JUST SAY “NO” TO FAILED DRUG POLICIES

I recently returned from Australia and began to connect with the addiction community there via several agencies and their newsletters and articles. One very thoughtful article published by Family Drug Support Australia (FDS) is excerpted here. Written by an emergency room physician who is on the front line with overdose victims, he is also a parent who is concerned for his children’s future unless drug policies in Australia change sooner rather than later. There, as in the US, bureaucrats spend years discussing options for change while people die in the tens of thousands. However, from people I’ve spoken with there and from all I’ve read, they are ahead of us in some significant areas. May we all learn from each other.

Stop sacrificing young lives at an altar of drug dogma
By David Caldicott
December 11, 2018

I am the very proud father of some very naughty children, and I would happily walk through fire for them. I am also an emergency consultant with an interest in illicit drug overdoses and, by obvious extension, how to reduce them.

Since the death of yet another young man at a music festival this weekend, from a presumed overdose, it is in this latter capacity that I have been asked, on several occasions now, “How do you feel about another festival death in New South Wales?”…

Put aside the politics & policy debates. A young man is dead before his time…Allow yourself, for one terrible moment, to let that wash over you, as if it were happening to your loved ones. And now tell me what you wouldn’t do, how far you wouldn’t go, to stop that happening to your family.

This is the perimeter around which I perpetually hover. I am the man who rings you to tell you that your child or partner is in our department, and that you need to come into hospital — right now. I am the man who will hold your hand if you need me to, and tell you that I am sorry…I am the man who will agree with you that you never suspected that your loved one, my patient, was in the slightest bit interested in using drugs. Every time I do this, part of me breaks, and I rush home to hold my own a little tighter.

Australia’s National Drug Strategy supposedly is based on the three pillars of demand reduction, supply reduction and harm reduction, but it is effectively a one-legged milking stool. Research conducted by the agents tasked with implementing drugs policy shows that the lion’s share of the money we spend on drugs policy goes into prohibition.

We are not without evidence to guide us from around the world. In the early 2000s, Portugal was in a worse place than where Australia is now. By flipping expenditure on drugs policy to shift the focus to health outcomes, Portugal now has a drug-related death rate 10 times lower than Australia’s.

…my heart breaks for the parents and loved ones of yet another curious, bright, naughty kid who was unlucky enough to eat the wrong thing at the wrong time…How would I cope with the loss of one of my own, in the knowledge that society has not implemented everything that it could to ensure the tragedy could be avoided? That some in society might think that it “serves them right”, dabbling with infractions of the law. Really? Death as a “learning outcome”? 

In the end, this issue is not going to be resolved… by opponents inspired by the un-attainable ideology of a “drug-free Australia”… This is an issue that will be bled out of Australia, life by life, until such time as parents decide: “No more.” I have yet to meet a parent who is prepared to sacrifice their child on this altar of ideology and I abhor those who embrace the rhetoric that suggests this is reasonable.

It’s not reasonable that young people should die before the generation that preceded them. It’s not reasonable to accept that as a norm. What is reasonable is for any civilized society to leave “nothing in the locker room” when it comes to keeping people alive.

Leadership requires bravery and wit, and whatever it is we’re seeing from politicians on drugs policy, it’s neither courageous nor clever. And if politicians of any shade can’t look down the barrel of a camera and say that they will commit to that, they don’t deserve the job with which they’ve been entrusted and for which we pay them.

David Caldicott is a consultant emergency physician at Canberra’s Calvary Hospital in Australia.
Original article can be found at:
https://www.fds.org.au/messageboard/opinion-piece-by-david-caldicott-from-canberra-s-calvary-hospital

 
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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 by displacing them from the opioid receptor sites in the brain.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.