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.

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.

Opioid Euphoria

What do you feel when you take a narcotic/opioid pain pill?

There are usually three reactions people have after having being given them for the first time for pain relief: we are disoriented and uncomfortable, even while our sensation of pain is temporarily deadened; we feel ambivalence combined with gratitude for the pain relief and the willingness to have that relief for the next pain-inducing event; or we feel that we have finally found nirvana.The truth about opioids, pain relief, and addiction has long been unclear and confusing. Sadly, this has been purposefully done by the makers of these drugs with one goal: profits. But these statistics are now becoming well known and will hopefully help reverse the trend of opioid addiction and deaths:

Approximately 25% of people who use an opioid will become addicted after a short period of use, which could be once, 3 days or a week.

The longer you use an opioid, the chances will increase that you will be addicted. This is because almost everyone will build up tolerance to them, which leads to addiction.

Genetics play a very important, but as yet not fully understood, role in what type of reaction each of us have to opioids. What is clear is that those families who have tendencies toward addictions – alcohol, drugs, food, gambling, sex, etc – will be those most likely to be drawn to opioids due to sensing them as pleasurable. There is something in their brain that is wired differently than others.

Our addiction doctor and recovery counselors have explained it to us and this is the essence: There are four areas of the brain that handle the substances and experiences we send it. Very simply put, they are:

Pain center: The PAG, known as the central gray, has cells that produce enkephalin that suppress pain

Emotional center: The amygdala regulates how we process emotions, memories, and rewards

Addiction center: The nuclean accumens, due to neuroplasticity, changes over time and builds up tolerance

Control center: The brain stem, the control center between the brain and the rest of the body, controls basic body functions like breathing, swallowing, heart rate, consciousness, etc.

The first three areas have the ability to build up tolerance, which is what keeps addicts coming back for more – and each time needing more. That is the nature of tolerance. The fourth area, the brain stem, has the least ability to build up tolerance. This is why an overdose – using an amount that is significantly more than what your body has built up a tolerance for – shuts down the respiratory center and you stop breathing.

In our family, and in the families of our son’s friends who are addicts or alcoholics, there are definite genetic predispositions to alcoholism that is traceable back many generations. Other addictions are no so easily identified, but they are there. It is not something anyone initiated or wanted or can change. But what can change is knowing the genetic trait is present and taking preventative steps as early in life as possible.

Talking openly and honestly about our predecessors – and our own – addictions is the first step. Seeking wise informed counsel for what things to avoid, especially while young, may help prevent some of the pitfalls. But for most teens, and especially for those from high risk families, experimentation will be unavoidable. Knowing as soon as possible if your child is moving away from their normal behavior and intervening with proven methods may save them – and you – from the pain that hundreds of thousands parents like my husband and I have now had to live with.

H.A.L.T.

What does the acronym HALT mean? And why is it an important part of a recovery plan? Hungry, Angry, Lonely, Tired: these are warning signs, red flags. HALT is a tool to remind us to stop – halt – and take a moment to listen to what our emotions and body are telling us.

I am not an alcoholic or addict – you may not be either. So why did I use ‘us’ as I wrote this blog? Because all of us are subject to these basic needs – human needs – and if they are not met, we will instinctively search until we find a way to have them fulfilled. Our responses may not be as self-destructive as an addict or alcoholic, but they will affect our relationships in one way or another. Let’s be careful to not make such a wide differentiation between addicts / alcoholics and us: the ‘us vs them’ mentality that makes ‘us’ superior and ‘them’ inferior.

Hungry. This can be physical, emotional, or spiritual hunger. Physical hunger is fairly easy to satisfy, but for many addicts, getting nutritional meals can be a struggle. Yet it is still easier than getting the affection and understanding that is even more vital to our well-being. This is why a strong support system is so important – and must already be in place before a time of need. Attending meetings is good, but being part of a small group is even more critical.

Angry. This is a normal human emotion. The key is to self-assess and decide why we are angry and what we can do about it. If the issue is out of our control or we aren’t ready to confront it, we look for other ways to release the anger. Exercising, meditation and prayer, and creative outlets can help, as is having a trusted friend or counselor to discuss our feelings with. Whatever we do, denying or repressing anger will not be healthy for us long term.

Lonely: We can be lonely in a crowd or in our room. It is a sense of being isolated, not understood, not appreciated, fearful. Withdrawing feels safe when we are overwhelmed or anxious, but for many addicts it can lead to relapse. I will never forget a conversation with our son when he said “I hate being alone”. I was shocked because he had always been more of an introvert than our daughter. But once he was addicted to opioids, I think the isolation that occurs while using became like prison to him. Perhaps it made him feel less ‘normal’, which he wanted so badly to be. A healthy relationship where we feel safe reaching out to in times of need will make all the difference.

Tired: We all get out of sorts when we are tired. When our lives are filled with activities such as work, school, family, meetings, our need for rest gets pushed to the side. But it is not healthy for us physically, spiritually, or emotionally and it affects our ability to reason and cope with difficulties. Relapse is just around the corner unless our body and mind are restored. It may be hard and uncomfortable to say we need a break to get some sleep, but it will benefit us and it is critical to maintaining sobriety.

Self-awareness and self-care are not self-ish, as many of us were taught when we were growing up. They are vital steps to help maintain a life on the path of recovery and will not only benefit us, but all our relationships.

 

The Well-Known Effects of Opioids

I was re-reading a book by George MacDonald, entitled The Curates Awakening. I had forgotten an aspect of one of the main characters plight: opioid addiction. What struck me as I read this paragraph was the age-old, well-known addictive qualities of opioids:

“From a tragic accident of his childhood, he had become acquainted with the influences of a certain baneful drug (opium), to which one of his Indian servants was addicted. Now…to escape from gnawing thoughts, he began to experiment with it. Experimentation called for repetition, and repetition first led to a longing after its effects, and next, to a mad appetite for the thing itself…on the verge of absolute slavery to its use.”

This was written in 1870. Laudanum – an opium tincture that contains almost all of the opium alkaloids, including morphine and codeine – was developed in the 16th century. By the 18th century, the medicinal properties of opium and laudanum were well known.

By the 19th century, laudanum was used in many patent medicines to relieve pain, to produce sleep, to allay irritation.The Romantic and Victorian eras were marked by the widespread use of laudanum in Europe and the United States. The early 20th century brought increased regulation of all narcotics as the addictive properties of opium became more widely understood. By mid 20th century, the use of opiates was generally limited to the treatment of pain, and were no longer medically accepted “cure-alls”. (Wikipedia)

How is it that the manufacturers of OxyContin (Purdue Pharma) and other prescription opioids claimed and advertised that they were not addictive? Their scheme was so persuasive that I have friends today that believe that if you are truly in pain, opioids are not addictive. This is absolutely false. And how did the FDA let this go on?

Yes, we can be thankful that new ways to deliver pain relief were developed for patients with extreme pain from cancer and terminal illnesses. I have seen the need for it when I cared for my sister who was dying of brain cancer and had a morphine drip. But the wholesale promoting – pushing – of these drugs for every ache and pain while knowing how absolutely addictive they were is unconscionable. Had we really understood the power of opioids when we first learned our son was addicted, we would have taken a much more pro-active approach to his initial recovery program.

On October 30, 2017, The New Yorker published a must-read multi-page exposé on Mortimer Sackler, Purdue Pharma, and the Sackler family, by Patrick Radden Keefe:
https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain

“The Sacker dynasty’s ruthless marketing of painkillers

has generated billions of dollars – and millions of addicts.”

The article links Raymond and Arthur Sackler’s business acumen with direct pharmaceutical marketing and the rise of addiction to OxyContin. The article implies that the Sackler’s bear moral responsibility for the Opioid epidemic. During the sixties, Arthur got rich marketing the tranquilizers Librium and Valium using techniques were sometimes blatantly deceptive. In 1974 Mortimer renounced his US Citizenship and lived a flamboyant life in his many residences in Europe.

OxyContin was introduced in 1996 and just since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids.Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin. According to the American Society of Addiction Medicine, four out of five people who try heroin today started with prescription painkillers. Our son is one of those statistics – and fatalities.

Access to Medications for Addiction?

In a conversation with a friend, she felt that drug addiction was basically related to poor choices and that recovery was also just a matter of choosing to stop. I guess at the core of it, she is right. An addict needs to decide they want to stop – but then what? Do they just exert will power, go through withdrawals and possibly a 12-step program, then all is well?

Sadly, this simplistic approach will not work for most opiate addicts. The physical changes that have taken place in the brain that cause the addiction need time – and lots of it – to even partially regenerate. The Ohio Society of Addiction Medicine recently posted this (https://ohsam.org/2018/01/12):

“Studies…have found that opioid addiction medications in general cut all-cause mortality among opioid addiction patients by half or more. The CDC, National Institute on Drug Abuse, and World Health Organization acknowledge their medical value.”

The blog continues to discuss the lack of access that the majority of addicts in America have to the three medicines that specifically treat opioid addiction and some of the reasons for it:

“A major reason for that is stigma. These medications are often characterized as ‘replacing one drug with another’…This fundamentally misunderstands how (opioid) addiction works. The problem is not drug use per se; most Americans, after all, use caffeine, alcohol, and medications without major problems. The problem is when drug use becomes a personal or social burden — risk of overdose or leading someone to commit crimes to obtain drugs.  Medications for opioid addiction, by staving opioid withdrawal and cravings without leading to a significant risk of overdose, mitigate or outright eliminate those problems — treating the core concerns with addiction.”

Then there is the issue of large segments of the country without doctors who can prescribe buprenorphine/naloxone due to licensing limits – and the costs for patients.

“In a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment…attributing the low rate to severe shortages in the supply of care, with some areas of the country lacking affordable options for any treatment — which can lead to waiting periods of weeks or even months.” By then, it is too late for many addicts seeking help.

“Another reason for the treatment gap is a lack of federal attention…the Cures Act committed $1 billion over two years…woefully short of the tens of billions annually that experts argue is necessary to deal with the opioid epidemic…the total economic burden of prescription opioid overdose, misuse, and addiction of $78.5 billion in 2013, about a third of which was due to higher health care and addiction treatment costs.”

I can say that our son desperately wanted to be free of his addiction that started when he was too young to realize the ball and chain that would drag him down and keep him from his hopes and dreams – and eventually take his life. Thankfully, he did have access to some medical help. Incredibly, even after so many relapses, his father and I felt he could beat his addiction without medication – if he just worked harder. We were sadly mistaken.