehab, and community, but also fight for a health insurance system – a social safety net – that cares for Americans from birth through death.

 

BLOG: MAT, Part 2

MAT––Medication Assisted Treatment. Dr. Hillary Kunins, a clinical addiction expert, dispels the notion that treating an addiction patient with medication is simply exchanging one drug with another. Here is a link for a 2 min video where Dr Kunins offers a simple explanation of why physical dependence is not the same as addiction.

Here are the drugs that are currently in use for opioid addiction. Methadone has historically been used for heroin addiction, since the early 1970’s, when it was authorized by the FDA but restricted to daily dispensing clinics. Because it is an opioid-like drug, it has tended to only keep addicts alive, but never really able to be drug-free.

Nearly a half-century ago, buprenorphine was developed in England, where chemists were competing to invent a less addictive painkiller than morphine––it turned out to be far more addictive. It is now sold as Subutex and is an opioid partial agonist. An agonist is a chemical that binds to a receptor and activates it, producing a biological response. Like heroin, buprenorphine attaches to the brain’s opioid receptors creating euphoria, but it does not plug in as completely, so its effects are reduced. It is slower acting and longer lasting, attenuating the rush of sensation and eliminating the plummets afterward. But there is still potential for abuse and it can produce side effects such as respiratory depression.

Naloxone (Narcan, Evzio, injectable or intranasal spray) was patented in 1961, and is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids and decreases the desire to take opiates. Whereas an agonist causes an action, an antagonist blocks the action of the agonist. It has been used in hospital “code arrest” emergency situations for decades. It was used on me before a surgery when I had been given too much anesthesia and was beginning to go in to respiratory arrest. It is being carried by emergency personnel and families of addicts because it can very quickly restore normal respiration to a person whose breathing has slowed or stopped as a result of overdosing with heroin or prescription opioid pain medications.

Naltrexone (Vivitrol, monthly injection) is an opiate antagonist that is more slowly released than naloxone. It is primarily used to manage opioid dependence or alcohol dependence and abuse by blocking neural pathways to the brain for dopamine neurotransmitters. It requires going through complete withdrawals and detoxification first because it will not work until opioids are out of the system. People who try to take opioids after taking naltrexone are at risk for opioid overdose and death since it takes using large amount of opioids to overcome its effects.

Suboxone––four parts buprenorphine, one part naloxone––was approved by the FDA in late 2002. Generally, although not accurate, when the word “buprenorphine” is used, people are referring to Suboxone. In addition to side effects from the buprenorphine in Suboxone, if a person has been taking it for a long time and they no longer receive it, they will suffer withdrawal symptoms similar to those suffered when stopping other forms of opiates. And, suffering from these withdrawal symptoms can worsen underlying mental disorders like anxiety or depression. At times, withdrawal can become overwhelming, which happened to jL, which sends patients into buprenorphine abuse and dependency. This has created a debate over the use of Suboxone and Subutex for addiction treatment.

A new study in The Lancet (January 27, 2018), sponsored by the National Institute on Drug Abuse (NIDA), compared the effectiveness of extended-release naltrexone with buprenorphine-naloxone in the US. The results were both promising and disappointing. While naltrexone is as effective as buprenorphine-naloxone once treatment begins, it is also significantly more difficult to actually start naltrexone because of the prolonged detox period—which can span more than a week—that buprenorphine-naloxone does not.

The biggest regret we have had since our son’s death in 2014 is that we did not take his doctors advice and have John Leif on Suboxone. There were many reasons that went into this decision, but the main one was that our health insurance did not pay the costs for any “mental health” coverage. Since we had so many years of our son’s relapses and recovery expenses, we decided to let him just “try harder” with the 12-steps and a sober living house. Sadly, it was not enough for a young man who desperately wanted to be clean and free of his enslaving addiction––he need MAT and we believe he would be alive today if he had been given that option.

Medication Assisted Treatment – Part 1

Medication Assisted Treatment, or MAT, is finally gaining acceptance as a response to drug addiction in the US––it is a cultural shift from the view that addiction is a “moral failure.” The Hazelden Betty Ford Foundation, one of the top drug treatment providers in the country, used to subscribe almost exclusively to the abstinence-only model, based on an interpretation of the 12 steps of Alcoholics Anonymous and Narcotics Anonymous popularized in American addiction treatment in the past several decades. But in 2012, they announced they would begin providing MAT. There are four opioid substitutes that are used for MAT in opioid addiction: methadone, buprenorphine, naloxone, and naltrexone. More on these in the next blog.

November 6, 2013, the New York Times did an extensive article discussing the development, use, and risks of opioid substitutes, in particular bupreorphine and the combination drug, Suboxone. The author explaining that “While addiction is considered a chronic, relapsing disease, experts believe that replacing illegal drugs with legal ones, needles with pills, or more dangerous opioids with safer ones reduces the harm to addicts and to society. Addicts develop a tolerance to its euphoric effects and describe themselves as normalized by it, their cravings satisfied. It also diminishes the effects of other opioids but, studies have shown, does not entirely block them, even at the highest recommended doses.”

In a Frontline report in 2016, one of the doctors who specializes in addiction medicine related that doctors are limited by the DEA to treat only 100 patients per year with Suboxone. The thought behind this law is that they don’t want it to be abused––and it can be abused, as a commodity sold on the street to ward of withdrawals or for those who cannot afford the cost of a doctor and the medication. Our family faced the dilemma of the high costs for the doctors visits and the Suboxone because they were not covered by our son’s health insurance. We made the decision for him to not use this option, all hoping that a sober living house and meetings would help him succeed in his desire for sobriety. He was dead from a heroin overdose 7 months later.

The physician on Frontline pointed out the contradiction––the contradiction that has frustrated me and my husband for years––that there is still no limit on how many oxycodone or other opioid prescriptions physicians can write—the very abuse of which is documented to be fueling the opiate epidemic and creating the need for Suboxone. I personally experienced this absurd mentality towards opiates when my oral surgeon sent me home with 60 Vicodin after a root canal––60. I used two. He is the same oral surgeon who did JL’s wisdom teeth extraction and gave him multiple prescriptions for Percocet two weeks before and two weeks after the surgery––which fueled his relapse on heroin and ultimately, his death. He should have his license revoked.

As of a 2017 report by SAMHSA (Substance Abuse and Mental Health Services Administration), physicians who have prescribed buprenorphine/Suboxone to 100 patients for at least one year can now apply to increase their patient limits to 275 under new federal regulations. It is good to see movement in the right direction and I hope there will be more progress soon, especially in terms of making medication options a covered public health care benefit available to addicts who want to get their lives back.

 

 

Finding Help Thru The Maze

My husband and I just returned from a wonder-full vacation in Europe. We felt privileged and blessed in every way. Although we were enjoying our new experiences together, our son’s death from a heroin overdose was never far below the surface. We carry a lingering pain, knowing that although we tried our best to help our son, the three of us could never seem to find our way through the maze of dead ends and wrong turns for the right treatment for his increasing dependence on the substance that would eventually take his life.

While we were in the Netherlands, my husband, a pharmaceutical scientist, was contacted by a client and asked to analyze data from a drug study that was being conducted 15 minutes away from where we were. The human study, in those with opioid addiction and the control group without, is searching for a better medical approach to help addicts when they want to become clean and sober.

Half a world away from home we were reminded of people struggling with opioid addiction. And half a world away, there is still shame and stigma attached to being an addict, and there are parents, families, and friends living with the pain of watching someone they love not actually living life but hanging on from day to day, never knowing when their loved one will be another statistic in the world-wide epidemic in which there are few viable options for help.

The ongoing opioid crisis has drawn attention to the widening gap between the high need and limited access to substance use treatment in the United States. A recent Substance Abuse and Mental Health Services Administration report found that of 21.7 million Americans in need of substance use disorder treatment, only 2.35 million received treatment at a specialty facility. This led to a new study recently published in the Journal of Addiction Medicine, where several researchers and physicians searched for the predominant barriers for addicts receiving treatment (https://scienmag.com/study-looks-at-barriers-to-getting-treatment-for-substance-use-disorders).

Four broad themes were identified:
Patient Eligibility – Difficulties in determining patient eligibility for a particular and appropriate treatment center.
Treatment Capacity – Even if a patient is eligible, providers have trouble finding out whether space is available.
Knowledge of Treatment Options – Health care providers may not understand the levels of available and appropriate care for substance use treatment.
Communication – Difficulties in communication between referring providers and treatment facilities contribute to delays to starting treatment. The need for direct referral – “from the emergency department to a bed” – is particularly high for patients with opioid use disorders.

“Access to substance use disorder treatment is often a maze that can be difficult to navigate for both providers and patients,” Dr. Blevins and coauthors write. Yes, and it was even more so for those of us who found our teenager using heroin in the early 2000’s. No one was talking, our doctors had no experience with opioid addiction, treatment options were extremely hard to find and expensive, and for many of us, not covered by insurance.

For those of us who tried so hard to maneuver our way through the maze, we continue to live with the pain from feeling that we failed our son in a million different ways, while we tried so hard to get it right. May our being open about our experiences help those of you still living a tension-filled life find the answers you need to get you through the maze quickly so there may be a different outcome for you or your loved one.

GENETICS AND OPIOID VULNERABILITY

Addiction is recognized as a disease by scientists, and now, finally, by most of us. It is no longer considered a moral weakness except by some who, like The Emperor and his new clothes, can’t see their own “moral weakness” but only those of others. Enough said.

As DNA research gains new insights by the day, we are learning how our DNA codes are regulated which will help in opioid treatments and prevention. Tiny differences in a persons DNA called single-nucleotide polymorphisms, SNPs, can indicate whether we have a higher or lower risk for addiction. Some of us have an opioid receptor gene with a single building block change that protects us against substance dependence in general and opioid dependence in particular. This is why the ‘opioid euphoria’ I wrote about doesn’t happen for us. But for others, variations in genes for three dopamine receptors – signaling pleasure – cause increased risk for opioid addiction.

Exposure matters in genetic expression, even across generations, according to how our body’s cells read them. In a recent study of opioids in rats (cited in the Ohio Society of Addiction Medicine’s blog on May 31, where much of this article is referenced from) the parents exposure to opioids changed the way their offspring read their DNA code, lessening their susceptibility to opioid addiction. This shows how one generation’s experiences can change the destiny of the next generation and although it hasn’t been studied in human substance abuse, it has been seen in other complex diseases like obesity.

Research suggests that people born into a culture of drug use may be more inclined to get and stay sober. Epigenetic’s may play a role. How this effects individuals born into a family with addiction issues like alcoholism, drugs, smoking, gambling, etc. is still unclear. For some of us, we observed behavior in our parents or relatives and made a concerted effort to not repeat it. Although our genes may have given us tendencies towards an addiction, a strong repulsion steered us away from it – and in my case, a strong dependence on the Lord.For our son, had we known how many of our relatives had addiction issues and how much power the addictive genes had, we would have been less permissive with our son in regards to drinking at an early age – and certainly more proactive once he was addicted to opioids. It might have changed the outcome for his life. I pray this information will help you, your family, and friends avoid the heartbreak we have had to live with.