Addiction Treatment 'Science' and Dead Rats

In my last post I teased that I would write about fake science.  I’ll try to make it interesting.
The internet allows everyone to do research about symptoms and treatments for any condition. If not for need for prescriptions, people could act as their own doctors.  But a huge dose of caution is necessary before anyone takes that path.
Realize first that doctors don’t treat themselves or even their family members.  The saying that ‘a person representing himself in court has a fool for a lawyer’ applies double in healthcare.  Treating someone close to one’s self introduces a bias that is hard to explain, but easy to notice.  As an example, I see a doctor annually to monitor a progressive condition that threatens my vision.  I would like to know the answer to a simple question:  how bad is it?  If I have a patient with that condition I can look at images of his/her retina and have an immediate, rough sense about what the person is facing.  But when I look at my own images and test results I sense nothing beyond fear or relief.  The problems with self-assessment are of course greater in the field of psychiatry and addiction.  After my relapse in 2001 I was told I needed treatment, and my assessment called for a brief refresher course on the twelve steps.  Three months later, still in residential treatment, I recognized how wrong I was.
A larger problem is that research on the internet is nothing like the research used by doctors or scientists.  There are a few sites that offer true research, such as Pub Med, where you can search my name and see the articles from my PhD work in the 1980s.   Doctors at academic hospitals or institutions often have access to an electronic database including thousands of peer-reviewed journals.  In grad school I spent time each morning in the library, reading the Science Citation Index for new stories about vasopressin and then searching the stacks for the article (medical libraries have so many journals that they take up 4 or 5 floors or more of a large building, with narrow halls between floor-to-ceiling shelves).  In the stacks I sometimes realized I was standing amidst the results of the hard work of millions of scientists over the past 50 years.
The information on the internet is useful because it helps patients ask the right questions.  But it is a mistake to consider it as research, or even to assume it is correct.  Doctors and scientists (and any good health practitioners) rely only on peer-reviewed literature.  And even then, a good scientist gathers a sense, over time, of the better peer-reviewed journals vs. the ones with less credence.  What is peer review?  When a scientist submits research for publication, the article is sent to 3 or 4 independent reviewers who work in the same field but have no connection to the author of the study.  I am a peer-reviewer for a couple of journals.  When I receive an invitation to review a study I have to disclose any bias or connection to the study or authors.  If I accept the invitation I have several weeks to carefully review the study, noting if the findings are valuable, whether the groups were sufficiently randomized and blinded, whether the statistics are correct or if a statistician should be involved, and whether the findings support the conclusions.  I then tell the journal editor my opinion, including whether the study should be accepted, rejected, or accepted with certain revisions.  Peer reviewers are not paid;  they provide the service because they recognize that the process is necessary and valuable.
The FDA regulates medications based on the results of research studies.  Some of the studies reviewed by the FDA are already published, and some may never end up in a formal publication.  But their process for evaluating medications is similar to the work of a peer-reviewer in that they determine whether the science is ‘good’ – double blinded, properly randomized, good statistics, etc.  Any claims about a medication MUST be deemed accurate by the FDA.
This post was inspired by an ad for Declinol, a supplement marketed to ‘treat’ alcoholism.  Supplements are not medications, and not subject to the same rules. Read the FAQ on the Declinol web site and note the answer about FDA approval.  Declinol is not subject to FDA approval because it is a nutrient, not a medication.  The FDA allows greater latitude for promotional claims about nutrients, but even makers of supplements are not allowed to lie.  The acrobatics of marketers of such products are sometimes funny, at least to us nerds, and Declinol is a classic example.  Note that the web page doesn’t say that it treats alcoholism or cravings;  it is a ‘SUPPORT for physical cravings, calmness, and overall well-being’.  What is a ‘support’?  Your guess is as good as mine.
Instead of making claims that can be found to be false, nutrients often show quotes by ‘satisfied customers’.  If the FDA believes that the quotes are misleading, that’s on ‘Bob from California’, not on the marketer of the nutrient.  Instead of describing how the nutrient works, nutrient marketers provide citations about the nutrient that support whatever the marketers want you to think.  So with Declinol we see ingredients like folic acid, with broad generalizations about the value of that substance.  Yes, Folic acid is valuable.  You can’t live without it.  But that’s a far cry from saying that taking extra folic acid has any value, let alone value in reducing alcohol intake.  We give folate to alcoholics in detox because they sometimes have dietary deficiencies caused by consuming nothing but alcoholic beverages.  If you eat meals a couple of times per day you almost surely have plenty of folic acid in your body, and any extra is metabolized and excreted..
Must nutrient ‘treatments’ or supplements contain a blend of vitamins.  It is very easy to write reassuring and positive statements about vitamins because by definition, vitamins (the term comes from ‘vital amines’) are molecules critical to normal function.  But many studies have shown that a typical diet provides adequate amounts of vitamins, even if that diet includes fast food.
Many nutrient ‘treatments’ also contain a couple special ingredients we’ll call ‘secret sauce’.  One secret sauce in Declinol is Kudzu, and support for Kudzu in reducing alcohol consumption can be found on Pub Med.  Like similar products, Declinol’s marketers take a finding about a substance and grossly generalize the findings to create an impression that was never part of the original finding.  According to the study about Kudzu, 20 people in a ‘natural settings laboratory’ (is that an oxymoron?) were given water, juice, and up to six beers, and told to drink at will.  And (wow) when people were given 2 grams of Kudzu first, they drank beer more slowly, and opened fewer bottles.
A couple of problems, though, in concluding relevance to treating alcoholism.  Were the 20 subjects alcoholics? It doesn’t say, but I would guess not because I don’t know if a study giving beer to alcoholics would pass the ethical review board.  Beyond that, WHY did they drink less alcohol?  If I gave you syrup of ipecac, you would probably drink less alcohol.  If I gave you a tablet of oxycodone, you would probably drink less alcohol.  That doesn’t mean that the substances are useful in treating alcoholism or alcohol cravings.  Why did the Kudzu group drink less alcohol? Did it truly reduce interest in alcohol in a study with very few subjects who may or may not have alcohol problems? Or did it leave a nasty taste in their mouths or destroy their taste buds?  Did it cause nausea or dizziness that made alcohol less enticing? Did it reduce vision so they couldn’t find the beer bottles as easily?
As for the title of this post, when I researched vasopressin one hot idea was that vasopressin enhanced learning and memory.  We measured that improvement in studies using ‘passive avoidance.’  We placed rats in a cage that had dark cubbies in one corner, and when rats invariably went into a certain cubby they received an electric shock.  We repeated the task with or without putting vasopressin into the rats’ brains and some rats ‘learned’ to avoid the electric cubby, supposedly by remembering the shock better than other rats.  There is a major flaw in the study that can often be applied to other ‘experiments’, including the one I cited about Kudzu:  the best performer in a passive avoidance task is a dead rat.
I have no idea whether Declinol reduces cravings or generates ‘well being’, whatever that is.   But nothing on their website pushes me toward that conclusion.  I hope readers will keep some of these comments in mind when the next big cure comes along.

Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here.  This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago.  I grew used doctors refusing to treat people addicted to heroin and other opioids.  I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise.  It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices.  I feel like I’m the conservative one at those meetings!
I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine.  The comment surprised me, because from here I don’t see the influence.  My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years.  I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.
Those are big things, and anyone reading my blog knows all the big things.  I want to write about the little things.  The easiest way to have influence is to write about the things that nobody else writes about.  After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence:  If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.
On the forum I try to keep things real – not in a cool way, but in a medical or scientific way.  I want people to use .  I know I sound like some old guy frustrated by all of the new words and acronyms on social media.  YES, dammit, I AM frustrated by those things!  But communication has become so…. careless in the era of Twitter and texting.  Find an old book and notice the words and phrases used by educated people 100 years ago.  Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends.  Does anyone communicate in sentences anymore?
I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?)   But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs.  Some large scams benefit from the informal attitudes toward health and medicine;  attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video.  As in ‘I can treat it myself if I can find the medicines somewhere.’
The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term.  Is ‘treat’ the right word?  From my perspective I’d say yes in some cases, and no in others.  Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year.  They said (and I believe them) that they hadn’t used opioid agonists for at least that long.  I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances.  There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances.  Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv.  Those in the second group talk about finding subbies.
I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies.  I correct them and tell them that I have a hard time trusting patients who talk that way.  After all, those are street terms.  A pharmacist doesn’t say ‘here’s your subs!’
So here’s the rub.  Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing?  Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not.  I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.
But I will continue to correct them, and let them know that their words create a certain impression.  Getting that point across would be enough influence for one day!

Help for Heroin Addiction

A couple comments for regular readers…  first, watch for an upcoming change to a new name.  For years I’ve debated whether to adopt a name centered on ‘buprenorphine’, rather than the more-recognizable ‘Suboxone’.  I believe that time has come.   Second, I’m going to ‘reset’ with some introductory comments about the proper approach to treating heroin addiction, intended for those who are seeking help – starting with this post.
I’m addicted to heroin.  Which treatment should I use?
I’ve treated heroin addiction in a range of settings, including abstinence-based programs and medication-assisted treatment with buprenorphine, naltrexone, and methadone. My education prepared me for this type of work, and my personal background created empathy for people engaged in the struggle to leave opioids behind.
The first barrier to success is on you. Are you ready to leave opioids behind? How ready? Are you so ready that you will be able to end relationships with people who use? Are you ready to stop other substances, especially cocaine and benzodiazepines? You will find help during treatment and you don’t have to take these steps entirely on your own. But you must at least have the desire to get there.
If you’re ready, the next step is deciding the treatment that is likely to help you. Many people see abstinence-based treatment as a ‘gold standard’ – the ultimate way to escape opioids. Unfortunately, that belief has fueled many deaths over the past ten years, as desperate people paid large sums of money for themselves or loved ones expecting programs to alter personality over the course of three months. It doesn’t work that way for most people!
During several years working in abstinence-based programs, I helped fix people who were broken by addiction. After a couple months, people left treatment with healthier bodies, cleaner complexions, and better hair. But over 90% of those people returned to opioid use, some within a few days. Some of them died because of their new lack of tolerance to opioids. In each case, counselors said the same thing: ‘he/she didn’t really want it’. But I remembered that they DID ‘want it’ when they were in treatment. In fact, some were considered star patients! At some point we must hold treatments responsible if they fail over 90% of the time.
My perspective changed. Now I wonder, why does anyone expects those treatments to work? A person is removed from a life of scrambling and drug connections and poverty, placed in a box and shined up for a few months, then put right back in the same using world and expected to act differently?
I eventually learned about medications that treat opioid addiction. I realized that opioid addiction truly is a medical illness that should be treated like any medical illness. Think about it – we treat high blood pressure, asthma, and diabetes over time. We don’t cure any of them. In fact, the only illnesses that we can cure are infectious diseases, and even that accomplishment is fading as organisms develop resistance to current medications. Given that we can’t really cure anything, why do we expect anyone to cure addiction – in 12 weeks?!
Medication-based treatments for addiction represent a transition to normalcy. Doctors and nurses were removed from treating addictive disorders decades ago because of historical events that I’ll eventually write about. Clearly, it’s time for health professionals to take a role in treating addiction. In the next article I’ll discuss the medications currently available, and the reasons that one might work better than another for certain individuals.
In the meantime please check out my youtube videos under the name ‘Suboxdoc’, where I discuss the use of medications, primarily buprenorphine, for treating addiction to heroin and other opioids.

Missing the Point of Buprenorphine Treatment

A forum reader wrote about concerns over a partner on buprenorphine.  Her concerns pointed out a common misperception about the goals of treatment of opioid use disorder using buprenorphine, or using methadone for that matter.
Her question, amended for privacy:
I married the love of my life.  He is still he love of my life but has been an addict for 15 of them. Our children have been greatly affected by his addiction.  He made promise after promise that he was clean, and I dove back in with complete faith time after time only to get burned.
His addiction started with recreational pills increasing over time, but now he is abusing Suboxone.   He was taking up to 12 mg depending on the day, but no pain pills for the last year. I suggested a Suboxone doctor and a plan to get off, and my husband called one and was able to get right in.
At the visit the doctor did a half ass intake and called in a prescription for an 8 mg tab for induction.   After induction they called in prescription for 20 mg/day.   My husband stayed with 4 mg once a day and was “blah” in the afternoon and irritable but not physically sick.  On his next visit to the doctor he was proud, but when he told the doctor he had only take 4mg in the mornings she got angry. She told him she wouldn’t see him anymore if that’s what he was going to do. He asked how long he would be on it and she wouldn’t give any kind of answer. I asked again before we left and she snapped at me.
I see a profound change in him after each time we see her and she tells him to take more. We walked away last time with another prescription for 16 mg a day which is just about double what he’s been taking for the last year and a half. So my question is, how does it make sense to treat someone taking 8 mg as their addiction with the same medication at double the dosage? Since seeing her he has decided he needs to take it more than once a day as well as up the dosage.  Is this right? Is it right to treat Suboxone addiction with Suboxone? A heroin addict isn’t treated with more heroin and a pill addict isn’t treated with more pills.  While I understand the concept of treating his original pill addiction with Suboxone, I am having a very hard time wrapping my head around what’s happening.
Me again… 
The writer raises interesting questions.  Regarding the ‘drug for a drug’ questions, buprenorphine has significant pharmacologic differences from heroin or pain pills. Those differences, including the long half-life and ceiling on agonist effects, allow the medication to create a level degree of mu-receptor agonism across the dosing interval.  Tolerance to that level mu agonism allows patients on the medication to feel ‘normal’ throughout the day, or at least normal from an opioid standpoint.
But her broader point provides an example of the basic misunderstanding many people have about medication assisted treatment, in focusing on the same short-term goals that their addicted loved ones have focused on: controlling the dose of opioid and tapering off.  That goal is natural, of course;  anyone who loves a person addicted to opioids wishes and hopes that the person will reverse the using behavior and climb down from opioid use.  Those hopes are bolstered by ads for rapid detox, even as studies show that detox is mostly useless.
My response:
I would not be concerned about increasing the dose of buprenorphine, because there is no increase in effect after a dose of about 8 mg per day.  A higher dose might reduce mild withdrawal symptoms at the end of the dosing interval, and sometimes provides a reduction in cravings through a placebo effect.
So why increase? Because the goal with buprenorphine treatment is to put cravings into remission for a considerable length of time. If your husband is still having cravings as he gets by on 8 mg, then his dose is not high enough. Buprenorphine is a safe medication that is used as a tool to extinguish the conditioning that was part of your husband’s addiction.
One of my patients saw a different buprenorphine physician for years, and her dose was constantly lowered over the past year. She would run out of medication after 24 days each month and then go without for 6 days, craving opioids and experiencing wtihdrawal during that time.  In some ways, her entire time in treatment was a waste.  She could boast, I suppose, that she was prescribed less buprenorphine over time. But in most ways she is just as far from stopping opioids as when she entered treatment, still lying to her husband, lying to her doctor, and feeling ashamed of herself.   All of those things  keep her addiction in the dark, where it stays active.
When I started treating her my goal was to promote legitimate behavior. I increased her dose to 12 mg per day, from 8 mg.   After a month she still ran out early, So I raised the dose to 24 mg per day. Now, after 6 months, she has taken the medication as prescribed. Her focus on buprenorphine is going down, as we want it to do. She isn’t lying, and she isn’t craving pain pills or buprenorphine. My goal is for her to take the medication like she would take a vitamin or blood pressure pill, without any special attention or interest.
How long will we do this? I can’t say now. We know from research that the longer a person stays on medication, the less risk of relapse after stopping. I don’t like to push anyone off buprenorphine, because I’ve seen so many people who have relapsed after being pushed off by their former doctors.  I find that many people eventually decide that the time has come to taper off buprenorphine, and those efforts are usually successful.  From my perspective, people forced to taper off buprenorphine do not generally do well.  That perspective is just an opinion, but an opinion based on treating 800 people with buprenorphine over the past 11 years.
Opinions aside, the goal is not about getting off opioids as fast as possible. Your husband can accomplish that in a couple weeks with a remote hotel room and a bottle of clonidine, or a couple weeks in jail. But those experiences rarely lead to prolonged abstinence, and they sometimes precede overdose, when people return to using with a lower tolerance.
I can’t tell whether your husband’s doc is on the right track or not– but she might be. She is a better doctor telling you that she can’t give a time estimate, than a doctor telling you he will be off in 3 months.  Ideally, your husband will be in a state of ‘remission’– on a dose of buprenorphine that virtually eliminates interest in opioids– for a year or more. He can taper for some of that time, but the taper should be slow enough that he doesn’t return to using.  If he returns to active use, he starts over in many ways.
Try to drop the focus on ‘how much’ or ‘how long’. Those things are not important; what is important is to get his interest back on you and the family, not on buprenorphine or other opioids. That will be easier if you let him know that he has your support, even if he takes a medication, and even if he needs that medication for a long time. You would want the same from him if you ever needed a medication for hypertension, diabetes, or anything else.

Opioid Induced Hyperalgesia Prevented by Buprenorphine?

“Buprenorphine is a kappa receptor antagonist. For these reasons, buprenorphine might be unique in its ability to treat chronic pain and possibly OIH.”

The opioid crisis has been fueled by the use of opioids to treat chronic pain.  Practice patterns have changed, but doctors are still criticized for their roles in the overuse of opioids.  I’ve sat through community ‘heroin forums’ (sometimes on stage) as sheriffs, politicians, and ‘recovered addicts’ firmly pointed fingers at health professionals.  I, meanwhile, kept my finger under the table, but had the thought that some of the people pointing would be the first to complain if they were forced to stop pain medication prematurely for their own good or ‘for the good of the community.’
Doctors can’t see into the future.  I suspect most cases of opioid overuse began with well-intended efforts to provide temporary pain relief.   But then for a variety of reasons things didn’t go as planned.  Maybe the planned knee or back surgery never took place because of patient indecision or insurance problems.  Maybe the lumbar strain didn’t heal after 6-8 weeks the way it was supposed to.  In any case, doctors who work with pain patients know what happens next.  Before the next appointment, the doctor plans to tell the patient that the time has come to stop opioids.  But after that suggestion, the patient replies that the pain is even worse now than when the pain meds were started.  “Actually (says the patient) I was going to ask you to increase the pain medication!”
Some doctors hold fast to their plan and initiate a taper.  Some doctors argue over the issue, and some manage to create enough fear in the office that no patient would dare talk back. Too often, patients are suddenly cut off high doses of opioids, precipitating withdrawal symptoms that drive them toward illicit pills or heroin.  Patients who manage to maintain scripts for opioids embark on a miserable journey that often ends badly.
I’ve converted many pain pill patients to buprenorphine patients over the years.  I could save time using a rubber stamp to document their histories:  (blank)-year-old man was started on pain pills after (blank) injury (blank) years ago; dose was increased over time using oxycodone then OxyContin then fentanyl patches; patient lost the ability to control the medications and ran out early, resulting in discharge from treatment.  Patient presents asking for treatment with buprenorphine.
Many past patients fit this description, riding the gray area between opioid dependence and pain.  Lawmakers and policy-writers seem to believe that most patients are either addicts or pain patients.  Doctors who work in the field know that most patients sit in the middle, with smaller groups on each side. **
I’ve been surprised at how well those pain patients do after changing to buprenorphine.  They usually feel much better overall, which is no surprise given the misery of living according to a cycle of relief and withdrawal.  More surprising is that their pain is reduced, sometimes completely.  I assume the reduction in pain relates to stopping the cycle of relief and withdrawal, although I don’t know the mechanism beyond that idea.  People who take opioids become more ‘somatic’ over time, more and more focused on symptoms including those that warn of impending withdrawal; perhaps buprenorphine reduces that tendency toward somatization.
Which brings us to opioid-induced hyperalgesia or ‘OIH’, where prolonged use of opioids makes pain symptoms worse.  I’m reluctant to go ‘all in’ on OIH, just as I reserved full judgement of the full range of symptoms blamed on TMJ, EBV, IBS, CFS, FM, MCS, WPW, PMS, PMDD, RSD, CRPS, RLS, GAD, SAD, DID, IED, and other ‘initialed diseases’ that have garnered headlines over the years.   (Can you name them all? *** Try THESE )   Attention on OIH has waxed and waned over the years, and is gaining attention now as PROP, the CDC, and SAMHSA talk down opioid use.
LOL.
But seriously, my problem with OIH starts with awareness that pain sensation is very complicated.  Different people describe varying pain intensity for the exact same stimulus.  And even within one patient, intensity varies according to mood, fear, the duration of the pain (expected and actual), the perceived reason for the pain, the perceived harm from the stimulus, the setting (e.g. home vs. laboratory), and many other variables.  It is one thing to see how long it takes a rat to flick its tail when placed over a heat lamp, but another when a human fills out a pain scale.
I also take note of selection bias, a phenomenon that occurs whenever science bumps into political forces where studies citing the occurrence of a phenomenon are more likely to get government funding and editor approval than studies denying the phenomenon.  And no, I’m not a denier—of anything.  But I know bias when I see it. I’ve seen articles that conclude ‘there is not enough evidence to rule OUT the existence of OIH’, which is the opposite of how good science is supposed to be conducted.
You’ll find a great review of OIH here: http://www.painphysicianjournal.com/current/pdf?article=MTQ0Ng%3D%3D&journal=60
A cautious reader of the literature will note that at best, OIH is more of a ‘basic science’ phenomenon than a ‘clinical phenomenon.’   Increased pain sensitivity in response to opioids is subtle.  If it wasn’t, it would have been described decades, even centuries ago.  The linked material references older comments that the authors suggest came from observations of OIH, but to my reading the comments more likely referred to the withdrawal that follows opioid use.  You’ll also notice, if you read the linked article, that most of the studies of OIH in humans look at pain sensitivity in long-term methadone patients.  But you’ll also read that in theory, methadone is one of the least-likely opioids to cause OIH.
Interestingly, the other opioid agent with lower likelihood to cause OIH is… buprenorphine.  From the link above:  Buprenorphine has been shown to be intermediate in its ability to induce pain sensitivity in patients maintained on methadone and control patients not taking opioids. Buprenorphine showed an enhanced ability to treat hyperalgesia experimentally induced in volunteers compared to fentanyl. And spinal dynorphin, a known kappa receptor agonist, increases during opioid administration, thus contributing to OIH. Buprenorphine is a kappa receptor antagonist. For these reasons, buprenorphine might be unique in its ability to treat chronic pain and possibly OIH.
In short, long term use of opioids appears to increase pain sensitivity.  But we are a long way from understanding the extent of that phenomenon.  Some studies suggest that all opioids are not equal in regard to OIH, and I wonder if the reported decrease in pain from relatively minor injuries such as lumbar strain, when people change from opioid agonists to buprenorphine, is caused by a decrease in opioid-induced hyperalgesia.
But then again, maybe those patients just thought they had pain because of a subconscious (or conscious) desire to get pain pills.
For whatever reason, people with chronic pain seem to do well on buprenorphine.  Hopefully all of the concerns over opioids will leave us at least that one treatment option.  Give the extreme safety of buprenorphine, that should be a no-brainer!
**At least that was the case until several years ago, when I began seeing more and more patients who ‘started heroin recreationally’- an oxymoron if there ever was one.
***TMJ = temporomandibular join disorder, blamed for chronic headaches and other symptoms; EBV = Epstein Barr Virus; IBS = irritable bowel syndrome; CFS = chronic fatigue syndrome; FM = fibromyalgia; MCS = multiple chemical sensitivity; WPW = Wolf Parkinson White; PMS = premenstrual syndrome; PMDD = premenstrual dysphoric disorder; RSD = reflex sympathetic dystrophy;  CRPS = complex regional pain syndrome; RLS = restless leg syndrome; GAD = generalized anxiety disorder; SAD = seasonal affective disorder; DID = dissociative identity disorder; IED = intermittent explosive disorder.

Congress Acts on Opioid Dependence (ugh)

I won’t weigh in on the upcoming election, for fear of being barraged with insulting tweets by one candidate or ‘offed’ by the other.  But the current opioid dependence crisis provides a great chance to learn whether you stand on the side of ‘limited government’ or the alternative.
The TREAT Act takes 5 minutes to read, that would have increased the cap on buprenorphine patients.  President Obama undermined the TREAT Act by announcing his own plans to raise the cap soon after the TREAT Act was presented in the Senate.  After 7 years without mentioning heroin or opioid addiction, it’s hard to believe Obama’s actions were a coincidence.   Only a master politician can ignore 200,000 deaths, and then claim to solve the problem single-handedly despite a do-nothing Congress!
As I wrote earlier, few doctors will make use of Obama’s lousy offer.  Today Congress approved a bipartisan bill that will reportedly signed ‘begrudgingly’  by President Obama– who complained that the Bill ‘doesn’t go far enough.’  I wonder how many pages HIS Bill would be.
I invite readers to check out the language of the TREAT Act in regard to the buprenorphine cap– and then read the language of the ‘Comprehensive Addiction and Recovery Act of 2016‘.  And then, please, tell me how many patients doctors will be able to treat with buprenorphine.  The new law will provide treatment authority for nurse practitioners and physician assistants– I think.  How?  When?  How many?  I see a number of details that are left to the HHS Secretary–  a post that changes a couple times during a 4-year Presidential term.
How do we set up practices based on rules that change every couple years?!
I’m no political scientist, so I’m just reading the Bill and trying to figure it out– and I encourage you to do the same.  Myself, I prefer the language of the TREAT Act, but hopefully the attorneys will get this new thing figured out and let us know how many people we get to help with buprenorphine.

Obama's Lousy Suboxone Offer

I was reading more about Obama’s executive order over at Dr. Burson’s blog.  I guess she is a ‘competitor’ in the blogging world, but I have to admit that her blog has a lot more detail about the issue than I do.  If you haven’t been there yet, check it out.  Keep coming back here too of course!
She wrote recently about the rules that would be required by the Feds, in order for them t o allow us the ‘right’ to treat people with buprenorphine.   I wrote to Dr. Burson after reading her post that she is providing the facts, and I can’t help but provide the emotion.  And after reading the baggage tied up with the ‘right’ to treat heroin addicts, I am.. ‘pissed’!  I realize that isn’t a word that doctors should use.  But honestly… I just don’t have another one!
Dr. Burson wrote that according to the current proposal, Doctors begging the Federal Government to treat another 100 addiction patients must 1. Use electronic medical records; 2. Accept insurance for the treatment; and 3. Require counseling of patients treated with buprenorphine products.  There were other requirements as well, but these were the three that I remember for irritating me the most.
Dr. Burson goes through her reactions to the requirements, and mine are mostly the same.  As a solo psychiatrist, I don’t see the value of electronic records.  Many of my patients don’t WANT their addiction treatment in a database. They know the stigma that they face already every time they go to the pharmacy.  Some of them work for employers who would discriminate against people once-addicted to opioids.  Some of them know they would be accused of ‘impairment’ for taking buprenorphine.  Those of us who prescribe buprenorphine know that they are not impaired– and that they’ve worked at jobs for years with no problems should speak volumes.  BUT IT WON’T.  We all know that ‘impairment’ can be in the eye of the beholder– and once someone thinks it is there, it IS there.  Once accused, how do you prove you’re not impaired?
I realize that at first glance, accepting insurance sounds like a good deal.  But now, I am able to see at most 2 patients per hour.  I have accepted insurance in the past, and that’s a completely different business.  Insurance companies reimburse psychiatrists at a rate that anticipates seeing 4-5 patients per hour.  Medicaid reimburses far below that, expecting doctors to make up the difference through commercially insured patients.  But that doesn’t work when treating addiction, where the large majority of patients are on Medicaid.  The only way it works is if the doctor works for a network where knee replacements and MRI scans subsidize addiction treatment, or where care is ‘mass produced’ by a team that minimizes the time doctors spend with patients.
I LIKE seeing two patients per hour.  The Obama team says if that is the case, I can’t see more than 100 patients, no matter how much my home town needs my services..  How ironic… if I spend less time per patient, I can have MORE patients.
I’ve written about the counseling issue before.  The requirement is a nod toward the huge counseling/rehab industry that has tried to block medication-assisted treatment at every turn.  Shouldn’t something as personal as counseling be decided by each individual patient?  Is there any other illness that requires counseling in order for patients to receive medication?  Of course diabetics would benefit from nutritional counseling– but would we consider withholding insulin without it?!
Who will decide, by the way, if the counseling is adequate?  Will the doctor stop your medication if you miss too many sessions?  What if you have nothing to talk about– so you still have to go? How many times? What type of ‘counseling’ counts?  Can a person get a massage and call it ‘counseling’?  If I get my ears candled, is that good enough? Group therapy?  Music therapy?  I saw recently that Madison WI has practices offering ‘float therapy’– is that OK? What about equine therapy?
I think you get my point.
As I mentioned in an earlier post, the TREAT Act would have increased the cap and allowed doctors to decide the best course of action for each patient.  The doctor remained in charge of patient care– sort of like ‘if you like your health insurance, you can keep it.‘  President Obama stepped in front of the TREAT Act to offer something different.  I can almost hear him saying with a Bronx accent… ‘how can you turn down dis’ deal?’
With all the heroin deaths, he’s putting forward ‘an offer you can’t refuse’.   No thanks…. I’ll stay at 100.

Obama and the TREAT Act

I just read an article in the Daily Beast that reads like a better version of something I would write about the value of medication-assisted treatment of opioid dependence.  I appreciate Christopher Moraff telling a story that has been untold far too long, and I hope the story raises questions across the country.
But I have something else on my mind that deserves a story of its own.  I am just a small-town psychiatrist in the Midwest, of course, and so I could be missing something.  I watch Veep and House of Cards, but I assume that the political games in those shows are grossly exaggerated.  I’ll offer a bit of background… but if you already understand why people opposed to increasing the buprenorphine cap are idiots, just skip the next few paragraphs.
The Recover Enhancement for Addiction Treatment Act, a.k.a. TREAT Act, is a Bill with bipartisan support written in response to the epidemic of opioid dependence in the US.  If enacted into law, the TREAT Act (among other things) would increase number of patients that a physician can treat with buprenorphine from 100 to 500 and allow nurse practitioners and other ‘mid-level prescribers’ to treat opioid dependence with buprenorphine medications. For newcomers, treatment professionals debate the wisdom of raising the cap on the number of patients treated by each practioner.  Some people argue against medication treatment entirely and claim that abstinence is the only legitimate goal when treating addiction, despite the fact that abstinence-based treatments rarely work.  ‘Rarely’ is in the eye of the beholder, I guess– but even the most optimistic promoters of abstinence-based treatments claim they fail only 70% of the time– within ONE YEAR.   Other addiction docs advocate using medications that dramatically cut death rates, in concert with counseling.  They demand the counseling despite no evidence– none– that counseling improves outcomes in medication-assisted treatments.  But arguing against counseling is like arguing against… milk, I guess.  Who can argue against milk?
Then there are the extremists like me who argue that addiction is an illness that should be treated like any other illnesses and managed with medications, sometimes over the course of a person’s life.  Maybe counseling is indicated, and maybe not– but the need for counseling should not stand in the way of obtaining a life-sustaining medication.  After all, do we withhold insulin from diabetics who don’t receive nutritional counseling?  We extremists point out that there is no ‘cap’ on patients who are prescribed opioid agonists– the type of practice that started this epidemic in the first place.  We point out that literally no deaths have been caused by buprenorphine in patients who were prescribed the medication.  In all of medicine, THAT is the medication that needs a ‘cap’?  Doctors can treat unlimited numbers of patients with cancers, pain disorders, or complicated surgical procedures, but can’t handle more than 100 of THESE patients?!
I don’t see the point of the other groups, so I won’t try to explain their thought processes– accept one example.  Some docs are Boarded in Addiction Medicine– a secondary certification that can be obtained after certification in primary care or psychiatry.  Full disclosure– I am not Board Certified in Addiction Medicine.  I am Board Certified in Anesthesiology and in Psychiatry, and I worked with narcotics as a pain physician and anesthesiologist for ten years.  And I have a PhD in neurochemistry.  From my perspective, I have enough things on the wall. But the docs who DID get boarded in addiction medicine are angry that they get nothing special for their efforts.  The law that created buprenorphine treatment was intended to increase addiction treatment by primary care practitioners.  But that’s sour grapes to the addiction docs, who want the sole right to treat more than 100 patients.  Never mind that 30,000 people die from overdose each year, and buprenorphine could save many of them.  The addiction-boarded docs are angry that they aren’t given special privileges.  Isn’t THAT a problem!
What does all of this have to do with President Obama?  A bipartisan group of members of Congress of worked on the Treat Act over the past 8 months.  Professional societies have come to compromises over the Bill.  According to Schoolhouse Rock, Congress creates laws and then if passed, the President signs them into law.  The President often pulls opposing factions together, encouraging them to get a Bill to his/her desk.  For most of President Obama’s term, about 20,000-30,000 young Americans have died each year– far more than the total number of Americans killed by war, terrorism, hurricanes, and other natural disasters combined.    Until a month ago, I’ve heard absolutely nothing from the US President– no calls to action, no pressure on lawmakers, no requests to call our congresspersons.  But as the TREAT Act was introduced in the Senate, President Obama announced that he will raise the cap by Executive Order.  A supporter of the President would say (I know, because I’ve heard them) that the important thing is that it got done– so who cares how it happened?
Readers of this blog know that I pretty-much dislike everybody… so it is no surprise that I’m not happy.  We have the TREAT Act sitting in Congress, needing a simple majority to be sent to the President’s desk and signed into law.  During an epidemic of overdose deaths, the support would not be difficult to find for most Presidents, even with an ‘obstructionist Congress’, as our President likes to call them.  A change in the law would be relatively PERMANENT, unlike an Executive order– which can be changed with a new President, or with a new set of political calculations by the same President.   And an Executive Order to change rules at HHS requires hearings for citizen comments, which take more time– time when more patients will die.  Shouldn’t President Obama have used the operations that other Presidents used for far-more controversial issues, and changed the law?  This temporary, delayed Presidential action will get kudos from articles like the one in the Daily Beast.  And Obama gets TV time and headlines to describe how he addressed the opioid epidemic, on his own– in spite of a ‘obstructionist Congress.’
What irks me the most, though, is that an Executive Order didn’t need to take seven years.  By 2010 the overdose epidemic was well-underway, and had already killed a couple hundred thousand young people.  Did President Obama need to wait until the TREAT Act was almost at his doorstep before taking ANY action to stem the surge in overdose deaths?  From the sidelines it looks like the deaths themselves didn’t provoke a response.  But the threat of bipartisan action during an election year?  I guess that’s another story!

Counseling Schmounseling

I just noticed a couple of my recent posts….  these people have it wrong, and that person has it wrong.  One of these days I really need to print something positive and uplifting.  But not today.
Excuse the self-flattery, but I like to think of myself as a physician scientist.  That concept motivated my PhD work, and cost me friend after friend in the years that followed!  A physician scientist isn’t all that difficult to be from an educational standpoint, especially in the age of the internet.  The one thing that is necessary is the willingness, or need, to question every assumption by the media, the government, physicians, laypersons, and other scientists.   Ideally, the questions are guided by a knowledge of p-values, the process by which scientific grants are awarded, an understanding of the peer-review process, and the realization that anyone elected to office knows less about science than most other humans on the planet.
Last night I came across an opinion piece– I think in the Bangor Daily News, but I could be wrong about that– that argued that we will never stem the heroin epidemic without use of medications.  The comment section after the article was filled with the usual angry banter over methadone and buprenorphine that now follows every article about medication assisted treatment.  As an aside, why are the abstinence-based treatment people so angry about medication?  There are people out there who choose to treat cancer using crystals, but they don’t spend time bashing monoclonal antibodies!
Here is the part of this post where I start losing friends…  but let me first say that I know some counselors.  I like counselors.  In fact, some of my best friends are counselors.  But in the comments after that article I read the same thing over and over–   that meds aren’t the important thing, and that counseling is what really makes all the difference.  A couple weeks ago  the person sitting to my right said the same thing during a discussion about  medication-assisted treatments.  And that same phrase is repeated ad nauseum in lecture after lecture in ASAM lectures and policy statements related to addiction.  The phrase has even been codified into some state laws.  And why not?  It is something we all ‘know’, after all.
If we are going so far as writing laws requiring that people have counseling in order to obtain medication, shouldn’t we do one thing first?  Shouldn’t we determine if the comment is really true?
A couple years ago two papers came out– someone help me with the reference if you have them– that looked at abstinence rates after a year on buprenorphine in patients with or without counseling.  Guess what?  The counseling group did not do better!  In fact, the counseled patients did worse; not sigificantly so, but enough to clearly show that there was no ‘trend’ toward better performance in the counseled group (which would have been pointed out, were it true.)
I could hypothesize many reasons why the counseled groups would do worse.  Maybe they were angered by the forced counseling and therefore bonded less effectively with their physician.  Maybe they obtained a false sense of expertise in dealing with addiction, making them more likely to relapse, whereas the non-counseled group learned to just do as they were told.  Or maybe the counselors send out signals, consciously or unconsciously, that interfered with medication treatment.
The thing is, we have no idea which of these things, if any, are going on!  There have been no systematic studies or other attempts to understand what happens during the combination of counseling and medication treatments.  We just have a bunch of people saying ‘do them both!  do them both!–  a comment that apparently feels so good to some people that they just cannot consider things any other way.
For the record, I see ALL my patients for at least 30 minutes for every appointment.  As a Board Certified Psychiatrist, I guess that means I’m counseling them.  And from what I can tell, it seems to be working pretty well.  But even in my own case, I would never draw firm conclusions unless someone does a double-blind study and collects the data.
I encourage all physicians, scientists or not, to question some of what we ‘know’ about addiction treatment.  Is it really all about the counseling?  Maybe— but then again, smart people used to ‘know’ the world was flat, and the Earth was the center of the Universe.

I'm Addicted to Heroin. What Should I Do?

I’ve been spending more time answering questions on SuboxForum, and less time writing blog posts.   I’ll share a comment from today in the hopes that someone looking for help will stumble across this page.
A newcomer to SuboxForum posted this succinct question:
Will someone PLEASE help me take the first steps into the right direction? I have been on opiates and heroin for 10 years and it is starting to ruin my life. I don’t know what to do first?
My less-succinct reply, with minor editing:
Sometimes people get too focused on choosing the right approach and end up doing nothing—sometimes called ‘paralysis by analysis.’  Your options are largely determined by your circumstances– so your first mission is to find out what is available.  There are people who put down medication-assisted treatments like buprenorphine (aka Suboxone) and methadone, saying that they are ‘replacing one drug for another’.  But either of those approaches have much better success rates than residential treatment, and they are both easier to start.
Methadone or buprenorphine will each stabilize your situation fairly quickly, allowing you to step back and weigh your options without the daily search for opioids.  With either buprenorphine or methadone treatments you lose nothing by getting started.  If you start buprenorphine and decide it isn’t right for you, you can simply go back to heroin or oxycodone.  The same is true for methadone.    People rarely make that choice– and when they do, it usually wasn’t a deliberate change, but rather the addiction gained the upper hand and pulled them away.  But the point is worth making that you can always go back– because every now and then someone comes here and complains to be ‘stuck on buprenorphine’.  I try to point out that they are stuck on opioids– and they can always go back to where they were before they started buprenorphine.
The question is whether you have access to either medication in your area.  If you Google ‘find addiction treatment’ or a related search, you will get listings of many outdated web sites.  I’m disappointed to see that even the SAMHSA site is extremely outdated, listing programs that are no longer available and not showing newer treatment programs for either methadone or buprenorphine.
I have a web site that lists a number of buprenorphine doctor directories at SuboxDocs.com.  The site is a ‘directory of directories’, and some of the databases are more current than others.
I’m just now noticing how difficult it must be to find a treatment program.  The last time I really looked at the databases was maybe 5 years ago, and I remember seeing a number of sites that were fairly current.  I assumed that the information was only better now– but it appears to be worse.  If anyone reading this knows of good resources for FINDING treatment, leave a comment!
Another option for someone seeking treatment is to call your county health department.  I would think that most counties would have a list of programs in their area.  Finally, many people hear about a treatment program through word of mouth.  I don’t usually recommend increased contact with people who are actively using, but if you are in contact anyway, you might as well ask!
Buprenorphine treatment will have a higher ‘front end’ cost.  In my area, initial costs are $300-$500.  Ongoing costs include the medication (usually covered by Medicaid or private insurance) and the cost of monthly doctor visits.  Things to consider when choosing a long-term provider:  Are doctor visits covered by Medicaid or insurance?  If not, what will the visits cost?  Who pays for drug testing?  How much does that cost?  If you don’t have any insurance at all, will the doc prescribe plain buprenorphine (which is less costly than combination products)?  Are you required to be in counseling?  If so, how often, and where?  Some docs use buprenorphine to fill their counselors’ time slots, which pushes ethical borders a bit in my opinion.  Other considerations… Does the doctor provide other services such as mental health treatment?  Does the doc allow you to be treated with benzodiazepines?  What is the doc’s attitude toward marijuana?  Will you be kicked out if you test ‘dirty’?  Is the doctor ‘punitive’– i.e. will you be tossed from the program if you struggle a bit?  Or will the doctor work with you, if you don’t get it perfect right away?
Methadone programs in my area are covered by Medicaid, making them essentially free for people with that coverage.  But as people do better and find jobs, they often lose Medicaid and have to pay for methadone out of pocket, which can be costly… although never costlier than active addiction, especially when you factor in all of the related costs that come with actively using.
If you do not have access to medication-assisted treatments, you may need to consider abstinence-based treatment programs.  I’m not a big fan of abstinence programs for opioids because of the high relapse rates with those substances, and the high death rate during relapse.  And of course, an abstinence-based program requires detox and withdrawal.  People who lack an understanding of the usual course of opioid dependence see abstinence-based treatment as the best option.  But the only way to see things that way is by ignoring all of the data, or by assuming that in THIS case, things will go differently than usual.  That thought is very seductive to the parents of addicted young people, and I have known a number of people who died after falling victim to that seduction.
Most people who have been addicted to opioids for a year or more have already learned that detox alone provides little value.  If simple detox works for you, you were probably physically dependent, not addicted.  If you have detoxed and then relapsed several times, another detox is not likely to be helpful.  In fact, detox introduces danger into the equation, as many overdose deaths occur after a person has been through detox, either voluntary at a treatment program, or forcibly through incarceration.  Methadone and buprenorphine are both safer options because they keep tolerance high, reducing the risk of overdose.
My bias toward medication-assisted treatment comes across loud and clear, I know.   I don’t intend to assert that residential programs have NO value; I just think that too-often people enter them without understanding the long odds for finding success.  The people who do best with abstinence-based treatments are those who are monitored for a long time and have a lot to lose, such as people trying to regain professional or occupational licenses, or trying to avoid prison.  In all cases, the treatment is just the beginning of a lifetime of working to maintain sobriety.
An aside to the treatment community:  I often give talks about the need to treat addiction as an illness (and I generally accept requests to speak for a couple hours on the topic, in case anyone has need for a speaker!).  For decades, we all envisioned a paradigm where addiction responded to intensive, months-long abstinence-based treatments, followed by lesser-intense ‘aftercare’ and meetings.  Physicians had minor roles, or no role at all.   There is a growing awareness that things need to change.  I don’t claim that doctors understand addiction better than the current treatment community, and in fact I assume that the opposite is true.  But doctors can prescribe medications with the power to preserve life far more reliably than abstinence-based treatments.
There is a saying–  ‘perfect is the enemy of good’.  We are losing thousands of lives in the search for a ‘perfect’ treatment.  For almost all other illnesses, doctors provide medications and recommendations in order to ‘manage’ the illness.   Now more than ever, addiction warrants the same medical approach.