Heroin/Methadone

Legalizing opioids may give Americans greater freedom over their decision-making, but at what cost? One painful aspect of the public debates over the opioid-addiction crisis is how much they mirror the arguments that arise from personal addiction crises.

If you’ve ever had a loved one struggle with drugs — in my case, my late brother, Josh — the national exercise in guilt-driven blame-shifting and finger-pointing, combined with flights of sanctimony and ideological righteousness, has a familiar echo. The difference between the public arguing and the personal agonizing is that, at the national level, we can afford our abstractions.

When you have skin in the game, none of the easy answers seem all that easy. For instance, “tough love” sounds great until you contemplate the possible real-world consequences. My father summarized the dilemma well. “Tough love” — i.e., cutting off all support for my brother so he could hit rock bottom and then start over — had the best chance of success. It also had the best chance for failure — i.e., death. There’s also a lot of truth to “just say no,” but once someone has already said “yes,” it’s tantamount to preaching “keep your horses in the barn” long after they’ve left.

But if there’s one seemingly simple answer that has been fully discredited by the opioid crisis, it’s that the solution lies in wholesale drug legalization. In Libertarianism: A Primer, David Boaz argues that “if drugs were produced by reputable firms, and sold in liquor stores, fewer people would die from overdoses and tainted drugs, and fewer people would be the victims of prohibition-related robberies, muggings and drive-by-shootings.”

Maybe. But you know what else would happen if we legalized heroin and opioids? More people would use heroin and opioids. And the more people who use such addictive drugs, the more addicts you get. Think of the opioid crisis as the fruit of partial legalization. In the 1990s, for good reasons and bad, the medical profession, policymakers, and the pharmaceutical industry made it much easier to obtain opioids in order to confront an alleged pain epidemic. Doctors prescribed more opioids, and government subsidies made them more affordable. Because they were prescribed by doctors and came in pill form, the stigma reserved for heroin didn’t exist. When you increase supply, lower costs, and reduce stigma, you increase use.

And guess what? Increased use equals more addicts. A survey by the Washington Post and the Kaiser Family Foundation found that one-third of the people who were prescribed opioids for more than two months became addicted. A Centers for Disease Control study found that a very small number of people exposed to opioids are likely to become addicted after a single use. The overdose crisis is largely driven by the fact that once addicted to legal opioids, people seek out illegal ones — heroin, for example — to fend off the agony of withdrawal once they can’t get, or afford, any more pills. Last year, 64,000 Americans died from overdoses. Some 58,000 Americans died in the Vietnam War.

Experts rightly point out that a large share of opioid addiction stems not from prescribed use but from people selling the drugs secondhand on the black market, or from teenagers stealing them from their parents. That’s important, but it doesn’t help the argument for legalization. Because the point remains: When these drugs become more widely available, more people avail themselves of them. How would stacking heroin or OxyContin next to the Jim Beam lower the availability? Liquor companies advertise — a lot. Would we let, say, Pfizer run ads for their brand of heroin? At least it might cut down on the Viagra commercials. I think it’s probably true that legalization would reduce crime, insofar as some violent illegal drug dealers would be driven out of the business.

I’m less sure that legalization would curtail crimes committed by addicts in order to feed their habits. As a rule, addiction is not conducive to sustained gainful employment, and addicts are just as capable of stealing and prostitution to pay for legal drugs as illegal ones. The fundamental assumption behind legalization is that people are rational actors and can make their own decisions. As a general proposition, I believe that. But what people forget is that drug addiction makes people irrational. If you think more addicts are worth it in the name of freedom, fine. Just be prepared to accept that the costs of such freedom are felt very close to home.

Source: http://www.nationalreview.com/article/453304/opioid-crisis-legalization-not-solution

 

St. Petersburg, FL – Thursday, August 31, 2017 – Drug Free America Foundation today introduced a first-of-its-kind Opioid Tool Kit in an effort to help address the opioid epidemic gripping the United States.

The Opioid Tool Kit was unveiled in conjunction with International Overdose Awareness Day, a global event held on August 31st each year that aims to raise the awareness of the problem of drug overdose-related deaths.

“With more than 142 people dying each day, drug overdoses are now the leading cause of death for Americans under the age of 50,” according to Calvina Fay, Executive Director of Drug Free America Foundation. “Moreover, deaths from drug overdose are an equal opportunity killer, with no regard to race, religion or economic class,” she said.

“While alcohol and marijuana still remain the most common drugs of abuse, the nonmedical use of prescription painkillers and other opioids has resulted in a crisis-level spike in drug overdose deaths,” said Fay.

The Opioid Tool Kit has been designed to educate people about the opioid epidemic and offer strategies that can be used to address this crisis. “The Tool Kit is also intended to encourage collaboration with different community sectors and stakeholders to make successful and lasting change,” Fay continued.

The Opioid Tool Kit is a comprehensive guide that defines what an opioid is, examines the scope of the problem, and addresses why opioids are a continuing health problem.  The Tool Kit also provides strategies for the prevention of prescription drug misuse and overdose deaths and includes a community advocacy and action plan, as well as additional resources.

Fay emphasized that the best way to prevent opioid and other drug addiction is not to abuse drugs in the first place.  “The chilling reality is that the long-term use and abuse of opioids and other addictive drugs rewire the brain, making recovery a difficult and often a life-long struggle,” she concluded. The Opioid Tool Kit can be found on Drug Free America Foundation’s website at https://dfaf.org/Opioid%20Toolkit.pdf.

Source:   https://dfaf.org/Opioid%20Toolkit.pdf..  August 2017

Medication-assisted treatment is often called the gold standard of addiction care. But much of the country has resisted it.

If you ask Jordan Hansen why he changed his mind on medication-assisted treatment for opioid addiction, this is the bottom line.

Several years ago, Hansen was against the form of treatment. If you asked him back then what he thought about it, he would have told you that it’s ineffective — and even harmful — for drug users. Like other critics, to Hansen, medication-assisted treatment was nothing more than substituting one drug (say, heroin) with another (methadone).

Today, not only does Hansen think this form of treatment is effective, but he readily argues — as the scientific evidence overwhelmingly shows — that it’s the best form of treatment for opioid addiction. He believes this so strongly, in fact, that he now often leads training sessions for medication-assisted treatment across the country.

“It almost hurts to say it out loud now, but it’s the truth,” Hansen told me, describing his previous beliefs. “I was kind of absorbing the collective fear and ignorance from the culture at large within the recovery community.” Hansen is far from alone. Over the past few years, America’s harrowing opioid epidemic — now the deadliest drug overdose crisis in the country’s history — has led to a lot of rethinking about how to deal with addiction. For addiction treatment providers, that’s led to new debates about the merits of the abstinence-only model — many of which essentially consider addiction a failure of willpower — so long supported in the US.

The case for prescription heroin

The Hazelden Betty Ford Foundation, which Hansen works for, exemplifies the debate. As one of the top drug treatment providers in the country, it 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, Hazelden announced a big switch: It would provide medication-assisted treatment.

“This is a huge shift for our culture and organization,” Marvin Seppala, chief medical officer of Hazelden, said at the time. “We believe it’s the responsible thing to do.”

From the outside, this might seem like a bizarre debate: Okay, so addiction treatment providers are supporting a form of treatment that has a lot of evidence behind it. So what?

But the growing embrace of medication-assisted treatment is demonstrative of how the opioid epidemic is forcing the country to take another look at its inadequate drug treatment system. With so many people dying from drug overdoses — tens of thousands a year — and hundreds of thousands more expected to die in the next decade, America is finally considering how its response to addiction can be better rooted in science instead of the moralistic stigmatization that’s existed for so long.

The problem is that the moralistic stigmatization is still fairly entrenched in how the US thinks about addiction. But the embrace of medication-assisted treatment shows that may be finally changing — and America may be finally looking at addiction as a medical condition instead of a moral failure.

The research is clear: Medication-assisted treatment works

One of the reasons opioid addiction is so powerful is that users feel like they must keep using the drugs in order to stave off withdrawal. Once a person’s body grows used to opioids but doesn’t get enough of the drugs to satisfy what it’s used to, withdrawal can pop up, causing, among other symptoms, severe nausea and full-body aches. So to avoid suffering through it, drug users often seek out drugs like heroin and opioid painkillers — not necessarily to get a euphoric high, but to feel normal and avoid withdrawal. (In the heroin world, this is often referred to as “getting straight.”)

Medications like methadone and buprenorphine (also known as Suboxone) can stop this cycle. Since they are opioids themselves, they can fulfil a person’s cravings and stop withdrawal symptoms. The key is that they do this in a safe medical setting, and when taken as prescribed do not produce the euphoric high that opioids do when they are misused. By doing this, an opioid user significantly reduces the risk of relapse, since he doesn’t have to worry about avoiding withdrawal anymore. Users can take this for the rest of their lives, or in some cases, doses may be reduced; it varies from patient to patient.

The research backs this up: Various studies, including systemic reviews of the research, have found that medication-assisted treatment can cut the all-cause mortality rate among addiction patients by half or more. Just imagine if a medication came out for any other disease — and, yes, health experts consider addiction a disease — that cuts mortality by half; it would be a momentous discovery.

“That is shown repeatedly,” Maia Szalavitz, a long time addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, told me. “There’s so much data from so many different places that if you add methadone or Suboxone in, deaths go down, and if you take it away, deaths go up.” That’s why the biggest public health organizations — including the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, and the World Health Organization — all acknowledge medication-assisted treatment’s medical value. And experts often describe it to me as “the gold standard” for opioid addiction care.

The data is what drove Hansen’s change in perspective. “If I wanted to view myself as an ethical practitioner and doing the best that I could for the people I served, I needed to make this change based on the overwhelming evidence,” he said. “And I needed to separate that from my personal recovery experience.”

Medication-assisted treatment is different from traditional forms of dealing with addiction in America, which tend to demand abstinence. The standards in this field are 12-step programs, which combine spiritual and moralistic ideals into a support group for people suffering from addiction. While some 12-step programs allow medication-assisted treatment, others prohibit it as part of their demand for total abstinence. The research shows this is a particularly bad idea for opioids, for which medications are considered the standard of care.

There are different kinds of medications for opioids, which will work better or worse depending on a patient’s circumstances. Methadone, for example, is only administered in a clinic, typically one to four times a day — but that means patients will have to make the trip to a clinic on a fairly regular basis. Buprenorphine is a take-home drug that’s taken once or twice a day, but the at-home access also means it might be easier to misuse and divert to the black market.

One rising medication, known as naltrexone or its brand name Vivitrol, isn’t an opioid — making it less prone to misuse — and only needs to be injected once a month. But it doesn’t work in the same way as methadone or buprenorphine. It requires full detoxification to use (usually three to 10 days of no opioid use), while buprenorphine, for example, only requires a partial detoxification process (usually 12 hours to two days). And instead of preventing withdrawal — indeed, the detox process requires going through withdrawal — it blocks the effects of opioids up to certain doses, making it much harder to get high or overdose on the drugs. It’s also relatively new, so there’s less evidence for its real-world effectiveness.

One catch is that even these medications, though the best forms of opioid treatment, do not work for as much as 40 percent of opioid users. Some patients may prefer not to take any medications because they see any drug use whatsoever as getting in the way of their recovery, in which case total abstinence may be the right answer for them. Others may not respond well physically to the medications, or the medications may for whatever reason fail to keep them from misusing drugs.

This isn’t atypical in medicine. What works for some people, even the majority, isn’t always going to work for everyone. So these are really first-line treatments, but in some cases patients may need alternative therapies if medication-assisted treatment doesn’t work. (That might even involve prescription heroin — which, while it’s perhaps counterintuitive, the research shows it works to mitigate the problems of addiction when provided in tightly controlled, supervised medical settings.)

Medication can also be paired with other kinds of treatment to better results. It can be used in tandem with cognitive behavioral therapy or similar approaches, which teach drug users how to deal with problems or settings that can lead to relapse. All of that can also be paired with 12-step programs like AA and NA or other support groups in which people work together and hold each other accountable in the fight against addiction. It all varies from patient to patient.

It is substituting one drug for another, but that’s okay

The main criticism of medication-assisted treatment is that it’s merely replacing one drug with another. Health and Human Services Secretary Tom Price recently echoed this criticism, saying, “If we’re just substituting one opioid for another, we’re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.” (A spokesperson for Price later walked back the statement, saying Price supports all kinds of drug treatment.)

On its face, this argument is true. Medication-assisted treatment is replacing one drug, whether it’s opioid painkillers or heroin, with another, such as methadone or buprenorphine.

But this isn’t by itself a bad thing. Under the Diagnostic and Statistical Manual of Mental Disorders, it’s not enough for someone to be using or even physically dependent on drugs to qualify for a substance use disorder, the technical name for addiction. After all, most US adults use drugs — some every day or multiple times a day — without any problems whatsoever. Just think about that next time you sip a beer, glass of wine, coffee, tea, or any other beverage with alcohol or caffeine in it, or any time you use a drug to treat a medical condition.

The qualification for a substance use disorder is that someone is using drugs in a dangerous or risky manner, putting himself or others in danger. So someone with a substance use disorder would not just be using opioids but potentially using these drugs in a way that puts him in danger — perhaps by feeling the need to commit crimes to obtain the drugs or using the drugs so much that he puts himself at risk of overdose and inhibits his day-to-day functioning. Basically, the drug use has to hinder someone from being a healthy, functioning member of society to qualify as addiction.

The key with medication-assisted treatment is that while it does involve continued drug use, it turns that drug use into a much safer habit. So instead of stealing to get heroin or using painkillers so much that he puts his life at risk, a patient on medication-assisted treatment can simply use methadone or buprenorphine to meet his physical cravings and otherwise go about his day — going to school, work, or any other obligations.

Yet this myth of the dangers of medication-assisted treatment remains prevalent — to deadly results.

In 2013, Judge Frank Gulotta Jr. in New York ordered an opioid user arrested for drugs, Robert Lepolszki, off methadone treatment, which he began after his arrest. In January 2014, Lepolszki died of a drug overdose at 28 years old — a direct result, Lepolszki’s parents say, of failing to get the medicine he needed. In his defense,  Gulotta has continued to argue that methadone programs “are crutches — they are substitutes for drugs and drug cravings without enabling the participant to actually rid him or herself of the addiction.”

This is just one case, but it shows the real risk of denying opioid users medication: It can literally get them killed by depriving them of lifesaving medical care.

The myth is also a big reason why there are still restrictions on medication-assisted treatment. For example, the federal government still caps how many patients doctors can prescribe buprenorphine to, with strict rules about raising the cap. This limits how accessible the treatment is. A Huff Post analysis found that even if every doctor who can prescribe buprenorphine did so at the maximum rate in 2012, more than half of Americans with opioid use disorders could not get the medication. That’s on top of barriers to addiction treatment in general. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country, particularly rural counties, lacking affordable options for treatment — which can lead to waiting periods of weeks or even months. Only recently has there been a broader push to fix this gap in care.

The medications used in treatment do carry some risks

None of this is to say that the medications used in these treatments are without any problems whatsoever. Methadone is tied to thousands of deadly overdoses a year, although almost entirely when it’s used for pain, not addiction, treatment — since it’s much more regulated in addiction care. Buprenorphine is safer in that, unlike common painkillers, heroin, and methadone, its effect has a ceiling — meaning it has no significant effect after a certain dose level. But it’s still possible to misuse, particularly for people with lower tolerance levels. And there are some reports of buprenorphine mills, where patients can get buprenorphine for misuse from unscrupulous doctors — similar to how pill mills popped up during the beginning of the opioid epidemic and provided patients easy access to painkillers.

Naltrexone, meanwhile, can heighten the risk of overdose and death in case of full relapse. Overdose and death are risks in any case of relapse, but they’re particularly acute for naltrexone because it requires a full detox process that eliminates prior tolerance. (Although this would typically require someone to stop taking naltrexone, since otherwise it blocks the effects of opioids up to certain doses.)

But when taken as prescribed, the medications are broadly safe and effective for addiction treatment. For regulators, it’s a matter of making sure the drugs aren’t diverted into misuse, while also providing good access to people who genuinely need them.

The fight over medication-assisted treatment is really about how we see addiction

Behind the arguments about medication-assisted treatment is a simple reality of how Americans view addiction: Many still don’t see it, as public health officials and experts do, as a disease.

With other diseases, there is no question that medication can be a legitimate answer. That medication is not viewed as a proper answer by many to addiction shows that people believe addiction is unique in some way — particularly, they view addiction as at least partly a moral failing instead of just a disease.

I get emails all the time to this effect. Here, for example, is a fairly representative reader message: “Darwin’s Theory says ‘survival of the fittest.’ Let these lost souls pay the price of their criminal choices and criminal actions. Society does not owe them multiple medical resuscitations from their own bad judgment, criminal activity, and self-inflicted wounds.”

This contradicts what addiction experts broadly agree on. As Stanford psychiatrist and Drug Dealer, MD author Anna Lembke put it, “If you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual’s control on some level.”

Many Americans may understand this with, say, depression and anxiety. We know that people with these types of mental health problems are not in full control of their thoughts and emotions. But many don’t realize that addiction functions in a similar way — only that the thoughts and emotions drive someone to seek out drugs at just about any cost.

Some of the sentiment against medications, as Hansen can testify, is propagated by people suffering from addiction. Some of them believe that any drug use, even to treat addiction, goes against the goal of full sobriety. They may believe that if they got sober without medications, perhaps others should too. Many of them also don’t trust the health care system: If they got addicted to drugs because a doctor prescribed them opioid painkillers, they have a good reason to distrust doctors who are now trying to get them to take another medication — this time for their addiction.

The opioid epidemic, however, has gotten a lot of people in the addiction recovery world to reconsider their past beliefs. Funeral after funeral and awful statistic after awful statistic, there is a sense that there has to be a better way — and by looking at the evidence, many have come to support medication-assisted treatment.

“I remember sitting there,” Hansen said, speaking to his experience at a funeral, as a mother sang her dead son a lullaby, “thinking that we have to do better.”

Source:  German Lopez@germanrlopezgerman.lopez@vox.com  Jul 20, 2017

 

Blue Cross Blue Shield issued a report on the opioid crisis with their data from all members in their commercial plans.  Early in the document, they report a pair of striking numbers.

First, that 21% of members filled a prescription for an opioid in 2015. I’ve heard these kinds of numbers before, but I never get numb. That’s 1 in 5 members, despite growing attention to excessive prescribing of opioids.

Second, a 493% increase in diagnosis of opioid use disorders over 7 years. My reaction is that this has to reflect changes in coding or diagnostic practices rather than the population. It’s implausible that there was an increase this large in the number of people with an opioid use disorder.

The document then devotes a great deal of attention to opioid prescribing.

Toward the end, there are a couple of graphics that caught my attention.

First, a map showing rates of opioid use disorders.

 

Then, this:

Though critical to treating opioid use disorder, the use of medication-assisted treatments (e.g., methadone) does not always track with rates of opioid use disorder (compare Exhibits 10 and 11). For example, New England leads the nation in use of medication-assisted treatments but it has lower levels of opioid use disorder than other parts of the country

 

So . . . they note that New England has average rates of opioid use disorders, yet they have high rates of utilization of medication-assisted treatment. This caught my attention because New England has higher rates of overdose, as depicted in the CDC graphics below.

Number and age-adjusted rates of drug overdose deaths by state, US 2015

 

Statistically significant drug overdose death rate increase from 2014 to 2015, US states

(It’s worth noting that BCBS is not among the top 3 insurers in Maine or New Hampshire, but they are the biggest in Massachusetts and Vermont.)

It begs questions about what the story is, doesn’t it?

I don’t presume to know the answers.

§ What was the sequence of events for the high OD rates and the utilization of MAT? And, what impact, if any, has the expansion of MAT had on overdose rates?

§ Is the BCBS data representative? (This brand new SAMHSA report suggest that the data about use is representative.)

§ We know that opioid maintenance meds reduce risk of OD, but we also know that people stop taking these meds at high rates. Does this imply that, in the real world, these meds end up providing less OD protection than hoped?

§ What are the policies and practices of the other insurers in the state?  (For example, we know that Anthem [the largest insurer in Maine and Vermont] recently ended prior authorization requirements for MAT. It’s not clear how restrictive they had been. They also are attempting to institute reformsto address the fact that, “only about 16 to 19 percent of the members taking the medications for opioid use disorder also were getting the recommended in-person counseling.”)

§ Are there regional differences in drug potency that explain this?

Let’s hope that more insurers follow suit and share their data.

Source:   https://addictionandrecoverynews.wordpress.com/2017/07/16/blue-cross-blue-shield-publishes-major-opioid-report/

Residential treatment has received a lot of criticism and scepticism over the last several years, especially for opioid use disorders. (Some of it is deserved. Too many providers are hustlers and others provide little more than detox with inadequate follow-up. Of course, many of the same criticisms have been directed at medication-assisted treatment. But, that’s not what this post is about.)

At any rate, the Recovery Research Institute recently posted about a study looking at completion rates for outpatient and residential treatment.   The study looked at A LOT of treatment admissions, 318,924.  Residential completion rates appear to have surprised a lot of people:

Results: Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment.

But, what really surprised some readers was this:

Compared to clients with a primary alcohol use disorder:
Clients with marijuana use disorder were only 74% as likely to complete residential treatment.
Clients with an opioid use disorder were 1.29x MORE likely to complete residential treatment.

So opioid users were much more likely to benefit from residential treatment compared to alcohol users. . . .

We speculate that for opioid abusers, the increased structure and cloistering of residential treatment provide some protection from the environmental and social triggers for relapse or that otherwise lead to the termination of treatment that outpatient treatment settings do not afford. Indeed, environmental risk characteristics in drug abusers’ residential neighbourhoods, such as the presence of liquor stores and indicators of concentrated disadvantage at the neighbourhood level, have been found to be associated with treatment non-continuity and relapse.

Such environmental triggers may play a particularly substantial role for those addicted to opioids compared to those seeking treatment for marijuana abuse. Since opioid users have the lowest raw completion rates in general, this finding that residential treatment makes a greater positive difference for opioid users than it does for any of the other substances represents an important result that merits further investigation. Given the current epidemic of opioid-related overdoses in the U.S., our results suggest that greater use of residential treatment should be explored for opioid users in particular.

For the differences between residential and outpatient, they say the following:

In general, residential treatment completion rates are usually higher compared to outpatient settings, but what is particularly noteworthy is that even after controlling for various client characteristics and state level variations, the likelihood of treatment completion for residential programs was still nearly three times as great as for outpatient settings. Given the more highly structured nature and intensity of services of residential programs compared to outpatient treatment, it is understandable that residential treatment completion rates would be higher. It requires far less effort to end treatment prematurely in outpatient settings com-pared to residential treatment.

Given the strong association between treatment completion and positive post-treatment outcomes such as long term abstinence, the large magnitude of difference between outpatient and residential treatment represents a potentially important consideration for the choice of treatment setting for clients.

Source:  https://addictionandrecoverynews.wordpress.com/2017/07/13/opioid-users-complete-residential-at-higher-rates

Author: Mark Gold, MD

Mortality resulting from opioid use (over 33,000 in 2015) is now epidemic in the U.S., exceeding drug-related deaths from all other intoxicants. Dr. Ted Cicero of Washington University, Dr. William Jacobs, Medical Director of Bluff Plantation, and I discussed the opioid over-prescribing and switch to heroin at DEA Headquarters on November 17, 2015. Things have gone from bad to worse. In a recent JAMA article (March 2017), Dr. Bertha Madras, Professor in the Department of Psychiatry at Harvard Medical School, offers compelling analysis and recommendations to rein in this crisis.

Physicians have increasingly prescribed opioids for pain since the AMA added pain as the “fifth vital sign,” which, like blood pressure, mandated assessment during each patient encounter. As a result of this and acceptance of low-quality evidence touting opioids as a relatively benign remedy for managing both acute and chronic pain, prescriptions for opioids have risen threefold over the past two decades.

Addiction, overdose and mortality resulting directly from opioid misuse increased rapidly. In addition, the influx of cheap heroin, often combined with homemade fentanyl analogues, became increasingly popular as prescription opioids became harder to attain and cost prohibitive on the streets. Consequently, a proportion of prescription opioid misusers transitioned to cheaper, stronger and more dangerous illicit opioids.

Opioid Mortality

The breakdown in mortality was confirmed by surveys (2015) revealing a disproportionate rise in deaths specifically attributable to: fentanyl/analogs (72.2%) and heroin (20.6%) compared with only prescription opioids, at less than eight percent. The unprecedented rise in overdose deaths and association with the heroin trade catalyzed the formation of federal and state policies to reduce supply and increase the availability of treatment and of a life saving opioid antagonist overdose medication Naloxone, a short-acting, mu 1, opioid receptor antagonist. Naloxone quickly reverses the effect of opioids and acute respiratory failure provoked by overdose.

Yet, according to Dr. Madras, the current federal and state response is woefully inadequate. She writes: “Of more than 14,000 drug treatment programs in the United States, some funded by federal block grants to states, many are not staffed with licensed medical practitioners. An integrated medical and behavioral treatment system, under the supervision of a physician and substance abuse specialist, would foster comprehensive services, provide expedient access to prescription medicines, and bring care into alignment with current medical standards of care.”

Why Does This Matter?

As baby boomers age and live longer, chronic non-cancer pain is highly prevalent. Opioids for legitimate non-cancer pain are not misused or abused by most patients under proper medical supervision. Yet there is no effective, practical means in this managed care climate whereby Primary Care Physicians (PCPs) can determine who is at risk for abuse and addiction and who is not. And frankly, addicts lie to their doctors to get opioids. Without proper training, physicians, who genuinely want to help their patients, get in over their heads and don’t know how to respond.

Further complicating the issue is that many of the affordable treatment programs do not employ medical providers who are trained and Board Certified in Addiction and Pain

Medicine, not to mention addiction psychiatry, or addiction medicine physicians. Thus the outcomes are dismal, which fosters doubt and mistrust of treatment.

Lastly, the lack of well-trained providers is due, in part, to the lack of training for medical doctors in addiction and behavioral medicine. At the University of Florida, we developed a mandatory rotation for all medical students in “the Division of Addiction Medicine.” We also started Addiction as a sub-specialty within psychiatry, where residents and post-doctoral fellows were immersed in both classroom and clinical training.

Since 1990, many other similar fellowship programs have started, yet few are training all medical students in the hands-on, two-week clerkship experience in Addiction Medicine like they have in obstetrics. We took this a step further when we developed a jointly run Pain and Addiction Medicine evaluation and treatment program which focused on prevention and non-opioid treatments. Many more are needed, as well as increased CME in addictive disease for physicians in any specialty.

Source:   http://www.rivermendhealth.com/resources/chronic-pain-opioid-use-consequences   June 2017

DATE: June 1, 2017

DISTRIBUTION: All First Responders

ANALYST: Ralph Little/904-256-5940

SUBJECT: Grey Death compound in Jacksonville & Florida

NARRATIVE:  The compound opioid known as Grey Death has been detected for the first time in North Florida. Although Purchased in March in St. Augustine, the basic drugs were from Jacksonville and may have been purchased pre-mixed.  Other  samples have occurred from March through May. Delays are due to testing requirements.  Grey Death has been detected in Florida since November 2016 in four counties south of NFHIDTA. Palm Beach reported a related death on May 19th.  Grey Death has been reported in the Southeast, with overdoses and at least  two deaths in Alabama and Georgia. It has  also been found in Ohio, Pennsylvania and Indiana. The compound is  a mixture of U-47700, heroin and fentanyl. Overall, different fentanyls, including carfentanil, have been detected and the amount of each ingredient varies.  The substance’s appearance is similar to concrete mixing powder with a varied texture from fine powder to rock-like. While grey is most common and is the color seen in St. Augustine, pictures indicate tan as well. The potency is much higher than heroin and can be administered via injection, ingestion, insufflation and smoking.

DANGER: Grey Death ingredients and their concentrations are unknown to users, making it particularly lethal. Because these strong drugs can be absorbed through the skin, touching or the accidental inhalation of these drugs  can result in absorption. Adverse effects, such as disorientation, sedation, coughing, respiratory distress or cardiac  arrest can occur very rapidly, potentially within minutes of exposure. Any concoction containing U-47700 may not respond to Narcan, depending on its relative strength in the mix.   Light grey powder in a test tube.

CONCLUSION: Responders are advised to employ protective gear to prevent skin absorption or inhalation. Miniscule (grains) of this substance are dangerous. Treat any particles in the vicinity of scene or potentially adhering to your or victim outer clothing or equipment as hazardous.

Source:  HIDTA Intelligence brief.   1st June 2017

As Cpl. Kevin Phillips pulled up to investigate a suspected opioid overdose, paramedics were already at the Maryland home giving a man a life-saving dose of the overdose reversal drug Narcan.

Drugs were easy to find:  a package of heroin on the railing leading to a basement; another batch on a shelf above a nightstand.

The deputy already had put on gloves and grabbed evidence baggies, his usual routine for canvassing a house.  He swept the first package from the railing into a bag and sealed it; then a torn Crayola crayon box went from the nightstand into a bag of its own.  Inside that basement nightstand:  even more bags, but nothing that looked like drugs.

Then—moments after the man being treated by paramedics come to—the overdose hit.

“My face felt like it was burning.  I felt extremely lightheaded.  I felt like I was getting dizzy,” he said.  “I stood there for two seconds and thought, ‘Oh my God, I didn’t just get exposed to something.’ I just kept thinking about the carfentanil.”

Carfentanil came to mind because just hours earlier, Phillips’ boss, Harford County Sheriff Jeffrey Gahler, sent an e-mail to deputies saying the synthetic opioid so powerful that it’s used to tranquilize elephants had, for the first time ever, showed up in a toxicology report from a fatal overdose in the county.  The sheriff had urged everyone to use extra caution when responding to drug scenes.

Carfentanil and fentanyl are driving forces in the most deadly drug epidemic the United States has ever seen.  Because of their potency, it’s not just addicts who are increasingly at risk—it’s those tasked with saving lives and investigating the illegal trade.  Police departments across the U.S. are arming officers with the opioid antidote Narcan.  Now, some first responders have had to use it on colleagues, or themselves.

The paramedic who administered Phillips’ Narcan on May 19 started feeling sick herself soon after;  she didn’t need Narcan but was treated for exposure to the drugs.

Earlier this month, an Ohio officer overdosed in a police station after bushing off with a bare hand a trace of white powder left from a drug scene.  Like Phillips, he was revived after several doses of Narcan.  Last fall, SWAT officers in Hartford, Connecticut, were sickened after a flash-bang grenade sent particles of heroin and fentanyl airborne.

Phillips’ overdose was eye-opening for his department, Gahler said.  Before then, deputies didn’t have a protocol for overdose scenes; many showed up without any protective gear.

Gahler has since spent $5,000 for 100 kits that include a protective suit, booties, gloves, and face masks.  Carfentanil can be absorbed through the skin and easily inhaled. and a single particle is so powerful that simply touching it can cause an overdose, Gahler said.  Additional gear will be distributed to investigators tasked with cataloguing overdose scenes—heavy-duty gloves and more robust suits.

Gahler said 37 people have died so far this year from overdoses in his county, which is between Baltimore and Philadelphia.  The county has received toxicology reports on 19 of those cases, and each showed signs of synthetic opioids.

“This is all a game-changer for us in law enforcement,” Gahler said.  “We are going to have to re-evaluate daily what we’re doing.  We are feeling our way through this every single day . . . we’re dealing with something that’s out of our realm.  I don’t want to lose a deputy ever, but especially not to something the size of a grain of salt.”

Source:  – Erie Times-News, Erie, Pa. – May 28, 2017 – www.goerie.com  The Associated Press

Ohio had the most overdose fatalities in the United States in 2014 and 2015.

A newspaper’s survey of county coroners has painted a grim picture of fatal overdoses in Ohio: more than 4,000 people died from drug overdoses in 2016 in the state badly hit by a heroin and opioid epidemic.

At least 4,149 died from unintentional overdoses last year, a 36 percent climb from the previous year, or a time when Ohio had the most overdose fatalities in the United States so far.

“They died in restaurants, theaters, libraries, convenience stores, parks, cars, on the streets and at home,” wrote The Columbus Dispatch in its report revealing the findings.

Survey Findings

It’s likely getting worse, too, as coroners warned that overdose deaths this year are fast outpacing these figures brought on by overdoses from heroin, synthetic opioids fentanyl and carfentanil, and other drugs.

The Dispatch obtained the number by getting in touch with coroners’ offices in all 88 Ohio counties. Coroners in six smaller counties, according to the paper, did not provide the requested figures.

Leading the counties in rapid drug overdose rises are counties such as Cuyahoga, where there were 666 deaths in 2016, as well as Franklin, Hamilton, Lucas, Montgomery, and Summit.

The devastation, added the survey, did not discriminate against big or small cities and towns, urban or rural areas, and rich and poor enclaves.

“It’s a growing, breathing animal, this epidemic,” said Medina County coroner and ER physician Dr. Lisa Deranek, who has sometimes revived the same overdose patients a few times each week.

Fentanyl Overdoses

Cuyahoga County, which covers Cleveland, had its death toll largely blamed on fentanyl use. Heroin remains a leading killer, but the autopsy reports reflected the major role of fentanyl, a synthetic opiate 50 times stronger than morphine, and animal tranquilizer carfentanil.

“We’ve done so much, but the numbers are going the other way. I don’t see the improvement,” said William Denihan, outgoing CEO of Cuyahoga County Alcohol, Drug Addiction and Mental Health Services Board.

Cuyahoga County had 400 fentanyl-linked deaths from Nov. 21 in 2015 to Dec. 31 last year, more than double related deaths of all previous years in combination. The opioid crisis, too, no longer just affected mostly white drug users, but also minority communities.

Dr. Thomas Gilson, medical examiner of Cuyahoga County, warned that cocaine is now getting mixed into the fentanyl distribution and fentanyl analogs in order to bring the drugs closer to the African-American groups.

Plans And Prospects

The state’s Department of Mental Health and Addiction Services stated that the overdose death toll back in 2015 would have been higher if not for the role of naloxone, an antidote use for opioid overdose cases. It has been administered by family members, other drug users, and friends to revive dying individuals.

State legislature moved to make naloxone accessible in pharmacies without a prescription. Ohio topped the nation’s drug overdose death numbers in 2014 and 2015. In the latter year, it was followed by New York, according to an analysis by the Kaiser Family Foundation using statistics from the U.S. Centers for Disease Control and Prevention.

Experts are pushing for expanding drug prevention as well as education initiatives from schoolkids to young and middle-aged adults, which also make up the bulk of dying people.

And while the state pioneered in crushing “pill mills” that issue prescription painkillers, health officials warned that this sent addicts to heroin and other stronger substances.

Naloxone, too, is merely an overdose treatment and not a cure for the growing addiction. Last May 22 in Pennsylvania, two drug counselors working to help others battle their drug addiction were found dead from opioid overdose at the addiction facility in West Brandywine, Chester County.

Source:  http://www.techtimes.com/articles/208540/20170529/ohio-leads-in-nations-fatal-drug-overdoses-with-4-000-dead-in-2016-survey.htm  29.05.17

“I wish that all families would at least consider investigating medication-assisted treatment and reading about what’s out there,” says Alicia Murray, DO, Board Certified Addiction Psychiatrist. “I think, unfortunately, there is still stigma about medications. But what we want people to see is that we’re actually changing the functioning of the patient.” Essentially, medication-assisted treatment (MAT) can help get a patient back on track to meeting the demands of life – getting into a healthy routine, showing up for work and being the sibling, spouse or parent that they once were. “If we can change that with medication-assisted treatment and with counselling,” says Murray, “that’s so valuable.” The opioid epidemic is terrifying, especially so for a parent of someone already struggling with prescription pills or heroin use. It’s so important to consider any and all options for helping your child recover from their opioid dependence.

Part of the reason it’s so hard to overcome an opioid addiction is because it rewires your brain to focus almost exclusively on the drug over anything else, and produces extreme cravings and withdrawal symptoms as a result. By helping to reduce those feelings of cravings and withdrawal, medication-assisted treatment can help your son or daughter’s brain stop thinking constantly about the drug and focus on returning to a healthier life.

Medication-assisted treatment is often misunderstood. Many traditional treatment programs and step-based supports may tell you that MAT is simply substituting one addictive drug for another. However, taking medication for opioid addiction is like taking medication for any other chronic disease, such as diabetes or asthma. When it is used according to the doctor’s instructions and in conjunction with therapy, the medication will not create a new addiction, and can help.

As a parent, you want to explore all opportunities to get your child help for his or her opioid addiction, and get them closer and closer to functioning as a healthy adult – holding down a job, keeping a regular schedule and tapering, and eventually, stopping their misuse of opioids. Medication-assisted treatment helps them do that.

“MAT medications are most effective when they are used in conjunction with therapy and recovery work. We would never recommend medication over other forms of treatment. We would recommend it in addition to it.”

The three most-common medications used to treat opioid addiction are:

· Naltrexone (Vivitrol)

· Buprenorphine (Suboxone)

· Methadone

NALTREXONE

Naltrexone, known by its brand-name Vivitrol, is administered by a doctor monthly through an injection. Naltrexone is an opioid antagonist. Antagonists attach themselves to opioid receptors in the brain and prevent other opioids such as heroin or painkillers from exerting the effects of the drug. It has no abuse potential.

BUPRENORPHINE

Buprenorphine, known by its brand-name Suboxone, is an oral tablet or film dissolved under the tongue or in the mouth prescribed by a doctor in an office-based setting. It is taken daily and can be dispensed at a physician’s office or taken at home. Buprenorphine is a partial agonist. Partial agonists attach to the opioid receptors in the brain and activate them, but not to the full degree as agonists. If used against the doctor’s instructions, it has the potential to be abused.

METHADONE

Methadone is dispensed through a certified opioid treatment program (OTP). It’s a liquid and taken orally and usually witnessed at an OTP clinic until the patient receives take-home doses. Methadone is an opioid agonist. Agonists are drugs that activate opioid receptors in the brain, producing an effect. If used against the doctor’s instructions, it has the potential to be abused. There is no “one size fits all” approach to medication-assisted treatment, or even recovery. Recovery is individual.

The most important thing to do is to consider all of your options, and speak to a medical professional to determine the best course of action for your family. The best path is the path that helps and works for your child.

Source:  http://drugfree.org/parent-blog/medication-assisted-treatment/  19th May 2017

Carfentanil. If there was ever a drug designed to wreak havoc – this is it!

5 milligrams (about 1/16th the size of a baby aspirin) is strong enough to take down a one-ton Buffalo, actually make that 7 one-ton Buffalos, and it’s readily available through illicit sales on street corners throughout the US. It is also now one of the leading causes of opioid related death, which claimed over 33,000 lives (out of 52,000+ drug related overdose deaths) in 2015, the most recent year for which statistics are available.  Carfentanil first showed up in the Ohio area in mid-2016 and has been advancing it’s destructive power across the nation with a vengeance. If it came in a bottle, it would need to have a warning label that is longer than the Great Wall of China, stating something to the effect of “If you take this drug, you are committing suicide. Avoid it at all costs.” In fact, its only legal use is for the sedation of large animals, like “elephants”. Addicts generally work their way up to Carfentanil. The typical gateway is by medical prescription for something like Oxycontin, with the user then graduating to cheaper heroin once the prescriptions run out. In fact, the majority of heroin users admit they started with prescription opioids. They beckon you like the sirens from Greek mythology, tempting you past your breaking point. It eventually gets to a level that heroin is no longer nearly enough, so you start taking fentanyl, many multiple times stronger than morphine which sucked so many war veterans into addiction during the Vietnam era. Your tolerance builds as your habit expands from a few days a week to every day.  Eventually fentanyl too is not enough. What else is there? Carfentanil. ‘Do I risk it?’ is what an addict should now ask himself, but they rarely listen to their voice of reason. They jump ‘all in’ without any thought or concern of consequences, they just want to get high. Then again, oftentimes they don’t even get to make that choice, it’s made for them. Carfentanil is so cheap that it’s used as an additive on the street.

I read an article the other day where someone bought street Xanax. It was laced with Carfentanil; he was dead within minutes. This same scenario has repeated itself throughout the country, as drug dealers seek to convert a small amount of Carfentanil, into a large amount of sale-able product, mixing it with ‘whatever is available’, solely to line their pockets with addicts’ money. Carfentanil is also a concern for first responders. It is odorless, colorless and can be absorbed via skin contact, inhalation, oral exposure or ingestion. EMS crews typically wear protective gloves and masks because a dose as small as a grain of salt could kill a person even if just absorbed through the skin, much like Anthrax. The increases in opioid-related emergencies are overwhelming the country on a state-by-state and city-by-city basis. Incidents are up 13.3 percent in Minnesota, over 20 percent throughout Ohio and the numbers are even worse in Kentucky, New Hampshire, New Mexico and West Virginia. The growth in Native American communities is by far the worst at 32.7 percent. 50 people recently overdosed in one day alone in Philadelphia, which experienced 35 overdose related deaths over five days. Cincinnati had 174 overdoses in six days, Cleveland 46 in one day and tiny Akron 236 over 20 consecutive days. In Maryland, Gov. Larry Hogan declared a state of emergency after opioids killed nearly 1,500 residents in the first nine months of 2016. The US represents just 4.6 percent of the world’s population, yet we consume 80 percent of its opioids. So, where’s all this Carfentanil coming from?  The usual suspects. China and India were the largest suppliers for the illegal online pharmacies during the early 2000s.

Distributors located in the Caribbean and Central American countries, typically run by American ex-pats, bought knock-offs of everything from Viagra to Xanax to Oxycontin for pennies a pill, sending shipments ‘directly to your door’ without the need of a pesky prescription. Those same large suppliers simply shifted to the next hot product and now sell to Mexican cartels distributing it street-by-street. After recent pressure from the US Drug Enforcement Agency (DEA), China clamped down on bootleg opioid operations to curb the flow of illicit drugs into the US. Yet, the Mexican drug-lords are resourceful. I fear it won’t take too much time for them to find other suppliers to fill the gap. There’s already evidence of them trying to produce substantial quantities on their own, to eliminate the need for an outside source. According to the DEA, 144 people now die each day from a drug overdose. As recently as 10 years ago, gun related deaths outnumbered drug overdose deaths by a factor of 5-to-1. Today more people die from opioids than guns and traffic accidents combined. It is estimated that 600 people try heroin for the first time each and every day. The issue is now mission critical. President Trump has appointed a SWAT Team of business executives to tackle the opioid crisis, led by his son-in-law Jared Kushner, a leading businessman and near billionaire in his own right. They are already working with a ‘Who’s Who’ of Fortune 500 Company leaders including such luminaries as Apple’s Tim Cook and Microsoft’s Bill Gates, just to name a few. Kipu and our sister company, InRecovery Magazine, have reached out to this Team to offer our unique experience, knowledge, perspective and support. We are hopeful that this is a key step toward helping to start to turn the tide in this life-or-death struggle against addiction.

Source: http://campaign.r20.constantcontact.com/render?m=1125801102133&ca=c086bc62-9760-47b5-8dad-385b0609ab8d   May 2017

The opioid epidemic has led to the deadliest drug crisis in US history – even deadlier than the crack epidemic of the 1980s and 1990s.

Drug overdoses now cause more deaths than gun violence and car crashes. They even caused more deaths in 2015 than HIV/AIDS did at the height of the epidemic in 1995.

A new study suggests that we may be underestimating the death toll of the opioid epidemic and current drug crisis. The study, conducted by researchers at the Centers for Disease Control and Prevention (CDC), looked at 1,676 deaths in Minnesota’s Unexplained Death surveillance system (UNEX) from 2006 – 2015. The system is meant to refer cases with no clear cause of death to further testing and analysis. In total, 59 of the UNEX deaths, or about 3.5 percent, were linked to opioids. But more than half of these opioid-linked deaths didn’t show up in Minnesota’s official total for opioid related deaths.

It is unclear how widespread of a problem this is in other death surveillance systems and other states, but the study’s findings suggest that the numbers we have so far for opioid deaths are at best a minimum. Typically, deaths are marked by local coroners or medical examiners through a system; if the medical examiner marks a death as immediately caused by an opioid overdose, the death is eventually added to the US’s total for opioid overdose deaths. But there is no national standard for what counts as an opioid overdose, so it’s left to local medical officials to decide whether a death was caused by an overdose or not. This can get surprisingly tricky – particularly in cases involving multiple conditions or for cases in which someone’s death seemed to be immediately caused by one condition, but that condition had a separate underlying medical issue behind it.

For example, opioids are believed to increase the risk of pneumonia. But if a medical examiner sees that a person died of pneumonia, they might mark the death as caused by pneumonia, even if the opioids were the underlying cause for the death. “In early spring, the Minnesota Department of Health was notified of an unexplained death: a middle-aged man who died suddenly at home. He was on long-term opioid therapy for some back pain, and his family was a little bit concerned that he was abusing his medication,” said Victoria Hall, one of the study’s authors.

“After the autopsy, the medical examiner was quite concerned about pneumonia in this case, and that’s how the case was referred to the Minnesota Department of Health unexplained deaths program. Further testing diagnosed an influenza pneumonia, but also detected a toxic level of opioids in his system. However, on the death certificate, it only listed the pneumonia and made no mention of opioids.”

Since this is just one study of one surveillance system in one state, it’s unclear just how widespread this kind of underreporting is in the United States. But the data suggests that there is at least some undercounting going on – which is especially worrying, as this is already the deadliest drug overdose crisis in US history. “It does seem like it is almost an iceberg of an epidemic,” said Hall. “We already know that it’s bad. And while my research can’t speak to what percent we’re underestimating, we know we are missing some cases.” In 2015, more Americans died of drug overdoses than any other year on record – more than 52,000 deaths in just one year. That’s higher than the more than

38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic’s peak in 1995.

See more: • The Changing Face of Heroin Use in the US study • Today’s Heroin Epidemic – CDC

Source:  Prevention Weekly. news@cadca.org  May 2017

Meet Ryan Hampton, 36, recovery advocate, political activist and recovering heroin addict igniting America’s social media feeds with stories of hope, recovery and activism. From his advocacy that led Sephora to take their eyeshadow branded “druggie” off the shelves to the activism that urged an Arizona politician to apologize for a statement stigmatizing addiction, he’s certainly become a social media powerhouse for all things addiction, recovery and policy. And with an estimated 7 out of 10 people on social media platforms, it’s no coincidence he’s found success taking the addiction advocacy fight digital.

Today, more than 22 million people are struggling with addiction, and it’s estimated that as a result, more than 45 million people are affected. But what many people don’t realize is that there are more than 23 million people living in active, long-term recovery today. Yet, because of shame and stigma, many stay silent. To fight this often-lethal silence, Hampton has urged the public to speak up and share personal stories of recovery through his recently launched Voices Project. The project, a collaborative effort to encourage people across the nation to share their story, exists to put real faces and names behind the addiction epidemic.

A Personal Struggle

Before becoming a national recovery advocate and social media powerhouse, Hampton himself faced a personal struggle with addiction. A former staffer in the Clinton White House, Hampton did not appear to be a likely candidate for heroin addiction, or so stigma would say. But after an injury and subsequent prescription for pain medication, Hampton found himself addicted to opiates, eventually leading to a heroin addiction that would span more than a decade.  After a long struggle, Hampton decided to get help.

It was the phone call that started his recovery journey that changed everything – his life and his view on the power of his phone. After getting sober, he began connecting with others in recovery, amazed at the magnitude of the digital community. But still, while uncovering these online stories of recovery, Hampton lost four friends to opioid addiction.

It was a breaking point for Hampton – one that led to the beginning of a movement that would someday reach and impact millions.

A Notable Partner

Hampton began reaching out to others in recovery and started realizing the power of digital tools to connect and build an online recovery community. And as he was slowly networking and meeting others in recovery, on October 4, 2015, Hampton’s advocacy met its catalyst: Facing Addiction.   The non-profit organization hosted a concert at the National Mall in Washington, D.C., an event that drew thousands to the capitol with celebrities, musicians and other well-known names willing to publicly celebrate the reality of recovery and call for reform in the addiction industry. Hampton, a Los Angeles resident, tuned into the event from across the country through Facebook Live and was again inspired by the content delivered through his mobile phone.

After meeting co-founders of Facing Addiction, Jim Hood and Greg Williams, Hampton plugged in, partnered and even joined the Facing Addiction team as a recovery advocate.

The importance of online advocacy aligns with Facing Addictions’ national priorities, shares CEO Jim Hood, “When enough people tell enough stories and the people who are impacted by addiction look like all of us and our kids and neighbors and relatives, the stigma has to start going away. And then we can get to work.”

After partnering with Facing Addiction, Hampton understood the priorities, the strategy and the mechanism. Said by Hampton, “I stand on the shoulders of giants”.

Leveraging the power of the algorithms at his fingertips every day, Hampton has grown his online presence to be one of the most influential in the recovery movement. Digital communication helped him get to treatment, connected him with Facing Addiction, and now is the platform in which he is sharing recovery stories from across the nation.

In just one week, more than 200 stories were submitted to the Voices Project and over 500 people sent in personal messages to express their support. Among those speaking up are notable voices such as pro skateboarder and former Jackass member Brandon Novak;   Grammy Award-winning musician Sirah;  rapper Royce da 5’9’’;   American politician and mental health advocate Patrick Kennedy;  former child actress and now-addiction counselor Mackenzie Phillips, and more.

According to Royce da 5’9’’, “Addiction is a problem that we all have to deal with. It affects us all in one way or another, and having someone giving it a voice, a name and a face not only helps get rid of the stigma regarding addiction, but he’s [Ryan] on the forefront letting people know there are solutions out there and recovery is real.”

Patrick Kennedy shares the importance of building a digital recovery movement to influence and support political reform in the addiction recovery space. “With the push of a button we’ll be able to have others show up to support communities across the nation,” says Kennedy, “because their fight is our fight.”

“The face of addiction is everyone,” Sirah shares. “The Voices Project gives people a voice and a connection to hope.”

The hope offered through open dialogue about addiction and recovery has now grown into a digital movement.

The pages that Hampton started with $20 and an old computer have gained more than 200,000 followers across platforms, reaching nearly 1 million people each week. “We’re the fastest-growing social movement in history – and the funny thing is, we’re a community that nobody ever wanted to be a part of,” Novak says.

“This is the one space where we cannot be ignored. The time has come for us to speak out, and we’re a community that speaks loudly. With addiction, we’re dealing with imminent death every day,” Hampton says. “Through social media, we’ve found an innovative way to communicate with each other and connect with people we haven’t met, and now, we’re having this conversation with the rest of the world.”

Perhaps the most intriguing impact of Hampton’s work is the paradoxical ability to bring the work of addiction recovery advocacy online – only to take it back offline through real-world change in communities across the country. According to Hampton, the work he’s doing shouldn’t stay digital – it should impact community laws, help new non-profits emerge and influence real people to seek treatment and find it.

“No matter if you have social media or not – your way of doing this is talking about addiction at the dinner table, to a parent or a friend or an employer. You should not be afraid to tell your story of recovery or loss and, most importantly, your story of struggle and how you need help. It may not just change your life, it may change someone else’s life,” Hampton says.

At the crux of digital advocacy in the addiction recovery realm are real lives being saved – people finding treatment, families finding hope and those in recovery being freed of stigma that can keep them in shame and silence.  This is the mission that has fuelled Hampton’s work since the beginning. And Hampton’s reason is hard to refute: “My story is powerful, but our stories are powerful beyond measure.”

Source: https://www.forbes.com/sites/toriutley/2017/04/18/the-recovering-heroin-addict-shaking-social-media/2/#273606f0689c

Formerly inconceivable ideas—like providing drug users a safe place to inject—are gaining traction.

America’s opioid problem has turned into a full-blown emergency now that illicit fentanyl and related synthetic drugs are turning up regularly on our streets. This fentanyl, made in China and trafficked through Mexico, is 25 to 50 times as potent as heroin. One derivation, Carfentanil, is a tranquilizer for large animals that’s a staggering 1,000 to 5,000 times as powerful.

Adding synthetic opioids to heroin is a cheap way to make it stronger—and more deadly. A user can die with the needle still in his arm, the syringe partly full. Traffickers also press these drugs into pills that they sell as OxyContin and Xanax. Most victims of synthetic opioids don’t even realize what they are taking. But they are driving the soaring rate of overdose—a total of 33,091 deaths in 2015, according to the Centers for Disease Control and Prevention.

Hence the ascendance of a philosophy known as “harm reduction,” which puts first the goal of reducing opioid-related death and disease. Cutting drug use can come second, but only if the user desires it. As an addiction psychiatrist, I believe that harm reduction and outreach to addicts have a necessary place in addressing the opioid crisis. But as such policies proliferate—including some that used to be inconceivable, such as providing facilities where drug users can safely inject—Americans shouldn’t lose sight of the virtues of coerced treatment and accountability.

What does harm reduction look like? One example is Maryland’s Overdose Survivor Outreach Program. After an overdose survivor arrives in the emergency room, he is paired with a “recovery coach,” a specially trained former addict. Coaches try to link patients to treatment centers. Generally this means counseling along with one of three options: methadone; another opioid replacement called buprenorphine, which is less dangerous if taken in excess; or an opioid blocker called naltrexone. Overdose survivors who don’t want treatment are given naloxone, a fast-acting opioid antidote. Coaches also stay in touch after patients leave the ER, helping with court obligations and social services.

Similar programs operate across the country. In Chillicothe, Ohio, police try to connect addicts to treatment by visiting the home of each person in the county who overdoses. In Gloucester, Mass., heroin users can walk into the police station, hand over their drugs, and walk into treatment within hours, without arrest or charges. It’s called the Angel Program. Macomb County, Mich., has something similar called Hope Not Handcuffs.

Another idea gaining traction is to provide “safe consumption sites,” hygienic booths where people can inject their own drugs in the presence of nurses who can administer oxygen and naloxone if needed. No one who goes to a safe consumption site is forced into treatment to quit using, since the priority is reducing risk.

In Canada, staffers at Vancouver’s consumption site urge patrons to go into treatment, but they also distribute clean needles to reduce the spread of viruses such as HIV and hepatitis C. Naloxone kits are on hand in case of overdose. One study found that opening the site has reduced overdose deaths in the area, and more than one analysis showed reduced injection in places like public bathrooms, where someone can overdose undiscovered and die.

There are no consumption sites in the U.S., but in January the board of health in King County, Wash., endorsed the creation of two in the Seattle area. A bill in the California

Assembly would allow cities to establish safe consumption sites. Politicians, physicians and public-health officials have called for them in Baltimore; Boston; Burlington, Vt.; Ithaca, N.Y.; New York City; Philadelphia and San Francisco. Drug-war-weary police officers and harm reductionists would rather see addicts opt for treatment and lasting recovery, but they’ll settle for fewer deaths.

When all else fails, handcuffs can help, too. A problem with treatment is that addicts often stay with the program only for brief periods. Dropout rates within 24 weeks of admission can run above 50%, according to the National Institute on Drug Abuse. Courts can provide unique leverage. Many drug users are involved in addiction-related crime such as shoplifting, prescription forgery and burglary. Shielding them from the criminal-justice system often is not in society’s best interests—or theirs.

Drug courts, for example, keep offender-patients in treatment through immediately delivered sanctions (e.g., a night in jail) and incentives (e.g., looser supervision). Upon successful completion of a 12- to 18-month program, many courts erase the criminal record. This seems to work. The National Association of Drug Court Professionals reports that 75% of drug court graduates nationwide “remain arrest-free at least two years after leaving the program.”

What’s more, if the carrot-and-stick method used by drug courts is scrupulously applied, treatment may not always be necessary. This approach, called “swift, certain and fair,” has been successful with methamphetamine addicts in Hawaii and alcoholics in South Dakota. Some courts in Massachusetts and New Hampshire have now adopted it with opioid addicts. I predict that the combination of anti-addiction medication plus “swift, certain, and fair” will be especially effective.

With synthetic drugs similar to fentanyl turbocharging the opioid problem, the immediate focus should be on keeping people safe and alive. But for those revived by antidotes and still in a spiral of self-destruction, the criminal-justice system may be the ultimate therapeutic safety net.

Source:  https://www.wsj.com/articles/saving-lives-is-the-first-imperative-in-the-opioid-epidemic-1491768767  April 9, 2017

HARRISBURG, Pa. (AP) – They’re the tiniest and most innocent victims of the heroin addiction crisis but it doesn’t spare them their suffering.

They cry relentlessly at a disturbing pitch and can’t sleep. Their muscles get so tense their bodies feel hard. They suck hungrily but lack coordination to successfully feed. Or they lack an appetite. They sweat, tremble, vomit and suffer diarrhea. Some claw at their faces.

It’s because they were born drug-dependent and are suffering the painful process of withdrawal. “It’s very sad,” says Dr. Christiana Oji-Mmuo, who cares for them at Penn State Hershey Children’s Hospital. “You would have to see a baby in this condition to understand.”

As the heroin and painkiller addiction epidemic gripping Pennsylvania and the whole country worsens, the number of babies born drug dependent has surged.   Geisinger Medical Center in Danville, Pa. saw two or three drug-dependent babies annually when Dr. Lauren Johnson-Robbins began working there 17 years ago. Now Geisinger cares for about twice that many per month between its neonatal intensive care unit in Danville and the NICU at Geisinger Wyoming Valley Medical Center in Wilkes-Barre.

Penn State Children’s Hospital is averaging about 20 per year, although it had cared for 18 through last June, with the final 2016 number not yet available, says Oji-Mmuo.

PinnacleHealth System’s Harrisburg Hospital also sees about 20 per year. That’s less than a few years ago, but only because a hospital that used to transfer drug dependent babies to Harrisburg Hospital equipped itself to care for them. “Now everybody is facing it and trying to deal with it one way or another,” says Dr. Manny Peregrino, a neonatologist involved with their care.

The babies suffer from neonatal abstinence syndrome, or NAS, which results from exposure to opioid drugs while in the womb. An estimated 1 in 200 babies in the United States are born dependent on an opioid drug. More than half end up in a NICU, which care for unusually sick babies.

In 2015, 2,691 babies received NICU care in Pennsylvania as the result of a mother’s substance abuse, according to the Pennsylvania Health Care Cost Containment Council. That’s up from 788 in 2000, or a 242 percent increase in 15 years.

Nearly all babies born to opioid-addicted moms suffer withdrawal. The severity varies. About 60 percent need an opioid such as morphine or methadone to ease them through withdrawal. These babies typically spend about 25 days in the hospital.

Often, the only way to calm them is to hold them for long periods – so long that many hospitals enlist volunteer “cuddlers.” ”It really is a whole village. Everybody pitches in,” Peregrino says.

Giving medications to newborns can lead to other problems, so the preference is to get them through withdrawal without it. A scale based on their symptoms is used to determine which ones need medication. In cases where withdrawal isn’t so severe,

symptoms can be managed by keeping the baby away from noise and bright light, cuddling them, and using devices such as mechanical swings to sooth them.

Logan Keck of Carlisle feared the worst upon learning what her baby might face. The 23-year-old became addicted to heroin several years ago. She says it was prominent in her circle of high school classmates, and she became “desensitized” to the danger, figuring it couldn’t be as bad as some claimed.   Keck has been in recovery for more than two years with the help of methadone, a prescription drug used to prevent withdrawal and craving. She was a few weeks away from being fully tapered off methadone when Keck learned she was pregnant.

She was told stopping methadone during pregnancy would put her at risk of miscarriage. Keck further learned her baby might be born addicted. She gave birth on Feb. 1 at Holy Spirit-Geisinger in Cumberland County.

Her baby had difficulty latching on during breastfeeding and vomited milk into her lungs, but seemed fine otherwise. Keck expected she and her baby would go home soon after delivery.  But after a few days, withdrawal became obvious. Keck knows how withdrawal feels. “That’s when it really hit home for me – seeing her feel it,” she says.  Then she was hit again: she was discharged, but her baby remains in the NICU, possibly for several more weeks.

The opioid addiction epidemic affects people of all backgrounds and regions – rich, poor, urban, suburban. It’s prevalent in economically-stressed areas, including many of Pennsylvania’s rural counties.

Geisinger has found a bit of brightness within the 30-plus rural counties it serves. Some of the region’s doctors realized there was little access to methadone, which is dispensed from clinics usually located in more populated areas. That meant pregnant rural women lacked access to a legal drug that could keep them away from the risks of street drugs while also getting them onto the road to recovery. So the doctors became licensed to prescribe buprenorphine, another drug that staves off withdrawal and cravings for opioids. As a result, the majority of mothers of NAS babies at Geisinger have been taking buprenorphine during pregnancy, according to Johnson-Robbins.

Geisinger doctors have been pleased to find that buprenorphine, while it does cause NAS, withdrawal isn’t as severe as with methadone. It also impacts another major concern surrounding NAS babies: that the mother will continue to struggle with addiction and live a lifestyle that will prevent her from properly caring for her baby. Most Geisinger moms, being in recovery for a while, are better-equipped to care for their baby.

Still, there’s great concern about what happens to NAS babies after they leave the hospital. The mother might go back to heroin and become unable to properly care for her baby – there have been many news reports of addicted parents or fathers who neglected or otherwise hurt their babies, including a Pennsylvania woman who rolled over and suffocated her baby while high on opioids and other drugs. The mother might lack adequate housing or other means of having a stable home. There might be criminal activity in the home.

Delaware County woman says she didn’t know their whereabouts until news reports of their hospitalizations for alleged severe abuse.

“We are sending children out into compromised environments,” says Dr. Lori Frasier, who leads the division of child abuse paediatrics at Penn State Hershey Children’s Hospital. Those babies often return to the hospital as victims of abuse or neglect, Frasier says.

Another cause for worry is the fact that NAS babies can remain unusually fussy after leaving the hospital, potentially putting extra stress on a parent already dealing with the stress of addiction. “We know that crying, fussy babies can be triggers for abuse,” Frasier says. Cathleen Palm, founder of the Pennsylvania-based Center for Children’s Justice, said much more needs to done to provide help for mothers of NAS babies, and to monitor and protect the babies. “We have really been trying to get policy makers to understand the nuances,” she says.

Keck goes to Holy Spirit-Geisinger daily to breastfeed and hold her baby for one to two hours. Her time is limited by distance and the fact the baby’s father needs their only car for work. Looking forward, Keck says she’s in a stable relationship with the baby’s father, who is not an addict and accompanies her to the hospital. They have family support, and a Holy Spirit program will provide additional help.

Ultimately, Keck’s pregnancy and motherhood have taught her things that might have inspired her to make a different choice regarding heroin, including the fact it caused her newborn to suffer and forced her to go home without her baby. She agreed to be interviewed out of desire to get others to think and talk about such realities. “I want people to understand it’s something that’s not pretty,” Keck said. “It’s something that’s important to talk about.”

Source:  http://www.washingtontimes.com/news/2017/feb/18/born-addicts-opioid-babies-in-withdrawal

The letter below speaks of the heroin epidemic in the USA.  The figure of heroin and opioid addiction that has destroyed countless families and killed more than 50,000 Americans in 2015 alone is salutary.

A chronicle of President Barack Obama’s tenure must include the heroin epidemic that he leaves us with. Our nation is plagued with a systemic heroin and opioid addiction that has destroyed countless families and killed more than 50,000 Americans in 2015 alone. This one-year death toll is greater than the total number of Americans killed in action during the Vietnam War.

The opioid casualty count only tells part of the story. More than half a million Americans admit to being addicted to heroin, and each of them has a very difficult, if not impossible, road to recovery. Yet, heroin flows into our nation every day and is readily available for $5 a bag 24/7 on street corners throughout the cities and suburbs of America.

How was this level of accessibility not reason enough for President Obama to make slowing our porous borders a priority?  Obama, in his final days as president is now becoming more vocal about the epidemic he leaves behind. However, this is too little, too late in the extreme. His record-setting pardoning and lessening of drug dealer sentences, which have included heroin dealers, further erodes his record on the heroin epidemic. Classifying a heroin dealer as a nonviolent criminal in the face of the American opioid death toll is nonsense.

Perhaps Obama was one of the lucky ones that didn’t have a close friend or relative addicted or taken by heroin and he just didn’t notice the plague that took root under his watch.

Robert Cochran Stafford

Source:  http://www.app.com/story/opinion/readers/2017/01/14/letter-obama-legacy-includes-drug-addiction-epidemic/96557686/

National statistics show 2,367 users aged 18 to 24 sought treatment in 2015-16 as drug becomes increasingly unfashionable.   A total of 149,807 opiate addicts came for treatment in England during 2015-16, down 12% on a peak of 170,032 in 2009-10.

The number of 18 to 24-year-olds in England entering treatment for addiction to heroin has plummeted 79% in 10 years, as the stigma surrounding the drug and changing tastes in intoxication have made it increasingly unfashionable.

In the year to March, 2,367 people from that age group presented with heroin and opiate addiction at the approximately 900 drug treatment services in England, compared with 11,351 10 years earlier, according to statistics from the National Drug Treatment Monitoring System (NDTMS).

They constituted a tiny fraction of the 149,807 opiate addicts who came for help to kick their habit throughout the year, a number that is itself 12% down on a peak of 170,032 who came for treatment in 2009-10. The median age of those users was 39, the statistics showed.  Michael Linnell, the coordinator of UK DrugWatch, a network of drug treatment professionals, said many of the heroin users currently accessing treatment would have become addicted during a boom in the drug’s popularity in the late 1980s. Young addicts were “as rare as hen’s teeth”, he said.

Our neglect of ageing heroin users has fuelled the rise of drug-related deaths

“For the Thatcher generation who didn’t see a future and there were no jobs or employment and the rest of it, it was an alternative lifestyle in that you were really, really busy being a heroin user: getting up, scoring, nicking stuff to get the money to score and the rest of it,” Linnell said.

“There was a whole series of factors until you got to that point where people from those communities – the poorest communities – where you were likely to get heroin users, could see the visible stigma of the scarecrow effect, as some people called it.

“They didn’t want to aspire to be a heroin user because a heroin user just had negative connotations, rather than someone who was rebelling against something.”

Overall, 288,843 adults aged 18 to 99 came into contact with structured treatment for drug addiction during 2015-16, 52% of whom were addicted to heroin or some other opiate. Among opiate addicts, 41% were also addicted to crack cocaine, with the next highest adjunctive drugs being alcohol (21%) and cannabis (19%).

About half of those presenting to treatment – 144,908 – had problems with alcohol, a fall of 4% compared with the previous year. Among those, 85,035 were treated for alcohol treatment only and 59,873 for alcohol problems alongside other substances.

The most problematic drug among the 13,231 under-25s who came into contact with drug treatment services in the past year was cannabis, which was cited as a problem by 54%, followed by alcohol (44%) and cocaine (24%).

The numbers from this age group accessing treatment had fallen 37% in 10 years, which the Public Health England report accompanying the statistics said reflected shifts in the patterns of drinking and drug use over that time, with far fewer young people experimenting with drugs than in the past.  Karen Tyrell, the spokeswoman for the drug treatment charity Addaction, said the decline in problem drug use among young people reflected what drugs workers see on a daily basis, and credited evidence-based education, prevention and early intervention programmes for the change.

The shift, though, was precarious, Tyrell said, warning that yearly spending cuts to treatment services risked reversing the gains.

She added: “Of course, what this also means is that we have an ageing population of heroin users, many of whom have been using since the 80s or 90s, and who are now dealing with poor physical health and increasing vulnerability. In an environment of ever rising drug-related deaths, it’s imperative we don’t lose sight of their needs.”

Source:  https://www.theguardian.com/society/2016/nov/03/

Current brain science is suggesting strong plausibility that the opiate and heroin epidemic will continue to worsen with commercializing and industrializing production and sales of marijuana at levels the likes of tobacco, alcohol and prescription drugs. With more 21st century marijuana in our communities, opiate and heroin use rises. The brain science is beginning to explain why this is. We are, with marijuana research, where we were in the 1920s and 30s with tobacco research linking smoking to cancer.

Studies are revealing that the cannabinoid-opioid systems of the brain are intimately connected.

In the areas of the brain where cannabinoids bind, opioids bind as well, and if you modify one system, you automatically change the other. Specifically, there is a functional interaction between the mu and Cb1 receptors of the brain; these receptors commonly exist together on brain cells. The mechanism is not yet well understood; more research is needed. But ultimately cannabinoids and opioids are known to strictly interact in many physiological and pathological functions, including addiction. Overall, evidence confirms a neurobiological convergence of the cannabinoid and opioid systems that is manifest at both receptor and behavioral levels.

What does this mean? We are learning that brain cross-talk between the endocannabinoid and endogenous opioid systems may cause, if there has been early brain exposure to marijuana, changes in the sensitivity to other drugs of abuse such as heroin.

Specifically, the sensitivity may be blunted, which would cause a greater risk for abuse and addiction. This new science supports the plausibility that a person who uses marijuana as a teenager may be increasing his/her risk of opiate addiction later in life. For example, a 20 year old who takes an opiate pain killer for a skiing injury or wisdom tooth removal may become much more at risk of becoming addicted to that pain killer as a result of his or her earlier marijuana use – no matter how insignificant that earlier use may seem. To be clear, this does not mean every teen marijuana user will be challenged with opioid addiction when they take an opiate-based pain killer later in life, as certainly, not every cigarette smoker ends up with lung cancer. Nor does this remove the enormous accountability opioid medications have in the current opiate crisis. It does put some teeth behind that old-school term “gateway drug” as now there is clear scientific evidence of a neuropathway link between opioids and cannabinoids in the brain. Perhaps “pathway drug” is a more accurate term.

The opioid-marijuana brain cross talk is very real and the newest research shows very important experimental evidence on “epigenetics.” A study in rodents showed that somehow, sperm or ova evade genetic cleansing during reproduction and epigenetic modifications triggered by THC are carried forward to the next generation. These changes were produced by THC exposure during adolescence, and yet persisted during reproduction in adulthood long AFTER exposure ended. The research needs to be reproduced in humans but there are others studies on trans-generational effects of other drugs in humans that appear to be consistent with discoveries in rodents.

This research is indicating that with more 21st century marijuana use, we are not only exposing more people to a serious decline in cognitive & mental-health functioning, but we conceivably are also priming populations for more opiate addiction and brain changes. And alarmingly, this priming can take place in utero, even if marijuana use ceases prior to childbearing years.

So frankly, it may not be a coincidence that the states with highest rates of youth marijuana use are also experiencing a soaring heroin epidemic – a trend we are seeing rise across the United States.

This science-based possibility that marijuana exposures in the brain are a foundational feature of the opiate addiction crisis deserves to be weighed heavily in the current decision-making process in how best to change marijuana law – especially given our nation’s tobacco history and tobacco’s impact on health and healthcare costs.  We will learn more about all of this opioid-cannabinoid brain connection, and very soon. with what this science is revealing, if it takes 50 years like it did with tobacco to confirm smoking cigarettes causes lung cancer, our species may be facing a profound and permanent decline in cognitive functioning.

Those in the field of substance abuse and drug use prevention are grateful to our esteemed researchers in Massachusetts and throughout our nation working diligently every day to not only figure out this opioid-cannabinoid neuropathway link, but to explain it to the rest of us so we begin to truly understand what is at stake as the marijuana lobby pushes for full government protection to engineer, produce, market and sell marijuana products in every community for recreational use, like tobacco.

Source:   http://marijuana-policy.org/marijuana-and-opiateheroin-epidemic-brain-science-explains-a-connection/ Feb.2016     By Heidi Heilman, Founder and CEO Massachusetts Prevention Alliance (MAPA); Founder and CEO, Edventi  

The Marijuana Policy Initiative

Don’t Legalize. We Change Minds About Marijuana Legalization/Commercialization

A volunteer non-partisan coalition of people from across the US and Canada who have come to understand the negative local-to-global public health and safety implications of an organized, legal, freely-traded, commercialized and industrialized marijuana market.

With special thanks to Dr. Bertha Madras, Dr. Sion Harris, and Dr. Sharon Levy for their work in translating the complexities of the latest brain science. ___

References (partial list of a lengthy list)

1. Ellgren M, Spano SM, Hurd YL. Adolescent cannabis exposure alters opiate intake and opioid limbic neuronal populations in adult rats. Neuropsychopharmacology. 2007 Mar;32(3):607-15

2. Spano MS, Ellgren M, Wang X, Hurd YL. Prenatal cannabis exposure increases heroin seeking with allostatic changes in limbic enkephalin systems in adulthood. Biol Psychiatry. 2007 Feb 15;61(4):554-63.

3. Ellgren M, Artmann A, Tkalych O, Gupta A, Hansen HS, Hansen SH, Devi LA, Hurd YL. Dynamic changes of the endogenous cannabinoid and opioid mesocorticolimbic systems during adolescence: THC effects. Eur Neuropsychopharmacol. 2008 Nov;18(11):826-34.

4. DiNieri JA, Wang X, Szutorisz H, Spano SM, Kaur J, Casaccia P, Dow-Edwards D, Hurd YL. Maternal cannabis use alters ventral striatal dopamine D2 gene regulation in the offspring. Biol Psychiatry. 2011 Oct 15;70(8):763-9.

5. Spano MS, Ellgren M, Wang X, Hurd YL. Prenatal cannabis exposure increases heroin seeking with allostatic changes in limbic enkephalin systems in adulthood. Biol Psychiatry. 2007 Feb 15;61(4):554-63.

A new study finds the number of young children and teens hospitalized for opioid painkiller overdoses has almost tripled in recent years.

Opioid overdoses increased 205 percent from 1997 to 2012 among children ages 1 to 4, HealthDay reports. Among teens ages 15 to 19, overdoses increased 176 percent.

Most poisonings due to opioid painkillers among children under 10 were accidental. Lead researcher Julie Gaither of the Yale School of Medicine says young children are “eating them like candy.” Most overdoses among teens were accidental, although some were suicide attempts, Dr. Gaither noted.

Source: The study appears in JAMA Pediatrics. Partnership News Service thepartnership@drugfree.org  3rd Nov.2016

A synthetic opioid known as “pink” is legal in most states, even though it is almost eight times stronger than morphine, CNN reports.

The drug, also known as U-47700, is responsible for dozens of deaths nationwide, the article notes. Adam Kline, Police Chief of White Lake, Michigan, told CNN the drug can be legally purchased on the “dark web” in the form of a powder, pill or nasal spray. Last month, the Drug Enforcement Administration told NBC News it is aware of confirmed deaths associated with the drug in New Hampshire, North Carolina, Ohio, Texas and Wisconsin. The drug, along with other synthetic opioids, is being shipped into the United States from China and other countries.

Source:  thepartnership@drugfree.org  2nd Nov.  2016

Drug cartels are selling lethal doses of fentanyl disguised as street heroin and counterfeit OxyContin pills, two U.S. government agencies are warning.

The Drug Enforcement Administration and the Department of Justice are cautioning people who buy illegal drugs and painkillers on the street or in Tijuana, Mexico, that cartels are using fentanyl because they can produce it more cheaply. Just a few grains of fentanyl can be lethal, the agencies said. In September, authorities confiscated more than 70 pounds of fentanyl and 6,000 counterfeit pills, NBC 7 reports.

“It’s extremely profitable for the cartels. They aren’t having to wait for harvest. They aren’t having to harvest the poppy plants. They’re not having to manufacture that paste into heroin. They are literally just getting a chemical from China,” DEA spokeswoman Amy Roderick told NBC 7.

Source:  www.thepartnership@drugfree.org  13th October 2016

Filed under: Economic,Heroin/Methadone,USA :

Latest statistics show 305 admissions were diagnosed as drugs misuse in the year 2011/12 — compared to 97 in 2007/08.

Across NHS Tayside as a whole the number has more than doubled, with an increase from 244 five years ago to 512 last year.  Doctors have warned there is now a “constant background level of recreational drug use” in the region’s Accident and Emergency departments.

A&E consultant Dr Julie Ronald said people come in with drugs-related problems most weekends.  She said: “We deal with a lot of drugs-related admissions. It can be very time consuming — especially if patients cause disruption to the rest of the department.

“It’s something we see most weekends of some variety. The vast majority are brought in by ambulance.  Usually someone has been with the patient or found them and decided they require medical attention.”

Across Tayside, opioids — such as heroin — were the cause for more than 80% of admissions over the period.  Of these, 60 were categorised as resulting from multiple drugs or other less common drugs.

And 468 — more than 90% — were classed as emergency admissions. Also last year, 28 of the admissions were for cannabis-type drugs, nine were for cocaine, eight for sedatives or hypnotics and seven were for other sedatives.

Dr Ronald, who works in the A&E departments at Ninewells Hospital and Perth Royal Infirmary, said there has been a noticeable increase in younger patients for drugs misuse .She said: “There is a constant background level of recreational drug use. We’re always coming into contact with it. We do see heroin misuse. What we have certainly seen is more recreational legal high-type drugs.   A lot of teens and people in the younger age groups are coming in who have taken party drugs, such as bubbles or MCAT.”

Some 89 of the admissions for 2011/12 had to stay in hospital for a week or longer. Dr Ronald said: “A&E look after the vast majority of people coming in with recreational drug misuse. We tend to keep them in for a few hours for observation, or overnight if they need to be monitored for longer.”

Source:  www.eveningtelegraph.co.uk   15th June 2013

Dublin city coroner Dr Brian Farrell is to write to the Department of Health to highlight a link between methadone use and heart failure following an inquest into the death of a 30-year-old man.   Philip Wright of Celbridge, Co Kildare, died on December 13th, 2011, having collapsed after taking heroin.

He had discharged himself on December 12th from Connolly Hospital Blanchardstown where he had been taken off methadone, a heroin replacement drug, because of the dangerous effect it was having on his heart. Mr Wright had attended the hospital on December 9th after collapsing at home. He was also on antibiotics for a chest infection.

Dr Joseph Galvin, consultant cardiologist at the hospital, told the coroner an electrocardiogram (ECG) carried out on Mr Wright picked up a problem with his heart and his methadone was stopped on December 11th. He said the drug could put the heart out of rhythm by changing its electrical properties “in a dangerous way”.

Mr Wright’s heart returned to normal after he was taken off methadone, he said. Recent studies had shown up to 18 per cent of people on methadone had experienced the same heart problems, he said.   The doctor recommended that anyone who collapsed while using methadone should have an ECG carried out. “It is not as benign a drug as was first thought,” Dr Galvin said.

He also said he had recommended an alternative drug for Mr Wright to replace the methadone: buprenorphine.  By lunchtime on Monday, December 12th, Mr Wright had not received the drug. His father, James Wright, told the coroner his son feared he would go into severe withdrawal without it.  He discharged himself from hospital against medical advice and obtained heroin. He died of respiratory failure in the bathroom of his parents’ home the following day having injected the heroin.

Evidence was also given that the pharmacy in the hospital did not receive a request for buprenorphine for Mr Wright and there were issues around access to the drug.

There was also a recommendation that there should be an interval between the time methadone is stopped and buprenorphine is given.  Returning a verdict of death by misadventure, Dr Farrell said he would write to the department and to methadone maintenance authorities and clinics about the potential cardiac effects of methadone.

He would also raise the issue of availability of buprenorphine.

Source: www.irishtimes.com Sat. 5th Jan

THE methadone programme has failed drug addicts in Clydebank, a leading addictions worker said this week.

methadone-is-a-monsterDonnie McGilveray is the manager of Alternatives, a West Dunbartonshire charity that helps reform drug addicts, many of them methadone users.

He told the Post the methadone programme used to treat heroin addicts has gone unregulated — and described the green liquid as a “monster” that keeps people hooked for good.

His comments come after shock statistics were released last week showing that Clydebank pharmacies claimed £153,000 for methadone prescriptions in 2014.

Donnie told the Post: “I think methadone is helpful for a small cohort of people, the five to ten per cent of people who are chaotic, suicidal or maybe sex workers being used and abused by people. There is a small group of people who need to be made safe.

But that’s not what is happening. We’ve got this monster, a jolly green giant, that many, many addicts are stuck on. And again, it’s not just them who are stuck in this it’s the doctors and nurses who have an obligation to keep them safe.”

National data obtained by BBC Scotland showed pharmacists were paid £17.8 million for handling nearly half a million prescriptions of methadone in 2014. In Clydebank, £153,000 was paid to eight pharmacies to deliver 3,165 prescriptions of the heroin substitute. In Dalmuir Lloyds, £31,671 was claimed for prescribing and supervising methadone to addicts in 2014. But topping the chart was Lloyds Pharmacy on 375 Kilbowie Road which received £38,207 in payments. Pharmacists are paid around £2.32 for dispensing every dose of methadone and about £1.33 for supervising addicts while they take it. Chemists pay the wholesale cost of buying methadone from the government money they claim.

Around 60 per cent of the cash they are paid is made up of their handling fee for the drug and their charges for dishing it out to addicts. In 2013, pharmacies claimed back more than £17.9 million from the Scottish Government for handling 470,256 prescriptions of methadone — 22,980 prescriptions more than in 2014.

Donnie also told the Post he believes West Dunbartonshire, which has a long history of drug problems, is making progress tackling addiction. He said: “At the end of the day, the statistics don’t tell you how many people are on methadone or any details of the prescription, but what we can tell is the drug companies are making a killing from it.”

Figures released by the NHS in 2012 revealed that methadone-implicated deaths increased dramatically in cases where the individual had been prescribed the drug for more than a year.

The addictions worker told the Post he believes methadone should be reserved for the chaotic drug users and other substitutes such as Buprenorphine, Subutex and Dihydrocodiene should be implemented. He continued: “Methadone is not just a medical or pharmaceutical matter but a human rights issue. “The dilemma is that if you reduce someone’s methadone they become unstable and could relapse. Some of the people we work with at Alternatives have relapsed, it’s a regular situation.

If you start to reduce this person they could relapse and relapse significantly, and they might think they can go back onto heroin and inevitably could end up overdosing.”

He added: “That’s my position and I don’t envy the medical side of it in trying to square this problem.”

Top researcher Dr Neil McKeganey, from the Centre for Drug Misuse Research, said the methadone programme “is literally a black hole into which people are disappearing”.

The statistics of methadone prescriptions can be viewed online at:    www.marcellison.com/bbc/methadone

Alternatives is an organisation funded by West Dunbartonshire Council that helps bring recovering addicts back into society. The project has been around since January 1995, firstly covering Dumbarton and the Vale of Leven, latterly broadening out to Clydebank.

Source: http://www.archive.clydebankpost.co.uk/ 7th April 2015

According to the National Institute on Drug Abuse, “Besides the risk of spontaneous abortion, heroin abuse during pregnancy (together with related factors like poor nutrition and inadequate prenatal care) is also associated with low birth weight, an important risk factor for later delays in development. Additionally, if the mother is regularly abusing the drug, the infant may be born physically dependent on heroin and could suffer from neonatal abstinence syndrome (NAS), a drug withdrawal syndrome in infants that requires hospitalization. According to a recent study, treating opioid-addicted pregnant mothers with buprenorphine (a medication for opioid dependence) can reduce NAS symptoms in babies and shorten their hospital stays.”

Source:   http://www.wmdt.com/news    Sept 18th 2015

The overdose antidote is being offered for use in High Schools and is a sad indictment of the situation in the USA where lax drug policies have resulted in huge increases in drugs use – including heroin even amongst youth.

The opioid overdose antidote naloxone is being offered free to high schools around the country by the drugmaker Adapt Pharma, according to U.S. News & World Report.

Naloxone, sold under the brand name Narcan, quickly reverses overdoses from heroin and prescription painkillers. Naloxone will be offered in nasal spray form to high schools through state departments of education. The Clinton Foundation’s Health Matters Initiative is collaborating on the project.

Many states do not have rules that would permit high school staff to administer naloxone in an emergency without facing liability from parents or guardians, the article notes. There are significant variations in state and local rules about whether staff is allowed to administer medication to students. In some school districts, medication can only be administered by school nurses, who often work at more than one school.

The National Association of School Nurses (NASN) in June said that “incorporating use of naloxone into school emergency preparedness and response plans is a school nurse role.” In a statement, the group said “the safe and effective management of opioid pain reliever-related overdose in schools [should] be incorporated into the school emergency preparedness and response plan.” Last year, New York joined at least four other states in allowing public school nurses to add naloxone to their inventory. Other states with similar policies include Vermont, Massachusetts and Delaware.

Adapt Pharma is also providing a grant to NASN to support their education efforts concerning opioid overdose education materials. In a news release from the company, NASN President Beth Mattey said school nurses act as first responders in schools. “We educate our students, families, and school staff about prescription drug and substance abuse, and help families seek appropriate treatment and recovery options,” she said. “Having access to naloxone can save lives and is often the first step toward recovery. We are taking a proactive approach to address the possibility of a drug overdose in school.”

Source:  http://www.drugfree.org/join-together  26th Jan. 2016

The methadone programme in Scotland is “out of control”, an expert has warned.

Prof Neil McKeganey, from the Centre for Drug Misuse Research, said “it is literally a black hole into which people are disappearing”. Data obtained by BBC Scotland showed pharmacists were paid £17.8m for dispensing nearly half a million doses of methadone in 2014.

In response, the Scottish government said both doses and costs linked to opioid treatment had been dropping. Community Safety Minister Paul Wheelhouse told the BBC: “Fewer Scots are taking drugs – numbers are continuing to fall amongst the general adult population, and drug taking among young people is the lowest in a decade.”

However, a lack of data to measure the programme’s impact was the focus of criticism from Prof McKeganey. He said: “We still don’t know how many addicts are on the methadone programme, what progress they’re making, and with what frequency they are managing to come off methadone.

“Successive inquiries have shown that the programme is in a sense out of control; it just sits there, delivering more methadone to more addicts, year in year out, with very little sense of the progress those individuals are making towards their recovery.”

But David Liddell, director of the Scottish Drug Forum, disputed claims that addicts were parked on the methadone programme. He said: “What we know is the level of methadone being dispensed continues at the same level, but it’s not the same individuals. “Our sense is that of the 20,000-plus people on methadone, it will be less than half who are on it for a very long period of time.” However Mr Liddell admitted that, unlike England, there is currently no data in Scotland on whether users are relying on the programme indefinitely.

Regional increases

In 2013, pharmacies claimed back more than £17.9m from the Scottish government for dispensing 470,256 doses of methadone – 22,980 doses more than in 2014.

But despite this overall decrease, new data – obtained from National Services Scotland through a freedom of information request – revealed the amount of methadone dispensed has increased in more than a third of Scottish local authorities over the last two years.

The Edinburgh council area saw the largest increase in doses (2,949), followed by Falkirk (421) and Argyll and Bute (405). The largest decreases were found in Renfrewshire (5,842), Inverclyde (5,611) and East Ayrshire (5,598).

And while fees paid to pharmacies for dispensing methadone have declined over a four-year period, Prof McKeganey said the average annual outlay does suggest users are parked on the drug.

Prof McKeganey said: “The aspiration contained within the government’s ‘Road to Recovery’drug strategy explicitly said that the goal of treatment must be to enable people to become drug-free rather than remain on long-term methadone. These figures show you that we are not achieving that goal – we are not witnessing large numbers of people coming off the methadone programme.”

New strategy

Methadone has been at the heart of drug treatment strategies since the 1980s, but its use has been widely criticised by recovering addicts and drugs workers.

Methadone is by far the most widely used of the opioid replacement therapies (ORT), with an estimated 22,000 patients currently receiving it, but some users take it for years without being weaned off it altogether. Howevera review commissioned by the Scottish governmentin 2013 concluded methadone should continue to be used to treat heroin addicts.

There are alternatives, including prescribing medical heroin, but many in the drugs field say the debate should move away from these to an examination of how the wider needs of drug users can be met. Prof McKeganey said methadone does have a role to play in helping addicts wean themselves off heroin, but it should not be prescribed as widely as it is now.

An estimated 22,000 people are currently on Scotland’s methadone programme

He said he would like to see a two-year reassessment implemented so that if the “highly addictive” methadone does not seem to be working for an individual, they can then either try the more expensive suboxone, or enter a drug-free residential home. “That seemed preferable to me than leaving people on a methadone prescription for years – and then the worry is that you’ve turned your heroin addicts into methadone addicts.”

Figures released by the NHS in 2012revealed that methadone-implicated deaths increased dramatically in cases where the individual had been prescribed the drug for more than a year.

Recent figures from the National Records of Scotland also revealmethadone was implicated in nearly the same number of deaths as heroin in 2013.

‘Methadone millionaires’

The methadone data obtained by BBC Scotland reveals how much each individual pharmacy claimed back in fees from the Scottish government.

Last year more than £102,000 was claimed by just one pharmacy on Glasgow’s Saracen Street in Possilpark – an area ranked the third most-deprived in Scotland. The largest claims were made by pharmacy giants Boots and Lloyds, who reclaimed £3.8m and £3.3m respectively from their hundreds of branches across the country.

The fees paid back to pharmacies are not only for the dispensing of methadone, but for oral hygiene services, and the services of a supervisor to ensure the dose is taken onsite and not sold on the street. Pharmacies apply to enter into a contract with their health board to provide methadone services and must justify the need for such a service within that locality. Pharmacists in Greater Glasgow are currently paid £2.16 for dispensing every dose of methadone and £1.34 for supervising addicts while they take it.

The fees are negotiated with individual health boards to suit local needs, and are lower than in England.

But a spokesman from Community Pharmacy Scotland dismissed the“methadone millionaire” tagplaced on such pharmacies in the past by certain media outlets.

He said: “Methadone is an NHS prescription medicine and as such a community pharmacy is obliged to provide it when it has been prescribed for a patient by a GP.

“While community pharmacists are paid to administer the program, the income is far outweighed by the time, administration and difficulties that can often be encountered by taking on a role in this difficult area. The argument is not a financial one – but a health and social issue.”

A statement by the Scottish government did not address the lack of data to prove the programme was enabling addicts to become drug-free. However, Mr Wheelhouse said: “Both the number of items and the number of defined daily doses of opioid treatment have dropped steadily over the past five years and the cost of methadone is down 19% since 2010-11. He added: “Independent experts advise that opioid replacement therapy is a crucial tool in treating opiate dependency. However, we believe it is important that there are a range of treatments available that suit the unique needs of individuals.

“Prescribing opioid replacement therapy is an independent decision for individual clinicians, in line with the current UK guidelines on the Clinical Management of Drug Misuse and Dependence.”

Source: http://www.bbc.co.uk/news/uk-scotland-31943109 24th March 2015

President Obama this week told an audience in Jamaica that U.S. efforts against illegal drugs were “counterproductive” because they relied too much on incarceration—particularly for “young people who did not engage in violence.”

In what the president termed “an experiment … to legalize marijuana” in Colorado and Washington state, he said he believed they must “show that they are not suddenly a magnet for additional crime, that they have a strong enough public health infrastructure to push against the potential of increased addiction.”

In regard to Jamaica and the entire Caribbean and Central American region, he said, “a lot of folks think … if we just legalize marijuana, then it’ll reduce the money flowing into the transnational drug trade, there are more revenues and jobs created.”

To some of us, Jamaica hardly seems an auspicious location for encouraging “experimentation” with drugs, in particular because of the challenges already faced by their deficient institutions of public health and criminal justice. The U.S. Department of State 2015 International Narcotics Control Strategy Report(INCSR) states:

Jamaica remains the largest Caribbean supplier of marijuana to the United States and local Caribbean islands. Although cocaine and synthetic drugs are not produced locally, Jamaica is a transit point for drugs trafficked from South America to North America and other international markets. In 2014, drug production and trafficking were enabled and accompanied by organized crime, domestic and international gang activity, and police and government corruption. Illicit drugs are also a means of exchange for illegally-trafficked firearms entering the country, exacerbating Jamaica’s security situation.

Drugs flow from and through Jamaica by maritime conveyance, air freight, human couriers, and to a limited degree by private aircraft. Marijuana and cocaine are trafficked from and through Jamaica into the United States, Canada, the United Kingdom, Belgium, Germany, the Netherlands, and other Caribbean nations. Jamaica is emerging as a transit point for cocaine leaving Central America and destined for the United States, and some drug trafficking organizations exchange Jamaican marijuana for cocaine. . . .

The conviction rate for murder was approximately five percent, and the courts continued to be plagued with a culture of trial postponements and delay. This lack of efficacy within the criminal courts contributed to impunity for many of the worst criminal offenders and gangs, an abnormally high rate of violent crimes, lack of cooperation by witnesses and potential jurors, frustration among police officers and the public, a significant social cost and drain on the economy, and a disincentive for tourism and international investment.

This does not seem like a place where “legal” marijuana would contribute to “reduced money flow” to the transnational drug trade, or “create jobs.”  The president apparently thinks Jamaica should consider allowing more drugs, based on a faulty understanding of what is actually happening in Jamaica and in the U.S.

His charge of high incarceration rates for non-violent offenders is not factual. For instance, data show that only a fraction of one percent of state prison inmates are low-level marijuana possession offenders, while arrests for marijuana and cocaine/heroin possession and use were no more than 7 percent of all arrests,nationwide, in 2013.

Though critics of drug laws claim that hundreds or even thousands of prisoners are low-level non-violent offenders unjustly sentenced, the reality was shown recently by the President’s inability to find more than a handful of incarcerated drug offenders who would be eligible for commutation of their sentence because they fit the mythological portrait of excessive or unjust drug sentences.

Further, since 2007, the US is currently experiencing a surge in daily marijuana use, an epidemic of heroin overdose deaths (with minorities hardest hit), while the southwest border is flooded with heroin and methamphetamine flow, as shown by skyrocketing border seizures.

Importantly, Colorado, following marijuana “legalization,” has become a black-market magnet, and is currently supplying marijuana, including ultra-high-potency “shatter” to the rest of the U.S., leading to law suits by adjacent states. Legalization has not reduced criminal activity nor the threat of financial corruption.

As for Central America, Obama’s policies have shown stunning neglect. Actual aid for counter-drug activities, and for resources for interdicting smugglers have all diminished, while the countries of Central America have become battlegrounds for Mexican cartels, with meth precursors piling up at the docks, the cocaine transiting Venezuela to Honduras is surging, and violence is at an all-time high, with families fleeing north in unprecedented numbers. The Caribbean/Central American region has become deeply threatened, as noted by the State Department report above—torn apart by drug crime.

In this context the president encourages governments in the region to make drugs more acceptable and more accessible in their communities, and with even greater legal impunity?

Moreover, these developments have been accompanied by a steady drumbeat of medical science reports increasingly showing the serious dangers of marijuana use, especially for youth.   Yet President Obama speaks in a manner increasingly disconnected from the domestic and international reality of the drug problem.

Source:  David W. Murray and John P. Walters  WEEKLY STANDARD  April 11, 2015

The polarized legalization debate leads to exaggerated claims and denials about pot’s potential harms. The truth lies in between.

Pretty much everyone who has spent time smoking marijuana knows at least one diehard stoner. The guy whose eyes are always red, the girl who doesn’t use the term “wake and bake” ironically, the person who just can’t seem to ever get it together. These heavy smokers might work at a low-level job or they may be unemployed—but everyone who knows them well knows that they are capable of much more, if only they had any ambition.

Is this really addiction? I believe that it is (and I don’t think that’s an argument against legalization). In fact, the reasons why marijuana is addictive elucidate the true nature of addiction itself.  Addiction is a relationship between a person and a substance or activity; addictiveness is not a simple matter of a drug “hijacking the brain.” In fact, with all potentially addictive experiences, only a minority of those who try them get hooked—and people can even become addicted to apparently “nonaddictive” things, like carrots. Addiction depends on learning, context and psychology, not just neurotransmitters.

With two states having already legalized recreational marijuana use and several more considering doing so, understanding the nature of addiction is more important than ever. Partisans on both sides of the debate have made extreme claims here; some legalizers saying there’s no such thing as marijuana addiction, while some prohibitionists claim “cannabis as addictive as heroin.”

Our concepts of addiction, however, come primarily from cultural experience with alcohol, heroin and, later, cocaine. No one has ever argued that opioids like heroin don’t have the potential to cause addiction because the withdrawal symptoms—vomiting, shaking, pallor, sweating and diarrhea—are objectively measurable. Opioids cause physical dependence that is evident when they become unavailable. The same is true for alcohol, where withdrawal is even more severe and can sometimes even be deadly.

So early researchers focused on these measurable symptoms related to alcoholism and opioid addictions in defining addiction: Using a drug could lead to becoming tolerant to it, tolerance could lead to dose escalation, which could in turn lead to physical dependence, and then the addiction could be driven by the need to avoid the painful symptoms of withdrawal. It was simple and physical.

In this view, however, cocaine and marijuana were not “really” addictive. While people can experience withdrawal symptoms like irritability, depression, craving and sleep problems when quitting these drugs, these are much more subjective and therefore can be dismissed as “psychological” rather than physical. You might really want coke or pot, but you didn’t need it like a real junkie, the thinking went.

And since most of us like to believe that we have much more control over our minds than we do over physical symptoms, “psychological” addiction is seen as far less serious than the “physical” type. It’s the remnants of this kind of thinking that mainly underlie the idea that marijuana addiction doesn’t exist. Unfortunately, that view of addiction is stuck in the 1970s.

In the 1980s—ironically, not long after Scientific American caused a big controversy by arguing that snorted cocaine is no more addictive than eating potato chips—entrepreneurs began marketing a ready-made smokeable form of the drug. The birth of crack shattered the idea that “physical” dependence is more serious than psychological dependence because people with cocaine addictions don’t vomit or have diarrhea when they quit; while they may appear desperate, it’s not in the physically obvious way of heroin or alcohol withdrawal. And so, if you are going to argue that marijuana is not addictive because you don’t get sick when you quit, you also have to argue the same for crack.

In the 1970s view, cocaine and marijuana were not “really” addictive: You might really want coke or pot, but you didn’t need it like a real junkie, the thinking went.

Good luck with that one, I say. Clearly, crack-addicted people are every bit as compulsive as those with heroin problems—and their criminal involvement if they can’t afford the drug is at least equally likely, though not as common as has been claimed. Crack dealt a deathblow to the “psychological” vs. “physical” distinction—and if it hadn’t, neuroscience was creeping up to show that the psychological and the physical aren’t exactly distinct anyway.

In the ‘70s and ‘80s, researchers also began recognizing that simply detoxing heroin addicts—getting them through the two-week period of intense physical withdrawal symptoms—is not effective treatment. If heroin addiction was driven primarily by the need to avoid withdrawal, addicted people should be out of the woods after they complete cold turkey. But as those of us who have been through it know, that is far from the hardest part.

While kicking heroin isn’t fun, staying off it in the long run is the problem—those “mere” psychological cravings are what drive addiction. Physical dependence isn’t the main problem; it isn’t even necessary. Indeed, we now know that you can actually have physical dependence without any addiction at all: There are some blood pressure medications, for example, that can have deadly withdrawal symptoms if not tapered properly, but people on these meds don’t crave them even though they are quite dependent. Similarly, antidepressants like Paxil have physical withdrawal symptoms, but because they don’t produce a high, you don’t see people robbing drug stores to get them.

So what is addiction, then, if tolerance, withdrawal and physical dependence aren’t essential to it? All of these facts point to one definition that can sum up the problem: Addiction is compulsive use of a substance or engagement in a behavior despite negative consequences. (Put more in neuroscience, addiction is a learned distortion in the brain’s motivational systems that make us persist in pursuing things linked to evolutionary fitness like food and sex.) Anything that causes pleasure via these systems—and that’s basically anything that is possible to enjoy—can be addictive to some person at some time. And that includes marijuana (and, for that matter potato chips).

This doesn’t mean that marijuana addiction is necessarily as severe as cocaine, heroin or alcohol addiction—in fact, it typically isn’t. If given the choice, most families would vociferously prefer having a member addicted to marijuana rather than to cocaine, heroin or alcohol. The negative consequences associated with marijuana addiction tend to be subtler: lost promotions, for example, rather than lostjobsworse relationships, not no relationships. And of course, no risk of overdose death.

Marijuana addiction may quietly make your life worse without ever getting bad enough to seem worth addressing; it may not destroy your life but it may make you miss opportunities.

But this is also what can make it insidious. Marijuana addiction may quietly make your life worse without ever getting bad enough to seem worth addressing; it may not destroy your life but it may make you miss opportunities. With any pattern of regular drug use, it’s important to continually track whether the risks outweigh the benefits, keeping in mind that addiction itself may distort this calculation. This is especially true with marijuana.

However, as with all other drugs, only a minority of marijuana users ever struggle with addiction. Research suggests that about 10% get hooked—and on average, marijuana addiction lasts six years. Even more than other addictions, marijuana addiction seems to be driven by self-medication of mental health problems—90% of people with marijuana addiction also have another addiction or mental illness, typically alcoholism or antisocial personality disorder.

This suggests that exposing more of the population to marijuana won’t necessarily increase the addicted population. First, people with antisocial personality disorder, by definition, tend not to be law abiding, so most have probably already tried it. Second, the percent of people with other pre-existing mental illness will not change because marijuana becomes legal—in fact, in the UK, when they reversed their prior liberalization of marijuana law because of fears related to increased schizophrenia, psychosis rates actually went up. (The link probably wasn’t causal, but it does suggest that legal crackdowns on cannabis don’t prevent related psychosis).

If some people with alcohol, cocaine or heroin addiction switch to marijuana instead, overall harm would be reduced. As I and others have been reporting at least since 2001, using marijuana as an “exit” drug is a real phenomenon, both in cocaine and opioid addiction.

When we consider the risks of various substances, we tend to do so in isolation—but that’s not how choices are made in the real world. Most people would rather their partners have no addictions—but again, some are clearly worse than others. Marijuana craving is rarely as severe as crack craving, as is obvious.

Still, like anything that can be pleasurable, marijuana can be addictive. This doesn’t mean all addictions are the same or that it is as addictive as the currently legal drugs alcohol and tobacco—the data shows it is less so.

Pretending it can’t do any harm at all, however—or that there aren’t people who are addicted to it—does no one any good. If we want better drug policy, as with other types of recovery, we need to avoid denial.

Maia Szalavitz is one of the nation’s leading neuroscience and addiction journalists, and a columnist at Substance.com. She has contributed to Timethe New York TimesScientific American Mindthe Washington Post and many other publications. She has also published five books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006), and is currently finishing her sixth, Unbroken Brain, which examines why seeing addiction as a developmental or learning disorder can help us better understand, prevent and treat it. Her last column for Substance.com was about why the oft-documented fact that most people age, or grow, out of substance misuse is not common knowledge.

Source: www.substance.com 15th October 2014

So who supports decriminalising cocaine, heroin, LSD, methamphetamine, ecstasy and all dangerous drugs, including marijuana?

No, it’s not your teenage nephew. It’s President Obama’s new acting head of the Justice Department’s Civil Rights Division, Vanita Gupta. In 2012, Gupta wrote that  “states should decriminalise simple possession of all drugs, particularly marijuana, and for small amounts of other drugs.” (Emphasis mine).

Last week, President Obama appointed Vanita Gupta to the position of acting head. According to the Washington Post, the administration plans to nominate her in the next few months to become the permanent assistant attorney general for the Civil Rights Division. Her views on sentencing reform – a bi-partisan effort in recent years – have earned her qualified kudos from some conservatives.

But her radical views on drug policy – including her opinion that states should decriminalise possession of all drugs (cocaine, heroin, LSD, ecstasy, marijuana and so on) should damper that support of those conservatives, and raise serious concerns on Capitol Hill.

As the deputy legal director of the American Civil Liberties Union and the director of its Center for Justice, Gupta’s legal and policy positions are well documented in her long paper trail, which, no doubt, will be closely scrutinised if and when she is nominated and gets a hearing before the Senate Judiciary Committee.

To begin, she believes that the misnamed war on drugs “is an atrocity and that it must be stopped.” She has written that the war on drugs has been a “war on communities of color” and that the “racial disparities are staggering.” As the reliably-liberal Huffington Post proclaimed, she would be one of the most liberal nominees in the Obama administration.

Throughout her career, 39-year old Gupta has focused mainly on two things related to the criminal justice system: first, what she terms Draconian “mass incarceration,” which has resulted in a “bloated” prison population, and second, the war on drugs and what she believes are its perceived failures.

She is particularly open about her support for marijuana legalisation, arguing in a recent CNN.com op-ed that the “solution is clear: …states could follow Colorado and Washington by taxing and regulating marijuana and investing saved enforcement dollars in education, substance abuse treatment, and prevention and other health care.”

Yet just last week the current Democratic Governor of Colorado, John Hickenlooper, said that legalising recreational use of marijuana was a “reckless.” And there is a growing body of evidence to prove his point: (1) pot-positive auto fatalities have gone up 100 percent in 2012, the year the state legalized pot; (2) the majority of DUI drug arrests involve marijuana and 25 to 40 percent were pot alone; (3) from 2011 through 2013 there was a 57 percent increase in marijuana-related emergency room visits – and there are many other indications of failure. New research, from a 20-year study, proves the dangers of marijuana.

But Gupta does not stop with marijuana. In calling for all drugs to be decriminalised – essentially legalising all dangerous drugs – Gupta displays a gross lack of understanding of the intrinsic dangers of these drugs when consumed in any quantity.

Heroin, LSD, ecstasy, and methanqualone are Schedule I drugs, which are defined as “the most dangerous drugs of all the drug schedules with potentially severe psychological or physical dependence.” Cocaine, methamphetamine, Demerol and other drugs are Schedule II drugs, defined as “drugs with a high potential for abuse…with use potentially leading to severe psychological or physical dependence.”

Sound public policy must be based on facts, not radical unsafe, and dangerous theories.

This article is reproduced by the kind permission of The Daily Signal, the multimedia news site created by the Heritage Foundation in Washington DC.

Source: conservativewoman.co.uk 22nd October 2014Bottom of Form 

Impact of Methadone on Brain Cell Development

Since 1999, there has been a dramatic increase in opioid overdose deaths and addiction to opioid drugs, including both prescription opioid pain relievers and heroin. Increased rates of addiction have also been seen among pregnant women, which has led to a significant increase in the number of babies born with neonatal abstinence syndrome.  Methadone is a long-acting opioid that is an effective treatment for addiction to opioid drugs and is often used to treat pregnant women. While methadone treatment is safer than non-medical use or abuse of opioids, it is known that methadone can cross the placenta, and little is known about the effects of methadone on an infant’s developing brain. 

During development, some brain cells, including oligodendrocytes, express opioid receptors that bind opioid drugs such as methadone. Oligodendrocytes are involved in multiple complex functions critical to normal brain development, including production of myelin, a substance that enables neurons to send electrical signals and communicate with other cells. In this study, researchers examined the effects of methadone on oligodendrocytes during development in an animal model. Rat pups were exposed to methadone both through the placenta and through maternal milk until postnatal day 14, a period that is equivalent to the third trimester in human pregnancy. The researchers found that therapeutic doses of methadone caused increases in multiple proteins found in myelin and an increase in number of neurons with mature myelin. This accelerated maturation and myelination could potentially disrupt normal connectivity within the developing brain.

These results highlight the importance of understanding how drugs that are used to treat addiction might impact the developing brain of infants prenatally exposed to them. They also raise questions about the impact of methadone on the adolescent brain, which is also still developing.

Source: The Opioid System and Brain Development: Effects of Methadone on the Oligodendrocyte Lineage and the Early Stages of Myelination, Dev Neurosci 2014;36:409–421

http://www.ncbi.nlm.nih.gov/pubmed/25138998

 

Filed under: Heroin/Methadone :

Drug traffickers in the central city of Da Nang have switched their focus on methamphetamine and heroin from opium and marijuana over the last two years, a senior police officer told a press conference on drug prevention on Friday.

Lieutenant colonel Nguyen Xuan Cuong, Deputy Head of Counter Narcotics Office under the city’s Public Security Department, said the number of traffickers caught with methamphetamine in 2012 was seven times more than the amount in 2011.

Cuong added the city’s narcotics police force last year arrested a total of 128 drug offenders with 921.4 grams of methamphetamine, 54 grams of heroin and 133.6 grams of marijuana extracts.

A report at the conference shows there are an estimated 1,500 addicts and drug users at rehabilitation centers across the city.

Source: www.tuoitrenews.vn   16th June 2013


AUSTRALIAN and international scientists may have found a cure for heroin and morphine addictions.

The discovery could have wide-reaching implications leading to better pain relief without the risk of addiction to prescription drugs, while also helping heroin users kick the habit.

Dr Mark Hutchinson from the University of Adelaide said a team of researchers had shown for the first time that blocking an immune receptor, called TLR4, stopped opioid cravings.

“Both the central nervous system and the immune system play important roles in creating addiction, but our studies have shown we only need to block the immune response in the brain to prevent cravings for opioid drugs,” Dr Hutchinson said.

The scientists, including a team from the University of Colorado Boulder, used an existing drug to target and block the TLR4 receptor. The National Institutes on Drug Abuse in the United States is further developing the drug, which has been proven to work in the laboratory, to test in clinical trials. As a result, clinical trials on patients could be underway in just two to three years time, Dr Hutchinson said.

If the clinical trials were successful, opioid drugs used to treat acute pain could potentially be co-formulated with the additional drugs to limit the chance of addiction. This approach could also treat patients with heroin or other opioid addictions who are admitted to hospital and require pain relief.

These patients generally needed larger doses of drugs like morphine to treat pain because their bodies have developed a higher tolerance. However, Dr Hutchinson said co-formulated drugs would mean these patients could be given lower doses.

“It might make it much easier to treat those already addicted or tolerant populations,” Dr Hutchinson said.

President of the Australian College of the Anaesthetists Dr Lindy Roberts said although opioids were important for the treatment of pain they could have adverse effects. She said treatments that could potentially separate the pain relief aspects of drugs from adverse effects were welcomed.

The findings were published this week in the Journal of Neuroscience

Source: www.The Australian.com 15.08.12

Filed under: Heroin/Methadone :

Concerned that this might on balance cause more deaths by limiting an effective treatment for opiate addiction, an expert panel convened by the US government has changed its mind on whether the risk of a fatal heart attack potentially posed by methadone justifies routine electrocardiogram screening of patients.

Summary

The QT interval (or QTc as corrected for the heart rate) is an indicator of heart function derived from electrocardiogram measures. It refers to the delay between two phases of the electrical activity of the heart which drives it in pumping blood round the body. The health risks associated with a prolonged interval are not clear. It can lead to torsades de pointes, a potentially life threatening heart attack, but some medications prolong the interval yet rarely cause this condition, and it can occur even when the interval is normal. The risk threshold has been set variously at for example 450ms (0.45 seconds) for men and 460ms to 470ms for women or 450ms for both, though it is generally accepted that intervals greater than 500ms pose a significant risk of torsades de pointes.

Some studies have reported that methadone may contribute to the elongation of the QT interval, heightening the risk of torsades de pointes. In response the US government convened an expert panel to assess the risk to patients and make recommendations to enhance their cardiac safety. The featured article is the latest report of that panel, superseding an earlier version.

The panel framed its recommendations on the understanding that methadone must remain widely available because it has been associated with an overall reduction in deaths, there are few therapeutic alternatives, and it is cost-effective. Treatment providers are encouraged to consider the report and take action to the extent that they are clinically, administratively, and financially able to do so, but nothing in the report is intended to create a legal standard of care or accreditation requirement, or to interfere with the judgment of the clinicians treating the patients.

Main findings

Based on evidence published in the peer-reviewed literature, the panel concluded that both oral and intravenous methadone are not just associated with QT prolongation but actually cause it. Prolongation to over 500ms is thought to confer a significant risk of heart arrhythmias. In all but one study of methadone maintenance treatment, a QT of this level was seen in 2% of patients. Taken in the aggregate, the evidence also supports the view that as methadone doses increase, so too does the likelihood of significant QT prolongation.

The panel’s recommendations

Panel members agreed that their recommendations must preserve patients’ access to addiction treatment. Among patients with QT prolongation related to relatively high doses of methadone, it is unclear to what degree reducing doses would risk them relapsing [to illicit opiate use], but higher doses are associated with better treatment retention and better outcomes.

The Panel affirmed that methadone can be used with reasonable assurance that it is effective and that its benefits exceed its risks, providing that the potential for QT prolongation is recognised, that patients receive electrocardiogram screening at indicated intervals, and that appropriate clinical action is taken in the presence of significant QT prolongation.

Panel members agreed that, to the extent possible, every opioid treatment programme should have a cardiac risk management plan with the following elements:
• Clinical assessment: Intake assessments should include: a complete medication history; personal and family history of structural heart disease; any personal history of arrhythmia or syncope (fainting); and use of QT-prolonging medications or illicit drugs such as cocaine which also have this effect.
• Electrocardiogram assessment: Largely due to concerns over the resource implications and its effectiveness in achieving meaningful reductions in methadone-associated cardiac events, panel members and ex officio members could not agree whether to recommend routine electrocardiogram screening within the first 30 days of treatment. However, they did agree that a baseline electrocardiogram at the time of admission and within 30 days should be performed on patients with significant risk factors for QT prolongation. Among these patients, additional tests should be performed annually or whenever the methadone dose exceeds 120mg a day. In addition to scheduled electrocardiograms, any patient who experiences unexplained syncope or generalised seizures should be tested. If marked QT prolongation is documented, torsades de pointes should be suspected and the patient hospitalised for monitoring through telemetry.
• Risk stratification: If the QT interval is over 450ms but less than 500ms, methadone may be initiated or continued, accompanied by a risk-benefit discussion with the patient and more frequent monitoring. For methadone-maintained patients with marked QT prolongation of 500ms or more, strong consideration should be given to adopting a risk minimisation strategy, such as reducing the methadone dose, eliminating other contributing factors, transitioning the patient to an alternative treatment such as buprenorphine, or discontinuing methadone treatment.

Methadone-related cardiac risk should be mentioned in the informed consent document presented to patients at intake, and patients should receive plain-language educational materials explaining this risk. Medical staff too should be educated about the risks posed by a prolonged QT interval and trained in assessing patients for risk of torsades de pointes and other cardiac problems.

The panel acknowledged that acting on these conclusions will challenge many opioid addiction treatment programmes. Identifying clinically relevant QT prolongation remains difficult, given the variability of electrocardiogram machine measurements and the difficulty of defining the precise risk a prolonged QT portends for any given individual. Programmes will find it a challenge to integrate cardiac arrhythmia risk assessment into the care of opioid-addicted patients without reducing access to vital addiction treatment services. The panel was also aware that not all methadone maintenance treatment providers can administer an electrocardiogram to every patient in all the circumstances they recommended. Opioid addiction treatment programmes and other providers are encouraged to consider implementing these conclusions to the extent that they are practically or financially capable of doing so.

Source: Martin J.A., Campbell A., Killip T. et al.
Journal of Addictive Diseases: 2011, 30, p. 283–306.

A change in the formula of the frequently abused prescription painkiller OxyContin has many abusers switching to a drug that is potentially more dangerous, according to researchers at Washington University School of Medicine in St. Louis.

The formula change makes inhaling or injecting the opioid drug more difficult, so many users are switching to heroin, the scientists report in the July 12 issue of the New England Journal of Medicine.

For nearly three years, the investigators have been collecting information from patients entering treatment for drug abuse. More than 2,500 patients from 150 treatment centers in 39 states have answered survey questions about their drug use with a particular focus on the reformulation of OxyContin. The widely prescribed pain-killing drug originally was thought to be part of the solution to the abuse of opioid drugs because OxyContin was designed to be released into the system slowly, thus not contributing to an immediate “high.” But drug abusers could evade the slow-release mechanism by crushing the pills and inhaling the powder, or by dissolving the pills in water and injecting the solution, getting an immediate rush as large amounts of oxycodone entered the system all at once.

In addition, because OxyContin was designed to be a slow-release form of the generic oxycodone, the pills contained large amounts of the drug, making it even more attractive to abusers. Standard oxycodone tablets contained smaller amounts of the drug and did not produce as big a rush when inhaled or injected.
Then in 2010, a new formulation of the drug was introduced. The new pills were much more difficult to crush and dissolved more slowly. The idea, according to principal investigator Theodore J. Cicero, PhD, was to make the drug less attractive to illicit users who wanted to experience an immediate high.

“Our data show that OxyContin use by inhalation or intravenous administration has dropped significantly since that abuse-deterrent formulation came onto the market,” says Cicero, a professor of neuropharmacology in psychiatry. “In that sense, the new formulation was very successful.”

The researchers still are analyzing data, but Cicero says they wanted to make their findings public as quickly as possible. The new report appears as a letter to the editor in the journal. Although he found that many users stopped using OxyContin, they didn’t stop using drugs.

“The most unexpected, and probably detrimental, effect of the abuse-deterrent formulation was that it contributed to a huge surge in the use of heroin, which is like OxyContin in that it also is inhaled or injected,” he says. “We’re now seeing reports from across the country of large quantities of heroin appearing in suburbs and rural areas. Unable to use OxyContin easily, which was a very popular drug in suburban and rural areas, drug abusers who prefer snorting or IV drug administration now have shifted either to more potent opioids, if they can find them, or to heroin.”

Since the researchers started gathering data from patients admitted to drug treatment centers, the number of users who selected OxyContin as their primary drug of abuse has decreased from 35.6 percent of respondents before the release of the abuse-deterrent formulation to 12.8 percent now.

When users answered a question about which opioid they used to get high “in the past 30 days at least once,” OxyContin fell from 47.4 percent of respondents to 30 percent. During the same time period, reported use of heroin nearly doubled.
In addition to answering a confidential questionnaire when admitted to a drug treatment program, more than 125 of the study subjects also agreed to longer phone interviews during which they discussed their drug use and the impact of the new OxyContin formulation on their individual choices.

“When we asked if they had stopped using OxyContin, the normal response was ‘yes,'” Cicero says. “And then when we asked about what drug they were using now, most said something like: ‘Because of the decreased availability of OxyContin, I switched to heroin.'”

These findings may explain why so many law enforcement officials around the country are reporting increases in heroin use, Cicero says. He compares attempts to limit illicit drug use to a levee holding back floodwaters. Where the new formulation of OxyContin may have made it harder for abusers to use that particular drug, the “water” of illicit drug use simply has sought out other weak spots in the “levee” of drug policy.

“This trend toward increases in heroin use is important enough that we want to get the word out to physicians, regulatory officials and the public, so they can be aware of what’s happening,” he says. “Heroin is a very dangerous drug, and dealers always ‘cut’ the drug with something, with the result that some users will overdose. As users switch to heroin, overdoses may become more common.”
Funding for this research comes from the Denver Health and Hospital Authority, which provided an unrestricted research grant to fund the Survey of Key Informants’ Patients (SKIP) Program, a component of the RADARS (Researched Abuse, Diversion and Addition-Related Surveillance) System.

Source: . Effect of Abuse-Deterrent Formulation of OxyContin. New England Journal of Medicine, 2012; 367 (2): 187 DOI: 10.1056/NEJMc1204141


Kouimtsidis C., Reynolds M., Coulton S. et al.
Drugs: Education, Prevention and Policy: 2011, early online publication.
Request reprint using your default e-mail program or write to Dr Kouimtsidis at drckouimtsidis@hotmail.com

Compromised by an inability to interest enough patients, the only randomised UK trial of cognitive-behavioural therapy for methadone patients was unable to be definitive but did find some signs of benefit and that the therapy had pulled some of the intended psychological levers.

Summary Cognitive approaches to treating substance misuse problems are still relatively new and it is important to understand how they work. Relevant treatment models emphasise the role of: self-efficacy to cope with situations associated with drug use without using; developing skills to cope with these situations as well as skills to generate broader lifestyle changes; and changing patients’ expectations of the positives and negatives of using the substance. Successful treatment is theorised to result from a reduction in the extent to which patients expect positive outcomes from substance use, an increase in their negative expectations, and enhanced self-efficacy and coping skills.

The featured study was the first study to directly test this model in the context of substitution treatment for opiate dependence. The findings derive from the UKCBTMM United Kingdom Cognitive Behaviour Therapy Study In Methadone Maintenance Treatment. study, which investigated the effectiveness and cost-effectiveness of cognitive-behavioural therapy for patients in opiate substitute prescribing programmes, itself the first randomised controlled trial of a psychosocial intervention in this setting in the UK.

At several UK treatment centres, the study randomly allocated substitute prescribing patients to keyworking only or keyworking plus cognitive-behavioural therapy, and assessed whether the additional therapy improved outcomes six and 12 months later. Additional therapy was offered weekly for 24 weeks but typically patients attended only four sessions. Therapists and keyworkers were recruited from existing staff and the therapists were trained and supervised in the therapy.

Perhaps because so few patients were eligible for and prepared to join the trial (just 60 did so of 369 who were eligible), though there were outcome gains from the extra therapy, none were statistically significant. Nevertheless, as measured by their effect sizes, A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen’s d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. In the featured study effect sizes were expected to be about 0.3. the gains were as large as expected in terms of reductions in the severity of addiction and heroin use, and improved compliance with prescribed methadone use. The cost of the extra therapy was more than outweighed by savings in health, social, economic, work, and criminal justice costs. Perhaps because patients had already been in methadone treatment for on average five months, these savings were less than in some other studies, and the difference in cost savings between therapy and non-therapy groups was not statistically significant.

Main findings

However, the featured report was less concerned with whether extra cognitive-behavioural therapy improved the end result of methadone treatment, than with how it might have done so. One way was expected to be by improving how well patients coped with life’s problems, a concept measured by a standard questionnaire which assessed different aspects of this ability. Relative to keyworking only, as expected, at six months the therapy was followed by a significant improvement in the degree to which patients positively reappraised problems, and a non-significant improvement in problem solving. Other domains where additional improvements were expected (logical analysis, seeking guidance and seeking alternatives) improved to roughly the same degree regardless of the extra therapy. Six months later (and 12 months after therapy had started) a similar analysis revealed that nearly all the expected mechanisms had improved after cognitive-behavioural therapy but deteriorated without it. The exception was logical analysis, where the reverse pattern was seen. Despite these trends, none of differences between patients who had or had not been offered cognitive-behavioural therapy were statistically significant, so chance variation could not be ruled out.

As expected, the degree to which patients felt confident that they could resist the urge to use drugs (‘self-efficacy’) increased after cognitive-behavioural therapy but decreased (at six months) or increased less (at 12 months) without this therapy. Patients were also asked about the good and bad consequences they expected from cutting down their heroin use. These measures changed in the opposite to what was expected; patients offered the therapy became relatively less positive and more negative about cutting down. Again, none of these differences between the two groups of patients were statistically significant.

Further analyses not reported here assessed changes among only patients who attended at least one session of their intended psychosocial intervention and related changes to the number of therapy sessions attended.

The authors’ conclusions

Though no definite conclusions can be taken from this study, there are indications that the therapy may be effective through at least some of the intended mechanisms, but also that methadone-maintained patients at services as configured in England in the 2000s generally reject the chance for this form of extra therapy.

The fact that few patients were prepared to join the study and that those who did attended few therapy sessions suggest there could be major barriers to implementing cognitive-behavioural therapy in routine practice in the British drug treatment system, perhaps associated with a culture of limited psychological therapy and relatively low expectations of clients’ engagement and compliance with treatment.

With such a small sample there is a heightened possibility that real differences made by the therapy will fail to meet conventional criteria for statistical significance and be mistakenly dismissed as chance variation. That this might have happened is suggested by the fact that the relative increase in days free of heroin use after six months was as great as expected. With a larger sample, it might well have also proved statistically significant. Economic analyses also found non-significant but appreciable net social cost-savings. The featured analysis supplements these outcome findings with indications that cognitive-behavioural therapy may have fostered some but not all of the crucial problem-solving skills.

The main seemingly counter-productive finding related to expectations about the pros and cons of reducing heroin use as measured by a scale yet to be validated. Also, more sessions of therapy did not further enhance the presumed psychological mechanisms through which the therapy worked. Nor were these mechanisms significantly related to substance use and other outcomes – again, perhaps due to the small sample size.

While appreciating the limits set by sample size, the non-significant trends suggesting that the therapy worked though the intended mechanisms were generally small in size. Of 22 comparisons between the two sets of patients, in only one had a mechanism (positively reappraising life’s problems) changed to a statistically significant degree in the expected direction – a result to be expected purely by chance. Together with a few counterproductive trends, these minor changes in the mechanisms thought to be specific to cognitive-behavioural therapy do not suggest it has a special role (that is, over and above other forms of psychological therapy) as a supplement to routine keyworking in the circumstances of the trial. At the same time the findings suggest that extra therapeutic contact did help stabilise patients who were prepared to accept it. Whether this needed to be cognitive-behavioural or a recognised therapy of any kind is impossible to tell from the study. Broader research offers little support for a distinctive role in addiction treatment for cognitive-behavioural approaches, results from which are generally equivalent to other approaches. It also seems that, at least in the mid 2000s, a steep hill remained to be climbed before formal psychological interventions of any kind were routinely and expertly implemented inBritain’s methadone clinics. How far that has changed is unclear. Details below.

CBT in methadone treatment

Guidelines from Britain’s National Institute for Health and Clinical Excellence (NICE) recommend cognitive-behavioural therapy not as a routine means of further stabilising patients, but to help with lingering anxiety and/or depression among those already stabilised in maintenance treatment. However, the analyses which led NICE to counsel against routine use did not show that cognitive-behavioural therapy was ineffective, just that it was not convincingly more effective than other well structured therapies.

Published in 2007, these guidelines did not have available to them the latest update of an authoritative meta-analytic A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention’s effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. review conducted for the Cochrane collaboration which combined results from studies comparing structured psychosocial interventions against normal counselling among methadone and other opiate substitution patients. Taking in new studies available up to 2011, it found that overall such interventions had improved neither retention nor outcomes (including opiate use) to a statistically significant degree. In particular, the same was true of the family of behavioural interventions including cognitive-behavioural therapy. Contrary to expectations, this update found contingency management conferred no significant benefits, contradicting both its earlier findings and the NICE guidelines referred to above.

In the Cochrane review, verdicts in respect of cognitive-behavioural therapy rested on three studies, one of which does not appear to have reported substance use outcomes but did find greater improvements in psychological health. Relative to drug counselling alone, so too did a study of male US ex-military personnel starting methadone treatment. A year later, in this study cognitive-behavioural patients had improved more on a much wider range of psychological, social and crime measures, but not in respect of substance use. From methadone plus routine drug counselling only, so complete were the reductions in opiate use that little space was left for additional therapy to further improve outcomes. These two US studies are supplemented by a German study which found that group cognitive-behavioural therapy led to significantly greater post-therapy reductions (at the six-month follow-up) in drug use than routine methadone maintenance alone. The effect was largely due to changes in cocaine use, but there were also minor extra improvements in abstinence from opiate-type drugs and benzodiazepines. What these three studies suggest is that offering extra psychotherapy (not necessarily cognitive-behavioural therapy in particular) improves psychological and social adjustment and perhaps too helps reduce non-opiate substance use, but that methadone maintenance itself as implemented in these studies was such a powerful anti-opiate use intervention that further gains on this front were harder to engineer.

CBT in substance use treatment generally

If in terms of core substance use outcomes, cognitive-behavioural therapy in methadone maintenance does little to improve on routine counselling, this will simply be in line with findings in respect of the therapy’s role in treating drug and alcohol problems in general. A review combining results from relevant studies suggested that it remains to be shown that cognitive-behavioural therapies are more effective than other similarly extensive and coherent approaches. Studies which directly tested this proposition often found little or no difference, even when the competing therapy amounted simply to well structured medical care.

The implication is that choice of therapy can be made on the basis of what makes most sense to patient and therapist, availability, cost, and the therapist’s training. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects may persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation.

Will CBT help methadone patients leave treatment?

Beyond core substance use outcomes is what in Britain is now a priority issue – whether more intensive therapy, even if it seems to add little to the powerful opiate use reduction effect of methadone treatment, might help people gain sufficient psychological and social stability to leave this treatment, and leave it sooner. In respect of psychotherapy in general and cognitive-behavioural therapy in particular, this remains a live possibility with some support from studies of during and post-treatment changes, though none have directly tested whether these enable patients to more safely leave the shelter of substitute prescribing programmes.

However, from the starting point revealed by the featured study, there seems a long way to go before structured psychosocial interventions of any kind are routine in Britain’s methadone services. An earlier report from the study commented that services were overstretched and understaffed and suffered from high staff turnover. Very few staff had been trained in psychological interventions and sometimes even basic individual client keyworking was extremely limited. Difficulties in engaging clients in the study were attributed partly to a low level of psychological interventions in services, which in turn led to low expectations of clients engaging with these interventions. Perhaps too, the authors speculated, some clients were reluctant to become involved in more intensive treatment or to address psychological issues not previously identified in usual clinical care. Most tellingly, the researchers observed “a nihilistic view of psychological intervention and clients’ capacity for change among some staff”.

In this climate, and with the added burden of research procedures, the small proportion of patients prepared to accept therapy and attend more than a few sessions is likely to be an underestimate of the possible caseload if cognitive-behavioural therapy were well promoted as a part of usual care, especially if elements of the approach were incorporated in keyworking rather than offered as an optional add-on.

In a different set of services probably sampled in the mid-2000s, perfunctory brief encounters focused on dose, prescribing and dispensing arrangements, attendance records, and regulatory and disciplinary issues characterised the keyworking service offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes. However, ‘relapse prevention’ was the most common therapeutic activity in the sessions, featuring in 44% of the last sessions recalled by the staff, a term often taken to imply cognitive-behavioural approaches. What staff included under this heading was unclear, and the time given to it averaged just seven minutes, but is does suggest that there is a platform which could be built on. Unfortunately the need to do this building to foster recovery and treatment exit has coincided with resource constraints which make widespread training in and implementation of fully fledged therapy programmes seem unlikely.

Thanks for their comments on this entry in draft to Christos Kouimtsidis of the Herts Partnership NHS Foundation Trust in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 December 2011

Source: www.findings.org.uk

A clinical trial to test better treatment options for chronic heroin addiction is expected to begin in Vancouver at the end of this year. Led by researchers from Providence Health Care and the University of British Columbia, it’s the only clinical trial of its kind in North America.

The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) is a carefully controlled three-year clinical trial that will test whether hydromorphone (Dilaudid(R)), a licensed pain medication, is as effective as diacetylmorphine, the active ingredient of heroin, at engaging the most vulnerable long-term street heroin users, so they will enroll in treatment programs and end their use of illicit drugs.

The intent of the SALOME project is to determine whether some participants become healthier and reduce their illicit drug use or are able to switch to other forms of treatment. SALOME also intends to test if, after stabilizing patients on injectable medications, they can transition to oral formulations without losing effectiveness.

This study builds on the North American Opiate Medication Initiative (NAOMI), which was North America’s first-ever clinical trial of prescribed heroin that took place from 2005 to 2008. NAOMI, which also was led by researchers from Providence Health Care and UBC, was a randomized trial aimed at testing whether medically prescribed heroin (diacetylmorphine) was more effective than methadone therapy for individuals with chronic heroin addiction who were not benefiting from other conventional treatments.

The results, published in the New England Journal of Medicine, showed that patients treated with the prescribed heroin were more likely to stay in treatment or quit heroin altogether and more likely to reduce their use of illegal drugs and other illegal activities than patients treated with oral methadone.

In the NAOMI study, the researchers also provided a small sample of patients with injectable hydromorphone, (Dilaudid(R)). An unexpected finding was that injection patients could not accurately discriminate whether they were receiving prescribed heroin or hydromorphone. The researchers also observed similar results and benefits with both these drugs although the small number of participants receiving hydromorphone did not permit any definite and scientifically valid conclusions to be drawn as to the efficacy of hydromorphone as a viable treatment option.

Should hydromorphone be proven to be as affective as heroin, the benefits of this form of injectable treatment may be more feasible and achievable without the emotional and regulatory barriers often presented by heroin maintenance.
SALOME, led by Dr. Michael Krausz, the Providence Health Care/UBC B.C. Leadership Chair in Addiction Research and Dr. Eugenia Oviedo-Joekes, Providence Health Care researcher and an assistant professor in UBC’s School of Population and Public Health, will enroll 322 individuals with chronic heroin dependency who currently are not sufficiently benefiting from conventional therapies, such as methadone treatment, at one site based in Vancouver, BC.

In the first stage, half of the 322 participants will receive injectable prescribed heroin, and the other half will receive injectable hydromorphone. Stage I will involve six-months of treatment. All volunteers retained in injection treatment at the end of Stage I will be eligible to enter Stage II.

In Stage II, half of the participants will then continue injection treatment exactly as in Stage I on a blinded basis while the other half will switch to the oral equivalent of the same medication (prescribed heroin or hydromorphone). Stage II will also involve six-months of treatment.

Throughout the treatment period, social workers will be assigned to both groups to assist them with reaching other addiction services and community resources such as counseling, housing and job training services.

Some 60,000 to 90,000 persons are affected by opioid addiction in Canada. This study will enroll the most chronically drug-dependent members of Vancouver’s population — those who are not benefiting from other treatments, such as methadone therapy and abstinence-based programs, and continue injecting street heroin.

The SALOME study is funded by the Canadian Institutes of Health Research, the Government of Canada’s agency responsible for funding health research in Canada, Providence Health Care and the InnerChange Foundation.

Quotes:
Dr. Perry Kendall, BC’s Provincial Health Officer –
“SALOME addresses critical social and ethical concerns dealing with addiction. Opioid-dependent people are in need of treatment options to avoid marginalization from the health care system and this study aims to answer questions that could lead to improvements in the health of persons with chronic addictions and identify new ways of reintegrating this population into society.”

“If the SALOME study shows that hydromorphone can go head-to-head with heroin as an alternative therapy for people who have failed optimally provided methadone, then I think this should be part of the treatment continuum that’s available through licensed physicians.”

Dianne Doyle, Providence Health Care President and CEO –
“Providence Health Care is supporting this research because it is so aligned with our mission, vision and values. We have a very long tradition of providing compassionate care to the most marginalized and needy in our community, including those suffering from addictions.”

“What we need to get from this research is a better understanding of what the right approaches are to treating addicted populations. In particular our hope would be that we could find a new approach for those people who are addicted and not benefiting from current approaches to care. This treatment option would be one more component of a range of services offered by Providence Health Care and Vancouver Coastal Health, all of which are intended to reduce the harm to individuals and others from drug use, and to support recovery from addiction and mental illness.”

About Providence Health Care

Providence Health Care is one of Canada’s largest faith-based health care organizations, operating 15 facilities within Vancouver Coastal Health. Guided by the principle “How you want to be treated,” PHC’s 1,200 physicians, 6,000 staff and 1,500 volunteers deliver compassionate care to patients and residents in British Columbia. Providence’s programs and services span the complete continuum of care and serve people throughout B.C. PHC operates one of two adult academic health science centres in the province, performs cutting-edge research in more than 30 clinical specialties, and focuses its services on six “populations of emphasis”: cardiopulmonary risks and illnesses, HIV/AIDS, mental health, renal risks and illness, specialized needs in aging and urban health.

About the University of British Columbia

The University of British Columbia (UBC) is one of North America’s largest public research and teaching institutions, and one of only two Canadian institutions consistently ranked among the world’s 40 best universities. Surrounded by the beauty of the Canadian West, it is a place that inspires bold, new ways of thinking that have helped make it a national leader in areas as diverse as community service learning, sustainability and research commercialization. UBC offers more than 50,000 students a range of innovative programs and attracts $550 million per year in research funding from government, non-profit organizations and industry through 7,000 grants.

To view the first video of the SALOME project, please visit the following link: http://www.youtube.com/watch?v=fFgV_bt8QAU&feature=youtu.be

To view the second video of the SALOME project, please visit the following link: http://www.youtube.com/watch?v=S8xfkkeHpdE&feature=related

Source:  www.marketwatch.com  13th Oct. 2011

Filed under: Addiction,Heroin/Methadone :

 

BRIAN DONNELLY

THE controversial heroin substitute methadone was implicated in more deaths than the drug itself in two areas of Scotland last year.
The figures for the Lothians show methadone was implicated in 33 deaths, while the comparable figure for heroin was 26. In Grampian, another historical centre of drug abuse, the substitute was a factor in 19 deaths, set against 14 for heroin.
The Scottish Drugs Forum (SDF), the national non- government drugs policy and information agency, said the prevalence of the substitute was “concerning”, while Tory health spokesman Murdo Fraser MSP said the figures showed there was a clear breakdown in the support system.

Source: www.Herald Scotland.com 17th Aug. 2011

 

A new study by a team of researchers in California shows it is possible to vaccinate laboratory animals against the effects of heroin. The vaccine not only blunted the painkilling action of heroin, it also prevented rats from becoming addicted to the drug. It didn’t keep the animals from gaining pain relief from many other opiates, suggesting the vaccine targets just heroin and a few related compounds. The experiments at the Scripps Research Institute in La Jolla, reported in the current edition of the Journal of Medicinal Chemistry, are the latest effort to bring the power of the immune system to bear against addictive substances. The next task is to see whether the vaccine prevents relapse in previously addicted and then detoxified rats.

Source: Reported in St.Petersburg Times July 28th 2011

A new study suggests that abuse of prescription opioids may be a first step on the path toward misuse of heroin and other injected drugs.
Science Daily reports that the researchers found four out of five injection drug users misused an opioid drug before they injected heroin. They also found that almost one out of four young injection drug users first injected a prescription opioid, and most later switched to injecting heroin.
The study, published in the International Journal of Drug Policy, found that risk factors for misusing opioid drugs include family history of drug misuse, and a past history of receiving prescriptions for opioids.
“Participants were commonly raised in households where misuse of prescription drugs, illegal drugs, or alcohol, was normalized,” lead researcher Dr. Stephen Lankenau, from Drexel University in Philadelphia, said in a news release. “Access to prescription medications – either from a participant’s own source, a family member, or a friend – was a key feature of initiation into prescription drug misuse.”
The study included 50 injection drug users between the ages of 16 to 25. They had all misused a prescription drug at least three times in the past three months. Nearly three-fourths of participants had been prescribed an opioid, often for dental procedures or sports injuries. Most had family members who misused one or more substances. The authors called on parents to carefully monitor and safeguard prescription drugs, especially opioids, in their home

Source: International Journal of Drug Policy June 2011

Prescription narcotics were involved in more drug overdose deaths in 2007 than heroin and cocaine combined, according to a new article. And in some states, the number of deaths from prescription painkiller overdose is higher than suicide or car crashes.
Approximately 27,500 people died from unintentional prescription narcotics overdoses in 2007, driven to a large extent by prescription narcotics overdoses, said researchers from the Centers for Disease Control and Prevention (CDC), Duke University and the University of North Carolina at Chapel Hill. Narcotics pain medications were also involved in about 36 percent of all poisoning suicides in the U.S. in 2007.
many deaths from both Operation Iraqi Freedom and Operation Enduring Freedom in Afghanistan, from the beginning of both wars through Feb. 20, 2011, said study researcher Dr. Richard H. Weisler, an adjunct professor of psychiatry at UNC Chapel Hill and Duke University.
Alternatively, the drug overdose deaths would be equivalent to losing an airplane carrying 150 passengers and crew every day for six months, researchers said.
The study findings come on the tail of another article published this month in the Journal of the American Medical Association, which showed that the risk of fatal overdose increases with the dose of drugs taken (though taking the medications as needed or as prescribed was not associated with overdose risk).
In 2009, the CDC’s National Youth Risk Behavior Survey revealed that 1 in 5 high school students in the United States have abused prescription drugs, including the narcotics painkillers OxyContin, Percocet and Vicodin. Narcotics, also called opioids, are synthetic versions of opium that are used to treat moderate and severe pain.
And in June last year, the CDC reported that visits to hospital emergency departments involving nonmedical use of prescription narcotic pain relievers has more than doubled, rising 111 percent, between 2004 and 2008.
Researchers said one of the key reasons for the increase in prescription drug overdose deaths is increased nonmedical use of narcotics without a prescription because of the feeling it produces. They also said that medical providers, psychiatrists and primary care physicians may fail to anticipate the extent of overlap between chronic pain, mental illness and substance abuse among their patients.
For example, 15 percent to 30 percent of people with unipolar, bipolar, anxiety, psychotic, non-psychotic and attention deficit/hyperactivity disorders will also have substance abuse problems, said study researcher Dr. Ashwin A. Patkar, associate professor of psychiatry and behavioral sciences at Duke University.
“Similarly, people with substance abuse are more likely to have another mental illness and a significant number of patients with chronic pain will have mental illness or substance abuse problems,” Patkar said in a statement.
Moreover, narcotics, benzodiazepines, antidepressants and sleep aids are commonly prescribed even though they are harmful and addictive when abused, researchers said. It’s the combinations of these drugs that are frequently found in the toxicology reports of people dying of overdoses.
Researchers suggest that before prescribing narcotics, doctors should try non-narcotic medications as well as — when possible — physical therapy, psychotherapy, exercise and other nonmedicinal methods.
The study was published last week in the Journal of Clinical Psychiatry.
Pass it on: Overdosing on narcotic painkillers accounts for more deaths than from heroin and cocaine combined.

Source:www.myhealthnewsdaily.com 27th April 2011

Some 56 heroin-dependent patients who had undergone detoxification treatment and were particularly motivated to remain heroin-free took part in a research study. Half of the participants were implanted with a total of 20 subcutaneous pellets containing naltrexone, which was gradually released from a saline solution with the aim of producing a six-month blockage effect. All the participants continued their normal follow-up treatments while the study was ongoing.
After six months, over twice as many in the group receiving naltrexone as in the control group (11 out of 23 as opposed to 5 out of 26) managed to refrain from using heroin and other morphine substances. Heroin use among those patients receiving naltrexone who did not manage to discontinue using heroin altogether was more than halved compared with their level of heroin use before they started treatment. In the control group the majority of patients relapsed to daily heroin use.
Satisfaction with the naltrexone implants was high. On a scale from 0 to 100 the participants gave the capsules a score of 85.

Clear-cut findings

Helge Waal, Professor emeritus at SERAF, would like to see the naltrexone implant included as one of the treatment options offered to heroin-dependent patients in Norway.
“Although this is a relatively small-scale study, the findings are so clear-cut that we think this should become an important treatment option for substance abusers.”

Source: The Research Council of Norway (2011, February 17) Retrieved February 18, 2011, from http://www.sciencedaily.com

EDINBURGH: The Scottish Executive’s anti-drug abuse policy was criticized sharply yesterday following a report that the government recommended heroin-substitute methadone is 97% ineffective.

Methadone, a drug used for recovery from heroin addiction, has a success rate of no more than 3.4%, according to Professor Neil McKeganey, chief researcher for Glasgow University’s Centre for Drug Misuse Research. McKeganey has just concluded a study on the effectiveness of the £12m a year Methadone programme.

The study observed a group of 695 heroin addicts who started taking treatment in 2001 at 33 different addiction centers across Scotland. A large percentage of this group was given methadone-based care while the rest were put on rehabilitation. Their progress was recorded over interviews 33 months after they started the treatment to see if they had become drug-free over a 90-day period.

The group given only-methadone had a very poor 3.4 percent recovery rate from drug addiction; whereas the group placed in residential rehabilitation (with no methadone throughout the treatment) showed a 29% success rate.

A key difference in methadone’s success rates between Scotland and England was also pointed out. While England emphasizes on getting people off drugs entirely, Scotland’s drug policy lacks any such direction; as a result, addicts simply substitute methadone with heroin.

McKeganey’s previous research had revealed a greater inclination to commit crimes among methadone patients when compared with addicts placed on abstinence programmes. People in the latter group also showed twice the level of interest in finding a job.

While the report makes no recommendation, sharp reactions have come in from various quarters demanding the Executive at least review its drug policy if not entirely scrap methadone. Tory leader Anabel Goldie said she recommended more investment in residential rehabilitation centres.

Meanwhile an official at the Greater Glasgow NHS facility said methadone may not be suitable for everyone but many addicts do benefit from it. He also said the government was looking to offer “a wider package of support” that would include rehabilitation, education and training, to addicts.

Source: Earthtimes.org. 30.10.06

Addicts require support from other recovering addicts, said the study.
Researchers believe they have identified some of the critical factors that determine whether alcoholics and heroin users can recover.
A study of more than 200 people in Glasgow found that spending time with other recovering addicts made success more likely.
Another predictor of success was whether addicts had something else in their lives to focus on, such as work.
The findings are due to be discussed at a conference in Glasgow.
The research was led by Dr David Best, a reader in criminal justice at the University of the West of Scotland.
“We found that the quality of life maintained by people in methadone maintained recovery wasn’t as good as for people in abstinent recovery” said Dr David Best Researcher He told the BBC’s Good Morning Scotland programme: “Addiction becomes an all-consuming and all-encompassing thing for people “In order for them to meaningfully sustain a recovery, it means it’s not sufficient to have just clinical interventions.
“There have to be a range of replacement activities and the more socially and community-based they are – including things like volunteering, parenting, education and training and obviously working – the more that void is filled and the more successfully individuals manage to build up an architecture of life that replaces that time spent in active addiction.”
The study also considered the role that methadone played in recovery.
Dr Best said: “Certainly as far as our research was concerned, we found that the quality of life maintained by people in methadone maintained recovery wasn’t as good as for people in abstinent recovery.
“It fits with previous research that we’ve done which has shown that there are some long-term effects of methadone, particularly around cognitive functioning, which may act as a mechanism for blunting the aspiration and hope and quality of life.
“It doesn’t mean recovery’s not possible in methadone but there may be some limitations to the extent of it.”
The study, which marks the first Recovery Academy conference in the city, drew parallels between alcoholism and heroin addiction.
Researchers said few differences were noted in the paths to recovery.Community Safety Minister Fergus Ewing, one of the speakers at the conference, said: “The Scottish government’s national drugs strategy, the Road to Recovery, recently reconfirmed by the Scottish Parliament, provides the framework for a fundamental change in our approach to tackling problem drug use through a focus on recovery.
“The Recovery Academy conference, the first of its kind in Scotland, provides the perfect platform for assessing the progress that is being made through this enhanced focus.
“Recovery from serious drug addiction is possible and the research being presented today clearly enhances our knowledge of the challenges faced.”
The event, taking place at the city’s Woodside Halls, is part of the wider Recovery Weekend, which invites people dealing with the effects of addiction, their families and friends to gather in Glasgow to meet and share ideas.

Source: http://www.bbc.co.uk/news/uk-scotland 24th Sept.2010

“This report summarises the key findings from a report exploring public attitudes towards illegal drugs and drug misuse in Scotland, based on data from the 2009 Scottish Social Attitudes survey. It focuses in particular on attitudes towards opiate misuse, and on views of potential policy responses to this. However, it also places such attitudes in the context of wider views and experiences of illegal drugs.”

Main Findings
■ Support for legalising cannabis – which increased in Scotland (as in the rest of the UK) in the late 1990s – has fallen considerably in more recent years, from 37% in 2001 to 24% in 2009. Attitudes towards prosecution for possession of cannabis for personal use also hardened between 2001 and 2009.

■ Most people said taking cocaine occasionally is wrong – 76% rated it as 4 or 5 on a scale where 5 meant ‘very seriously wrong’.

■ 45% of people agreed that ‘Most people who end up addicted to heroin have only themselves to blame’, while just 27% disagreed.

■ Around half (53%) disagreed that ‘most heroin users come from difficult backgrounds’ (29% agreed).

■ Among those in paid employment, around half (47%) said they would be ‘very’ or ‘fairly comfortable’ working alongside someone they knew had used heroin in the past, while around 1 in 5 would be uncomfortable.

■ Just a quarter (26%) said they would be comfortable with someone who was receiving help to stop using heroin moving near to them, while half (49%) would be uncomfortable.

■ There was no public consensus on what should be the top government priority for tackling heroin use in Scotland – 32% chose ‘tougher penalties for those who take heroin’, 32% ‘more help for people who want to stop using heroin’ and 28% ‘more education about drugs’.

■ Just 16% agreed that people who possess heroin for personal use should not be prosecuted (compared with 34% for cannabis).

■ Public support for providing clean needles to injecting drug users fell from 62% in 2001 to 50% in 2009.

■ Opinion on educating young people about safer drug use was split – 44% agreed that young people should be given information about how to use drugs more safely, but 40% disagreed.

■ Four out of five (80%) agreed that ‘the only real way of helping drug addicts is to get them to stop using drugs altogether’. However, 29% agreed that ‘most heroin users can never stop using drugs completely’, while 27% said they neither agreed nor disagreed or did not know.

■ 63% disagreed that ‘Someone who has been a heroin addict can never make a good parent, even if their drug problems are in the past’.

■ Around two thirds (64%) said that young children of heroin users should be placed into temporary foster care until the parents stop taking heroin. A further 1 in 5 believed the child should stay at home while the family receives help from social workers and just 8% said the child should be permanently adopted by another family.

The full report is also accessible online.

Source: http://uwsnealb.wordpress.com/2010/05/28/scottish-social-attitudes-survey-2009-public-attitudes-to-drugs-and-drug-use-in-scotland/ May 25 2010

MULTIPLE DRUG USE NOW THE NORM, HEROIN SHUNNED BY YOUNG
Government drug policy is too centred on heroin abuse, fails to take account of the realities of current usage trends and needs to focus on individual user behaviour if it is to reflect the true picture and formulate meaningful responses, a leading academic at National University of Ireland Maynooth urged.
‘A Dizzying Array of Substances; An Ethnographic Study of Drug Use in the Canal Communities’ is the result of a long-term study which closely examined the realities of drug use in local life of Rialto, Bluebell and Inchicore, three communities served by the Canal Communities Local Drugs Task Force. It was led by principal investigator Dr A Jamie Saris and primary field researcher Fiona O’Reilly at the Department of Anthropology, NUI Maynooth.
The ethnographic research, carried out mostly in 2008 and early 2009, gives the most compelling evidence to date that multiple drug use is the norm amongst drug users in the Canal Communities and, the researchers concluded, most probably in other areas.
“The big problem is that as far as government is concerned, ‘drugs’, from a treatment perspective, has traditionally meant heroin. Thus, the apparent leveling off of the need for a very opiate-centric treatment service in the Canal Communities in recent years is deceptive” said Dr Saris.
Besides the ethnographic work, the study surveyed, on a long term basis, 92 people using either heroin or methadone in the study area. Unsurprisingly most of those surveyed were on methadone (98%). Of those surveyed:
•63% claimed to have used heroin in the previous three months
•30% had used crack cocaine
•22% had used powder cocaine
•46% had also taken street tranquilisers
•50% were on prescribed tranquillisers, and
•60% had also smoked cannabis within the past three months.
“The majority of those registered on the methadone treatment programme are also using a cocktail of other substances, very often including heroin. Multiple drug use is the reality for nearly all users, and official policy needs to have this understanding at its centre”, Saris said.
In the course of their study, the research team also noted a strong stigma against heroin use amongst the 16-25 age group who still regularly used a lot of other substances, including cocaine and off-label prescription medication. “The reality is that these people are difficult for a treatment infrastructure built around opiates to service. If they have issues, they are more difficult to address,” said Saris.
” The stress that policy-makers and community activists place on ‘crack’ or ‘heroin’ or any other single drug as clear and present social dangers obscures the ubiquity of polydrug use. It makes it appear that these users are very different from other drug-users in the rest of society including cannabis and recreational cocaine users, and it also obscures how commonly legal pharmaceuticals, such as benzodiazepines, even methadone itself, are regularly consumed ‘illegally’.”
He said that a focus on drug use alone is the mistake. “The lives we examined, however damaged by an attraction to certain pharmaceuticals, are rarely defined solely by such behaviour. These people are also sons and daughters, fathers and mothers, partners and lovers, as well as employees and community members. This sensibility does in fact inform a lot of local community activities aimed at assisting users, but such work is often difficult to justify to official funders under the rubric of ‘treatment’, as currently understood. Unless we can understand who users are, what they are taking and why, we will not be able to assign the appropriate resources, treatments or management systems.”
Tony MacCarthaigh, chairperson of the Canal Communities Local Drugs Task Force commented that “individuals and not chemicals need to become the focal point of treatment, and treatment needs to assist individuals in developing another orientation not just to drugs, but to life”.
Source: www.addictiontoday.org 9th July 2010

Abstract

Aims
The present study represents the first large-scale test of the capacity to predict illicit drug treatment outcomes of an instrument [Stages of Change and Treatment Eagerness Scale (SOCRATES)] purporting to measure processes underlying stages of change. The main hypothesis was that ‘taking steps’ should be predictive of less frequent use of illicit opiates (heroin and non-prescribed methadone) at follow-up.

Design
The sample comprised 1075 people seeking treatment for drug abuse problems in 54 treatment agencies in England. The study uses a longitudinal, prospective cohort design. Structured interviews were conducted at treatment intake and at 1-year follow-up. Data were collected about illicit drug use (frequency of use of heroin, non-prescribed methadone, cocaine and amphetamines, and non-prescribed benzodiazepines) and other problems.

Findings
Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.
Conclusions
Readiness for change measures were not associated with illicit drug use outcomes. Of the 12 hypothesized relationships between readiness for change measures and outcomes, our results show only one ‘hit’ and 11 ‘misses’.

Source: Addiction Volume 102 Issue 2 Page null – February 2007 Addiction 102 (2)

A longer-acting alternative to methadone that never quite caught on following its FDA approval in 1993 may now greatly increase the number of addicts who stick with treatment, thanks to a new Johns Hopkins study.

The study suggests better ways of taking LAAM (levomethadyl acetate hydrochloride), a drug similar to methadone in its capacity to discourage heroin use and block withdrawal symptoms. However, unlike methadone, which addicts must use daily, LAAM can be taken three times a week, making it far more convenient and potentially less expensive.
LAAM isn’t widely used, because of both uncertainties about how effective it is in the first stages of addiction treatment and doubts that it would be accepted by addicts. Earlier this year, for example, only about 3,000 U.S. patients were getting the drug.
“Use of LAAM has been less than hoped for since its approval by the Food and Drug Administration,” says Rolley E. Johnson, Pharm.D, associate professor of psychiatry, who headed the Hopkins study. Early studies didn’t test participants’ responses at various dosages, and under the cautious little-by-little approach to giving the medication, it appeared less effective than methadone at the first stage of treatment. Because of this, many assumed that LAAM lacked the necessary opiate-like effects early on. “Users said they couldn’t feel the drug working and were more likely to drop out of treatment,” Johnson noted.
The new Hopkins study, however, reported in this month’s Archives of General Psychiatry, shows that at the proper dosage on the proper schedule, LAAM is safe, effective and acceptable to addicts. “It could become a valuable addition to heroin addiction programs. Its convenience compared with methadone is a great advantage for addicts who hold jobs,” says Hendree Jones, Ph.D., one of the investigators. “They can earn a living more easily while continuing to receive treatment.”
To test LAAM, researchers gave 180 heroin-addicted volunteers either low-, medium-, or high-dose schedules, phasing in the drug over 17 days. They then looked at a combination of drug tests on subjects’ urine samples and subjects’ own reports to get a picture of how their heroin use had changed.
Heroin use dropped in all groups. The reduction was significant, though, in the high-dose group, showing a more than 80 percent plunge in self-reported heroin use. Also, more than 80 percent of the volunteers stayed with the trials, says Johnson. “That’s high for a study like this. It’s a good sign that most participants accepted LAAM.”
Though LAAM seems to work best on the high-dose course, Johnson says, that dose also had the most subjects drop out of the study. “It’s mostly because side effects begin to appear at higher doses.” So he suggests an approach that uses careful monitoring as the dose gets higher. Johnson would like to see more studies to help figure the optimal LAAM dose for individual patients: “Then we’ll be able to help even more addicts.”
LAAM works on the tiny receptors in the membranes of nerve cells in the brain. It binds to the so-called mu opioid receptors, the same ones that heroin and methadone target. Once attached, molecules of LAAM stimulate the receptors. But because LAAM remains there for a relatively long time, it blocks receptor access for other opioid drugs: addicts take heroin, for example, and it has none of its usual effects.

Source. ScienceDaily. Retrieved March 11, 2009, from http://www.sciencedaily.com¬ /releases/1998/08/980817081828.htm

There were 897 deaths involving heroin or morphine in 2008, an 8 per cent rise compared with 2007 and the highest number since 2001. The number of deaths involving methadone rose throughout 2004 to 2008, to 378 in the latest year, an increase of 16 per cent compared with 2007 (and 73 per cent higher than in 2004). There were 235 deaths involving cocaine in 2008, continuing the long-term upward trend.

 

There were 99 deaths involving amphetamines in 2008, with nearly half of these being accounted for by deaths mentioning ecstasy. Cannabis was mentioned in 19 deaths in 2008, while the number of deaths mentioning GHB rose to 20 in 2008 from 9 in 2007. The number of deaths that mentioned benzodiazepines rose to 230 in 2008, an increase of 11.

 

Source: Office for National Statistics  26 August 2009

 

BABIES born to mothers who take methadone during pregnancy have developed a range of visual problems, according to a report by medical experts in Glasgow.


The study discovered that the mothers of all 20 infants referred to a specialist clinic for vision defects had taken opiates during pregnancy.  The problems included blurred vision, nystagmus (rapid and involuntary eye movement from side to side), squints, short-sightedness and cerebral visual impairment – signs that the brain was not processing the signals from the eyes correctly.  The results of the study are likely to add to the controversy surrounding the prescription of the heroin substitute methadone to drug users.The latest official statistics show that 572 babies were born to drug misusers in 2006-7, including 370 births to users of opiates such as methadone and heroin. The study, published in the Scottish Medical Journal, was carried out by doctors at the Royal Hospital for Sick Children at Yorkhill and Princess Royal Maternity. It is the first major investigation into how the use of opiates during pregnancy affects the development of vision in babies.

Researchers said there were “growing concerns” about the scale of the vision problems being picked up by eye examinations and about how long they would persist.

Neonatal consultant Helen Mactier said: “We were seeing a disproportionate number of babies who had visual difficulties whose mothers had a history of drug abuse.”
Ruth Hamilton, a consultant clinical scientist and an expert in vision who is involved in the research project, said: “This is about the long-term outcomes for these children. It may be that these babies will go on to develop problems later in life, and it is very important that we discover if there is something we can do.”

In the study, 19 babies had blurred vision, 14 nystagmus, six had squints, six were short-sighted and five had cerebral visual impairment.

A preliminary summary of the research has been presented to the Scottish Paediatric Society. It suggests routine eye examinations for children who were exposed to methadone in the womb, saying: “Children with a history of in-utero opiate exposure may benefit from a vision screening programme.”

Mactier said: “We deliver 150 babies a year to drug-using women and around 45 per cent of them are treated for withdrawal. These babies stay in hospital for a longer period, they are often sick and small. Their mothers are often heavy smokers, they may be from very socially deprived backgrounds, they have a high risk of depression.

“There is an increasing amount of evidence that babies born to drug-addicted mothers have a whole range of health problems.”  She said that, because of the often chaotic lifestyle of drug users, it was hard to single out methadone or any other factor as the principal cause of eye problems.

“Between two-thirds and four-fifths of women on prescribed methadone are also using illicit opiates, valium or similar drugs.” A secondary study will try to pinpoint which factors were most likely to cause of eye problems in the babies of drug-abusing mothers.

There are now 22,000 addicts in Scotland on a methadone programme. A study by Glasgow University’s Centre for Drug Misuse Research found that people on methadone programmes still take heroin. There are concerns the programme replaces one addictive drug with another, and that people are “parked” on methadone for years. There have also been cases of addicts’ children gaining access to methadone.

Earlier this month, the £50 million policy was criticised when an addict’s free supply was cut after almost 20 years.  A Scottish Government spokesman said official policy was to recommend methadone treatment for pregnant drug users on the grounds that prescribed drugs carried a lower risk than continuing to use illegal drugs.  He said: “Pregnant women who misuse drugs receive extra support and care suited to their personal needs.”

Source: ScotlandonSunday  28th Feb 2010

Filed under: Health,Heroin/Methadone :

Methadone withdrawal helps many people to withdraw from damaging heroin use. Methadone maintenance however keeps a person addicted …

I’ve been told that methampethamine addicts who binge use the drug can go on a tweaking stage and its dangerous. Can some explain this “tweaking phase” or provide a nice reference site that discusses this.

Response: cotton mouth, anxiety, paranoia, restlessness

I went to the doctor for help to get through a moderate heroin addiction back in 1976. The doctor put me on 40mg of Methadone per day and referred me to a Psychiatrist who continued this dosage until he lost his licence to prescribe methadone and had to send me and his other methadone patients to the government run methadone clinic. I think that methadone exacerbated my moderate heroin addiction culminating in over 30 years of daily pharmacy attendance and now 120mg per/day dependence.

Source: Drug Rehabilitation that works Blog Archives 28.01.10

Filed under: Heroin/Methadone :

ABSTRACT
The present study was conducted to determine whether methadone maintenance alters the pharmacodynamic effects of single doses of cocaine. Twenty-two current users of IV cocaine who were not seeking treatment for their illicit cocaine use participated while living on a research unit.
Eleven were maintained on methadone 50 mg PO daily as treatment for their opioid abuse; 11 were opioid abusers who were not physically dependent on opioids and who provided opioid-free urines throughout the study. Each subject received acute cocaine challenge doses of 0, 12.5, 25, and 50 mg intravenously in random order under double-blind conditions in separate test sessions.
Physiologic and subject-rated responses were measured before injection and for 2 h after. In the methadone maintenance group, cocaine challenge sessions occurred 15.5 h after the daily methadone dose. There were significant differences between the methadone-dependent and nondependent groups: 1) baseline differences related to chronic methadone administration and not associated with cocaine administration (lower respiration rates and pupil diameter; higher skin temperature) and 2) differences in response to cocaine administration; cocaine-induced increases in subject ratings of Drug Effect, Rush, Good Effects, Liking, and Desire for Cocaine and in heart rate were greater in the methadone maintenance patients compared to the non-dependent group.
These results indicate that the positive subjective effects and some physiological effects of cocaine are enhanced in methadone-maintained individuals, suggesting a pharmacological basis for the high rates of cocaine abuse among methadone maintenance patients.

Source: Psychopharmacology (Berl) 1996 Jan;123(1):15-25

Use of a controversial stomach implant designed to block the effects of heroin must be urgently reined in, according to drug specialists who say addicts are being harmed. A new report found that naltrexone implants commonly cause severe adverse reactions, including extreme dehydration and acute renal failure in those who are fitted with them.
Nine Sydney specialists writing in the Medical Journal of Australia have called for an urgent review of use of the product, which blocks the effects of heroin and stops cravings for about six months. It has not been registered or rigorously tested in Australia but about 1,500 addicts have obtained it through the Therapeutic Goods Administration’s Special Access Scheme for people with a life-threatening need.
Controversy has surrounded the use of the implants for several years, with advocates arguing they offer addicts the best chance of overcoming their addiction and opponents branding them dangerous and ineffective.
One study published last March linked the implant to five deaths. A new study published has found that of 12 implant patients who were admitted to two Sydney hospitals last year, eight hospitalisations were implant-related. Six were suffering severe dehydration, one had acute renal failure and another had an abscess at the implant site.
“These cases challenge the notion that a naltrexone implant is a safe procedure,” said study leader Nicholas Lintzeris, a senior addiction specialist at the Sydney South West Area Health Service. He called for the widespread and unregulated use of implants to be restricted until they have been properly tested for safety and effectiveness.
Professor Robert Ali, director of the Drug Alcohol Services Council in Adelaide, agreed the product should not be so widely available.
“The disturbing suggestions of mortality and morbidity from unregistered naltrexone implants makes a strong case for an independent review to determine whether this treatment is sufficiently safe for such widespread use,” Prof Ali said.
However, another specialist, University of Western Australia Professor of Addiction Gary Hulse, said a trial he had undertaken had found the implant to be just as safe and effective as the oral form of the drug. He defended its use and said many of the criticisms levelled at naltrexone occurred because people’s withdrawals from heroin were not being managed properly.
Source: www.theage.com April 17th 2008

 So much for harm reduction techniques reducing drug deaths.

An ageing population of heroin users does not fully explain the five year peak in deaths from drug poisoning in English and Welsh men. The increase is attributable to heroin, methadone, and morphine, and death rates were highest in young adults.
The UK has the highest prevalence of drug misuse in Europe.  The social laboratory of harm reduction as practised in the UK does not focus on prevention by creating and implementing drug use prevention activities and increasing drug free recovery facilities. Substitute prescribing protocols and needle exchange facilities have an important role in preventing further harm being incurred by users, but they cannot reduce the mental, physical, spiritual, and social harms caused by continued use or the severity of addiction with continued use.

Methadone maintenance, the flagship of drug treatment in the UK, needle exchange facilities, and drug consumption rooms have all failed to reduce or prevent the increasing use of addictive substances, as well as the associated deaths and bloodborne diseases.

The action plan on reducing drug related deaths referred to by the Department of Health spokesperson proposes more of the same. Abstinence is mentioned twice in the eight page plan, but there is no mention of increasing drug free recovery protocols or programmes.

Peter O’Loughlin principal, Eden Lodge Practice, Beckenham BR3 3AT peteroloughlin5@hotmail.com

Competing interests: PO’Lis an addictions counsellor and psychotherapist who is principal of a practice offering a non-residential service to those seeking to become free of alcohol, addictive psychoactive substance disorder, or addiction.
O’Dowd A. Deaths from drug poisoning in English and 1 Welsh men reach five year peak. BMJ 2008;337:a1521. (3 September.)
Morgan O, Griffiths C, Toson B, Rooney C, Majeed A, 2 Hickman M. Trends in deaths related to drug misuse in England and Wales, 1993-2004. Health Statistics Quarterly 2006;31:23-7.
European Monitoring Centre for Drugs and Drug 3 Addiction. The state of the drugs problem in Europe. Annual report 2005. www.europa.eu.in
Bargagli AM, Hickman M, Davoli M, Perucci CA, Schifano 4 P, Buster M. Drug related mortality and its impact on adult mortality in eight European countries. Eur J Public Health 2005;79:191-9.
Department of Health. Reducing drug-related 5 harm: an action plan. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_074850
Cite this as: BMJ 2008;337:a1671

Filed under: Health,Heroin/Methadone :

Researchers in the Discipline of Pharmacology have discovered a genetic variation that may help determine the most effective methadone dosage levels for individual heroin addicts.
The genetic discovery reveals why some people are either less efficient or more effective in distributing drugs throughout their body to the central nervous system.
Lead researcher Dr Janet Coller says accurate dosing of methadone is essential to successfully treat drug addicts because up to 62% fail to remain in the methadone program due to the severe withdrawal symptoms.
“Individualised dosing may decrease the incidence of withdrawal symptoms in some people and therefore encourage them to continue with the methadone treatment.”
An estimated 10 million people worldwide are heroin dependent, including 74,000 Australians, incurring enormous health, social and economic costs.
“More than 40,000 people are undergoing methadone treatment in Australia and only 38% of them are staying in the program at the moment. Most drop out at the start of the treatment when the withdrawal effects are severe,” Dr Coller says.
This breakthrough will allow individuals undergoing the methadone treatment program to be tested for the genetic variation to determine optimal treatment doses.
The pharmacology study was conducted collaboratively as part of Dr Coller’s postdoctoral and Daniel Barratt’s PhD studies, supervised by Professor Andrew Somogyi, with the assistance of Karianne Dahlen and Morten Loennechen, Masters of Science students from Denmark. The results have been published in the December issue of the journal Clinical Pharmacology and Therapeutics.
Source: University Of Adelaide (2007, January 29). Breakthrough For Heroin Addiction Treatment. ScienceDaily. Retrieved March 11, 2009, from http://www.sciencedaily.com¬ /releases/2007/01/070128135642.htm

Sometimes, small changes do add up. In the case of addictive diseases, tiny variations in a few genes can increase or decrease the likelihood of some people developing a dependency on heroin. Now, by examining a select group of genetic variants in more than 400 former severe heroin addicts, Rockefeller University researchers have identified several genetic variations in American and Israeli Caucasians that influence the risk for becoming addicted to one of the world’s most powerful substances.
In a collaborative effort with statistical geneticists and several methadone clinics, scientists led by Mary Jeanne Kreek, head of the Laboratory of the Biology of Addictive Diseases, analyzed 1,350 variations in 130 genes and found nine, from six genes, that were either more or less common in recovering heroin addicts when compared to Caucasians with no history of drug abuse. These small changes in the gene sequences can cause significant changes in protein function that can influence addictive behavior — changes that may affect people of different ethnic background differently.
“The idea of ‘personalized medicine’ makes this field really exciting but also very complicated,” says Orna Levran, a senior research associate in the Kreek laboratory and first author of the study. “Although seven of these variants increase the risk for developing heroin addiction in Caucasians, the same seven may not have the same effect in other populations. So ethnicity and, more precisely, genetic information in each individual may become important factors for treating and diagnosing addictions to different drugs.”
In their analysis, Kreek, Levran and their colleagues looked at a string of letters called nucleotides, the building blocks that make up genes. In each of the six genes, at least one letter is replaced by another, a genetic variation known as a single nucleotide polymorphism, or SNP. The researchers found that all of the single-letter variations exist in parts of the genes that do not translate into proteins but instead may have a regulatory or a structural effect.
Out of the nine SNPs, the group found six in the μ, δ and κ opioid receptors, a finding that reinforces the idea, and many other findings of the Kreek laboratory, that opiate receptors play a major role in severe heroin addiction. The remaining three SNPs were found in genes coding for the serotonin receptor 3B, casein kinase 1 epsilon, which acts as a regulator of the circadian clock genes, and galanin, which modulates appetite and alcohol consumption. This is the first study to show that specific variants in these genes are associated with heroin addiction, explains Levran.
The SNPs in the κ opioid receptor and casein kinase 1 genes were found more in the control group than the heroin addicts’ group, suggesting that they conferred protection from heroin addiction — not vulnerability to develop addiction.
“Individually, these SNPs probably have a small effect,” explains Levran, “but collectively, we are seeing that they could have a larger effect. One of the goals now is to find all of these gene variants and assess how they influence people of different ethnic backgound.”

Source: Rockefeller University (2008, October 5). Variations In Key Genes Increase Caucasians’ Risk Of Heroin Addiction. ScienceDaily. Retrieved March 11, 2009, from http://www.sciencedaily.com¬ /releases/2008/10/081002211720.htm


Filed under: Addiction,Heroin/Methadone :

Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial.
This unique randomised trial tested what would happen if detoxified opiate addicts were then maintained on a substitute drug, on an opiate-blocking medication, or simply counselled. The results led to the introduction of methadone prescribing programmes in Malaysia.
Abstract As a follow-on treatment after opiate detoxification, this study compared the efficacy of the opiate-blocking medication naltrexone, the opiate substitute buprenorphine, or no treatment other than the drug counselling all patients received. In Malaysia at the time naltrexone was the main long-term pharmacotherapy and maintenance substitute prescribing was not permitted.
Between July 2003 and May 2005, 215 people contacted the study of whom 143 heroin dependent patients began a preparatory 14-day detoxification programme in the study’s inpatient clinic. Most of the remaining contacts did not complete the study’s initial assessments; just 12 were excluded due to complicating conditions. 126 completed detoxification and started 24 weeks of weekly individual and group drug counselling in the study’s outpatient research clinic. For randomly selected patients, counselling was supplemented either by oral naltrexone, sublingual buprenorphine, or placebos. In the first week the medications were given daily, then multiple doses were given on Mondays, Wednesdays and Fridays. All the doses were consumed under supervision at the clinic and all the patients consumed similar tablets and capsules, either active or placebos depending on their assignment. Nevertheless, most on the active medications correctly identified what they were taking, though most on placebos did not. Typically the patients were poorly educated single men with a history of imprisonment who had been using heroin for on average 15 years and had used near-daily in the previous month.
Outcomes were assessed mainly by urine tests three times a week while patients were still in treatment, the credible assumption being made that the few tests missed by retained patients would have been positive for heroin, and that patients who dropped out of treatment had resumed heroin use. When it became apparent that buprenorphine was clearly the best option, the study was terminated early after 103 patients had completed it and 10 remained in treatment.
Supplementing counselling with naltrexone slightly improved treatment retention and heroin use outcomes, but not to a statistically significant degree according to the study’s stringent criteria. In contrast, outcomes on these measures were clearly and universally superior for the buprenorphine patients, significantly better than placebo, and generally also significantly better than naltrexone. For example, of the 24 weeks patients could have stayed in treatment, on buprenorphine they stayed on average for 17 weeks, naltrexone 12, and placebo 10 chart. Corresponding figures for retention without a positive/missed test for heroin use were 7, just over 3, and just under 3 weeks. For retention without relapse to sustained heroin use, the figures were 11, 9, and just under 6 weeks.
For the authors their findings showed the efficacy of maintenance treatment with buprenorphine in sustaining abstinence, delaying time to resumption of heroin use and relapse, and retaining patients in treatment, lending support to the widespread dissemination of maintenance treatment with buprenorphine as an effective public health approach to heroin dependence.
Uniquely the study answered the question: What would happen if continuing care for patients who completed detoxification consisted of low intensity counselling only or with attempts to sustain abstinence using naltrexone, versus effectively accepting that many will relapse and instead prescribing a substitute drug? When these were the only options available, the answer seemed to be that naltrexone offers no substantial advantages, but that substitute prescribing makes a big difference to how long and how many patients are able to live without regular resort to illegal opiates. Without this, for most rapid relapse is the norm even after they have been able to complete detoxification; opiate blocking medication does little to improve the situation.
Though this is the verdict from among the range of options on offer in the study, long-acting forms of naltrexone which last weeks or months might have tipped the balance in favour of abstinence-based therapy, and seamless entry in to (to the patient) acceptable forms of residential rehabilitation or intensive day care might have raised outcomes to the point where the choice of medication was less decisive. In both cases, the caveat is that compared to substitute prescribing, fewer patients are prepared to accept or can access these options, and in the case of residential rehabilitation, the costs per year of heroin use averted are likely to be considerably greater.
The main issue with the study from a UK perspective is its applicability to a country where these are not the only options available, and where even if they were, patients would be expected to be allocated to them on an individual basis in the light of what seems best for that individual. However, there are parallels. As in the featured study, in the UK (and elsewhere) failure to complete detoxification or post-detoxification relapse are the norm, long-acting naltrexone formulations have yet to be licensed and made widely available, and residential rehabilitation remains in short supply. The relevance of the study could be heightened if (as strongly advocated by some political advisers) substitute prescribing is de-emphasised in favour of abstinence-based approaches, especially if the need for economies forces these to take the form of naltrexone or counselling rather than intensive, extensive and expensive psychosocial rehabilitation.
Currently the study usefully reinforces existing guidance on the need for anti-relapse support after detoxification, the limitations of oral naltrexone as a means of providing or reinforcing that support, and the more widespread applicability and more securely established effectiveness of substitute prescribing using methadone or buprenorphine. It also provides an argument for maintenance prescribing to be made rapidly available for the many patients unable to avoid a return to regular opiate use after detoxification.
The implications of the study are supported by other studies of detoxification, oral naltrexone and substitute prescribing, though no other study has within itself compared these options. As commentators on the study put it, this wider research base indicates that “The preferred oral pharmacological treatment for opioid dependence should be agonist maintenance with either methadone or buprenorphine.” This verdict carefully limited itself to “pharmacological” treatments and to “oral” medications, leaving out more intensive or improved psychosocial approaches or long-acting implanted or injected medications.
In Australia, where polarised opinions favoured substitute prescribing or rejected this in favour of naltrexone, the federal parliament reacted by conducting a review of their respective advantages in the Australian context. The conclusion was that both had their place, but that place was much greater for substitute prescribing. Oral naltrexone was seen as a niche option for the minority of opioid-dependent individuals capable of remaining compliant with the treatment, but for most it had been consistently been linked with high rates of non-compliance, a greater risk of death and reduced likelihood of long-term success. In contrast, methadone and other opioid substitution treatments were seen as widely applicable treatments acknowledged as effective in reducing opioid dependence and associated health and social problems.
The featured study seems to support this conclusion, but perhaps not as strongly as it might have done. On one key measure – retention without relapse to sustained heroin use – buprenorphine’s advantage over naltrexone was small (two weeks) and not statistically significant, possible an artefact of the way relapse was defined. Despite its advantages, at best half the patients on buprenorphine stayed in treatment for six months, less than in other studies possibly due to insufficiently supportive psychosocial care, or because the study’s standard dose was at the lower end of what is considered effective. It also seems likely that buprenorphine’s advantage would have been greater had patients not been required to complete detoxification in advance, presumably weeding out those less able or willing to attain abstinence from opiates. On the other hand, the naltrexone patients might have been disadvantaged by the dosing schedule. Both buprenorphine and naltrexone are known to be able to bridge alternate-day dosing schedules, but in studies naltrexone is normally taken daily, providing a daily reminder to the patient that any heroin they try will be more or less wasted. Dosing every two or three days left gaps during which the patients might have been tempted to try heroin. However, this schedule probably reflects how both drugs are commonly prescribed in normal practice.
Source: Schottenfeld R.S., Chawarski M.C., Mazlan M Lancet: 2008, 371, p. 2192–2200.

Although methadone maintenance is an effective therapy for heroin dependence, some patients continue to use heroin and may benefit from therapeutic modifications. This study evaluated a behavioural intervention, a pharmacological intervention, and a combination of both interventions.

Methods

Throughout the study all patients received daily methadone hydrochloride maintenance (initially 50 mg/d orally) and weekly counselling.
Following baseline treatment patients who continued to use heroin were randomly assigned to 1 of 4 interventions:

(1)contingent vouchers for opiate-negative urine specimens (n29 patients);
(2) methadone hydrochloride dose increase to 70 mg/d (n=31 patients);
(3) combined contingent vouchers and methadone dose increase (n=32 patients); and
(4) neither intervention (comparison standard; n=28 patients). Methadone dose increases were double blind.

Vouchers had monetary value and were exchangeable for goods and services.
Groups not receiving contingent vouchers received matching vouchers independent of urine test results.
Primary outcome measure was opiate-negative urine specimens (thrice weekly urinalysis).

Results

Contingent vouchers and a methadone dose increase each significantly increased the percentage of opiate-negative urine specimens during intervention.
Contingent vouchers, with or without a methadone dose increase, increased the duration of sustained abstinence as assessed by urine screenings.
Methadone dose increase, with or without contingent vouchers, reduced frequency of use and self-reported craving.

Conclusions

In patients enrolled in a methadone-maintainence program who continued to use heroin, abstinence reinforcement and a methadone dose increase were each effective in reducing use.  When combined, they did not dramatically enhance each other’s effects on any one outcome measure, but they did seem to have complementary benefits.

Source: Author Kenzie et al published in Arch Gen Psychiatry. 2000;57:395-404
Filed under: Health,Heroin/Methadone :

In an unusual move, city Health Department officials are quietly encouraging physicians, hospitals, methadone clinics and prisons to prescribe the drug buprenorphine to heroin addicts, believing it will lure more addicts into treatment. Buprenorphine — a relatively new drug that goes by the nickname “bupe” and comes in a pill form — offers a new set of treatment options for opiate abusers, said Dr. Lloyd Sederer, executive deputy commissioner of the city Department of Health and Mental Hygiene.

Fewer side effects
Chemically, the drug partially blocks the same brain receptors that heroin and methadone target. But unlike those drugs, it doesn’t produce the same “high” or level of dependence. In addition, withdrawal from buprenorphine produces less severe symptoms and fewer drug cravings.

“The new medicine works differently in two ways,” Sederer said. “Bupe has a ceiling effect and reaches a certain point where it doesn’t get you higher, so it is much less likely to be abused or sold on the streets. With heroin and methadone, the more you take, the higher you get, and your lung function is depressed. The respiratory failure is what results in death.”

Methadone has been the standard for heroin addiction treatment since the early 1970s. But the syrupy, amber liquid is highly habit-forming and by law must be distributed — one dose at a time — at a special clinic. That stricture causes some who would seek treatment to shy away.

“People say that methadone leaves them punchy, and they have difficulty thinking and working,” Sederer said. “The long-term data on people in methadone programs shows that they are more stable, not involved in crime, and that’s a good thing, but only a small percentage are working [in jobs].”

Relatively new drug
Despite the potential benefits of buprenorphine, the drug remains virtually unknown and unused by the city’s heroin addicts. According to city health officials, only about 1,000 people use it, compared with an estimated 34,000 taking methadone.

Sederer and other city health officials want to see a significant change in those numbers. The goal is to have more than 100,000 opiate addicts using buprenorphine for detox maintenance by 2010.

“We are not reaching enough people with the treatments that we have,” Sederer said. “Not everybody should be on methadone.”

Like methadone, buprenorphine is heavily regulated, and may be prescribed only by certified doctors, of which there currently are 345 statewide. In addition, those prescribing the drug are bound by a 30-patient limit, a federal restriction guarding against prescription abuse that Sederer and other health officials hope will be changed so that more patients can be treated.

Some private doctors have been reluctant to prescribe the drug, fearing their offices would be inundated with addicts.

The drug’s pill form would be more attractive to white-collar users trying to avoid methadone clinics, experts said.

Somewhat complicating the picture, there are varying camps in the medical community about how to treat opiate addiction. Some, including Phoenix House, the country’s largest drug-free residential rehabilitation program, use bupe for detoxification; other programs use it solely as a maintenance drug to replace methadone.

Dr. Terry Horton, the medical director of Phoenix House in the city, calls buprenorphine “the most significant development in the treatment of opiate addiction in 40 years.”

“But,” Horton noted, “it is not a replacement for methadone but should be considered another tool we can use to treat opiate addiction.”

Could streamline treatment
The goal, drug treatment experts said, is for more doctors to be able to prescribe buprenorphine and for patients to be able to pick it up at the pharmacy.

Potentially, thousands of people could benefit from the drug. The city spends $50 million annually on treatment of an estimated 200,000 heroin addicts and 200,000 others addicted to prescription painkillers like Vicodin, Percocet and OxyContin. The state Office of Alcoholism and Substance Abuse Services will spend $313.7 million in 2005-06 to treat those battling against alcohol and other drug-related addictions, spokeswoman Jennifer Farrell said.

Source:BY CURTIS L. TAYLOR STAFF WRITER;July 10, 2005

A review article has outlined the benefits of buprenorphine (Subutex) in the treatment of intravenous drug use. The drug, which was added to the World Health Organization’s (WHO’s) list of essential drugs in July 2005, may be beneficial in reducing HIV transmission through injection practices, as well as treating HIV-infected drug users.

Injection drug use is a major factor in the transmission of HIV internationally. Around 10% of all HIV transmissions can be attributed to the consequences of intravenous drug use including needle sharing or unsafe sex. Drug use has also been linked to the majority of HIV transmissions in central and Eastern Europe and Southeast Asia.

The most commonly used treatment for addiction to opioids, such as heroin and morphine, is replacement therapy with methadone. This drug mimics the effects of opioids by binding to the same receptor molecules as these drugs. These receptors, called mu-opioid receptors, are found on the surface of cells in the brain and spinal cord and trigger the drugs’ sedating, euphoric and pain-killing effects.

Methadone works by preventing the withdrawal symptoms and craving brought about when an addict stops injecting drugs. By reducing the frequency of drug injection, it has been shown to reduce the incidence of HIV infection. However, the use of methadone has a number of problems, including being itself addictive, and its risk of causing breathing problems and overdose. It also interacts with many HIV drugs.

Buprenorphine, in contrast to methadone, is a partial agonist of the mu-opioid receptor. This means that it binds to the receptor less strongly than methadone and is less likely to be abused itself. It is also very difficult to overdose on buprenorphine as its effects plateau at high doses, and it has fewer interactions with HIV drugs, so is easier to use in patients taking antiretroviral therapy.

“The introduction of buprenorphine, a new medication to treat opioid dependence that has fewer restrictions than methadone, holds promise for reducing HIV transmission and improving the care of patients with opioid dependence and HIV disease,” write the review’s authors, Lynn Sullivan and David Fiellin from Yale University School of Medicine. “Methadone has a long history of proven efficacy and benefits in treating opioid dependence, and the addition of buprenorphine serves to expand the treatment options”.

Buprenorphine has become more widely available over the last ten years, and is available alone or in combination with naloxone, a drug that blocks the mu-opioid receptor. It is taken as a tablet dissolved under the tongue daily or three times a week, and was recently added to the WHO’s list of essential drugs. This lists all medicines that should be available in adequate amounts and at an affordable price within all health systems, and are selected according to public health relevance, efficacy, safety and cost-effectiveness.

In their review, the authors summarise the results of cost-effectiveness studies comparing buprenorphine to methadone. These have concluded that buprenorphine treatment programmes may be preferable, both in the treatment of opioid dependence itself, and in its effects on reducing new HIV infections.

However, despite the drug’s benefits, the authors point out that few studies have examined its effects on HIV risk behaviours, such as needle sharing and unsafe sex, although larger scale studies are planned.

In injecting drug users (IDUs) who are already HIV-positive, there is evidence from the French Manif 2000 cohort study that use of buprenorphine improves adherence to antiretroviral drugs. Although this was not associated with a better response to therapy, and over half of the patients reverting to drug use during the study, they point out that, despite limited evidence, buprenorphine is less likely to interact with HIV drugs than methadone.

AZT (zidovudine, Retrovir) and some protease inhibitors may increase buprenorphine levels, but the pharmacological properties of buprenorphine mean that its effects are not increased above a ‘ceiling’ level, so increased buprenorphine levels are unlikely to cause dangerous side-effects. However, the authors write, “as efforts continue with the goal to integrate use of buprenorphine into HIV care, further studies will need to be undertaken to make more than theoretical statements about these interactions.”

In conclusion, there is room for substantial optimism about the inclusion of buprenorphine in the treatment of IDUs for the prevention of HIV transmission and the treatment of IDUs who are already HIV-positive. Although the practicalities of treatment programmes remain to be fully evaluated, many of the questions surrounding the drug’s role will be answered in ongoing and future studies.

“In the meantime, office-based clinicians, for the first time in nearly 100 years, have the opportunity to provide a unique treatment to minimise the adverse impact of opioid dependence,” the authors conclude.

Reference Sullivan LE et al. Buprenorphine: its role in preventing HIV transmission and improving the care of HIV-infected patients with opioid dependence. Clin Infect Dis 41: 891-896, 2005.

Source: Clinical Infectious Diseases September 2005

By examining the neurons of heroin-hooked rats, Ivan Diamond and colleagues at CV Therapeutics in California found that the AGS3 gene can increase the output of pleasure and addiction signals from a region of the brain known as the nucleus accumbens. This region was already known to be important for pleasure and reward, and central to heroin addiction. The research, published in Proceedings of the National Academy of Sciences, shows exactly which gene triggers the pleasurable response.

Source: The Guardian, 2 June
Filed under: Heroin/Methadone :

Chronic liver disease may be to blame for the increased number of older, more experienced heroin users dying from overdose in Australia, a new study has found.

More than 350 heroin users die in Australia each year – typically older, unemployed men killed by an overdose. Puzzled as to why the most experienced are the most likely to die, researchers at the National Drug and Alcohol Research Centre (NDARC) carried out Australia’s first study analysing the autopsy results of hundreds of deceased addicts.

Increased purity of the drug has commonly been blamed for the deaths but these new results put forward systemic disease as a more likely cause.

Pathology results of 841 people who died in NSW between 1998 and 2002 found “appalling levels” of disease, particularly among older users, study author and NDARC professor Shane Darke said.

More than 70 per cent were hepatitis C positive, and almost half had evidence of current hepatitis.  One in 10 aged 35-44 years had chronic liver disease – a figure that jumped to 25 per cent in the over 44 age group.

This was most prominent disease recorded, “strongly suggesting” it was a factor in their deaths.

“We’ve long been puzzled as to why these experienced users die after decades of doing what they’ve always done, and often there’s not even much morphine found in their blood,” said Prof Darke, from the University of NSW.  “Now we know liver disease is a strong candidate for an explanation for why they drop down dead.

“Their liver decays, the ability to metabolise the drugs and alcohol decreases and that’s it.”

Older users also had high levels of lung disease and heart disease, particularly serious coronary artery disease.
Almost half of those aged over 44 had multiple organ disease, Prof Darke said.

“They pretty much all smoked, drank and took other drugs so they’d been living hard since their teens,” he said. “This shows just how sick these people really are, I mean crikey, it’s amazing they could even walk around.”  He said the results showed the importance of getting younger addicts into treatment programs to break this cycle.

“And given what we know now, we need to monitor things like their liver and heart disease within that treatment setting because this is what could kill them,” Prof Darke said.

Statistics show half of heroin users are dead by the age of 50, mostly from overdose – more than 14 times the rate of other people.

Source: au.news.Yahoo June 2006
Dallas (Texas) police are seeing a new drug on the streets and in the schools directed at young people called “cheese.” The new drug mixture is a ‘starter form’ of heroin, containing Tylenol PM and up to 8 percent heroin. Due to chemical interference caused by acetaminophen and diphenhydramine hydrochloride, forensic analysis can be challenging, according to police.

‘Cheese’ appears to be a favorite of Hispanic juveniles, both male and female.

With the growing Hispanic community in Houston County and Warner Robins, police are concerned, but according to Lt. Lance Watson of the Warner Robins Police Department Narcotics Investigation Unit, have not seen it yet.

“It may come up,” Watson said. “With the big ice deal in metro Atlanta recently, we feel the effects down here. The supply may dry up and people are willing to try something new.”

Users as young as 13 are known to be experimenting with this drug, according to Narconon, a drug addiction recovery organization similar to Alcoholics Anonymous.

Typically described as a light tan colored powder with granules varying from fine powder to 1.5 millimeters in size, ‘cheese’ is typically found folded inside a small paper bindle.

In a similar fashion to snorting cocaine, ‘cheese’ is snorted through a tube into the nose. The effects that one may experience from ‘cheese’ are euphoria, disorientation, lethargy, sleepiness, and hunger, according to Narconon. As heroin has proven to be highly addictive, ‘cheese’ appears to follow in the same characteristic and symptoms of withdrawal may onset as fast as within 12 hours of cessation of use, according to Narconon.

Another characteristic that attracts youth to “cheese,” Narconon warned, is the cost. Typically, a capsule of ‘cheese’ can be purchased for $5 to $10, making it affordable for the very young.

Source: Houston Daily Journal. 25th Sept.2006
Filed under: Heroin/Methadone :

Medical examiners taking part in the Drug Abuse Warning Network (DAWN) said that overdoses of heroin, cocaine, and alcohol mixed with other drugs topped the causes of drug-related deaths in 2000, Substance Abuse Funding News reported April 9.
The report, ‘Mortality Data from the Drug Abuse Warning Network 2000’, found that in 30 cities, more than half of the deaths reported to DAWN were drug-induced and involved multiple drugs.  The data was based on death reports made to DAWN in 2000 from 137 medical examiner jurisdictions from 43 cities.
Among the jurisdictions taking part in the study, the highest number of drug-related deaths were reported from Los Angeles, Calif, 1, 192; Philadelphia, Pa., 942; New York City, N.Y., 924; Chicago, Ill., 869; and Detroit, Mich., 704.Source: The Substance Abuse and Mental Health Services Administration (SAMHSA).  May 2002

Methadone substitution has long been used as a treatment for heroin addiction. But a new 33-year follow-up study has found that equally satisfactory results are possible without recourse to long-term prescribing of opioids.

Until now there has been no long-term study of people addicted to injected heroin who have been treated without the prescribing of methadone substitute.

This study set out to look at the outcome for patients treated for injected heroin 33 years after they were first seen, and 26 years after they were first followed up. Measures included sustained abstinence from heroin, continued maintenance on methadone and deaths.

86 people with heroin addiction first seen in 1966-67 in a small town in the south-east of England were studied. At the time of diagnosis the patients were aged between 16 and 20, were single and living at home with their parents. They all injected heroin.

All the patients were treated in the local general psychiatric service, which differed from most other UK services for heroin addiction in that it did not prescribe methadone substitute for 23 years after recruitment of the patient group (i.e. until 1989).

The main provisions of the service were immediate help in times of crisis; personal counselling; regular follow-up; an ongoing relapse prevention group; and symptomatic relief with drugs other than methadone.

The first follow-up took place after six years. At that assessment 13% of the patient group were judged to have stopped using any illegal drugs, 51% were still injecting, 6% had died and 12% had experienced alcohol-related problems.

For this follow-up study, 45 of the original patient group were located and their clinical state assessed using multiple sources, including personal interviews with some of them.

It was found that 42% of the group had been abstinent for at least 10 years. 10% were taking methadone and were classified as addicted. 22% had died. 8% of the group could not be located.

The authors of this study compared their results with three other British studies. They found the death rates comparable (15%-20%), but the rates of abstinence and methadone dependency differed.

The researchers comment that it is encouraging that trend studies show agreement that the proportion of people maintaining sustained abstinence rises with time, whilst the proportion of those still addicted declines.

One worrying feature, however, is the high proportion of premature deaths, mainly due to overdoses. As overdose with opioid drugs is often mentioned as a cause of death, there is a need for closer monitoring of these drugs, and regular health screening and intervention to reduce premature deaths.

The advantages of long-term substitute prescribing of methadone are obvious in terms of increased social stability and reduction of crime. However, the researchers were struck not only by the number of premature deaths in people taking methadone, but also by the negative perceptions of life among those who are currently prescribed this opioid.

The findings of this study highlight the need to compare outcomes between people prescribed substitute drugs for addictions, and those who are not.

Reference Nehkant H, Rathod R, Addenbrooke WM and Rosenbach AF (2005) Heroin Dependence
in an English town: 33-year follow-up. British Journal of Psychiatry, 187, 421-425

UK DRUG DEATHS SOAR

LONDON: British deaths from ecstasy, cocaine and amphetamines have rocketed 47 per cent in the past year.The toll topped 1500 for the first time, fuelled by a rise in so-called “recreational hard drugs taken by weekend users.
Ecstasy, cocaine and speed are increasingly used by young people who take cocktails of drugs every weekend.The findings emerged in a study of coroners reports which suggested stronger tablets, easier availability, falling prices and the growing popularity of drug cocktails were behind the rising death toll.
Dr Fabrizio Schifano, who led the research at the European Centre for Addiction Studies at St George’s Hospital Medical School in South London, said recreational users did not see themselves as addicts or considered they were at risk of dying’  Schifana said.
Many weekend users took a cocktail of drugs and alcohol in sessions of up to 12  hours.In dozens of fatal cases, the victims also smoked cannabis.Cocaine was involved in 147 deaths lost year, a 47 per cent rise on 2001, Amphetamines were linked to 53 deaths, a 60 per cent rise. There were 64 ecstasy-related deaths, up 34 per cent.
Dr Schifono so that even a small amount of a drug could kill a hardened user who had built up a tolerance over months or years. In a process called “reverse tolerance”, the user suddenly become acutely sensitive and died.The first death in Britain from a new synthetic form of morphine called Oxycontin was recorded ast year.Called “hillbilly heroin” it has killed hundreds in the US.Overal drug-related deaths rose by about 6 per cent on 2001 last year – from 1495 to 1583, About 45 per cent were due to heroin, morphine and other drugs.The greatest increase in drug-related deaths were in West London. Brcdgend and Glamorgan Volleys, West Yorkshire, Nottinghamshire, North Northumberland and East Lancashire.

Source:Sunday Times(Australia) Oct 2003

Ben Mitchell argues that drugs should not be legalised.

In the UK, the social and economic costs of drug misuse account for between £10 billion and £18 billion a year. Around 250000 problematic drug users’ contribute to 99% of these costs.1 These addicts spend around £16,500 a year each to feed their habits, with most of this coming from the proceeds of crime2. Hard drug users, who indulge in heroin, crack cocaine and powder cocaine, are responsible for 50% of all crimes3.

On the one side, them are proponents of ‘harm reduction’. In the case of heroin, they want to see persistent users prescribed heroin under the NHS.

Opponents compare the Dutch and Swedish approach to drugs over the last 25 years, and point out that drug use in the Netherlands, which has adopted a policy of ‘harm reduction, has seen use of cannabis amongst the young more than double, with use of ecstasy and cocaine by l5 year olds rising significantly.

By contrast, in Sweden, the goal has been to create a ‘drugs free society,’ with everyone from the police to schools working towards such a strategy. As a result, overall lifetime prevalence of drug abuse, amongst 15-16 year-olds. is 8% in Sweden, compared to 29% in the Netherlands. In 1998, only 496kg of cannabis were seized in Sweden, compared to 118 in the Netherlands, now described as the drugs capital of Western Europe5 . This is because in Sweden drug use is seen as inimical to a civilised, tolerant society, whereas in the Netherlands drugs have been accepted as a ‘way of life’ and have contributed hugely to crime.

The UK’s approach to drugs is deeply flawed. with the government sending out confusing and misleading messages. Cannabis has been downgraded from a class B to class C drug; yet many people widely believe that cannabis has been decriminalised.

The ‘Lambeth Experiment’, which led the way to reclassification, caused an explosion in the number of drug dealers preying upon the area6. The experiment has to all intents and purposes ‘allowed’ people to smoke cannabis publicly. But, the moral and ethical question still remains: is it acceptable to tolerate something which is proven to damage both the health and judgement of individuals, and can also affect relationships with families, friends and the wider society?

There are now several experiments being conducted across Europe in an effort to contain heroin addiction. In Switzerland, since 1994, 1,000 of the country’s 33 heroin addicts have been prescribed pure heroin. The aim is to stabilise the health of addicts and prevent them from using heroin in public, thus taking their habit away from the black market.

Swiss officials claim that the experiment is working because crime is down, However, addicts are now becoming dependent on prescription heroin and hopes of weaning them off the substance have quickly faded.

The Police Federation disputes that legalisation would cut crime. This assumes that the powerful international drug cartels would simply fade away into the night. More likely scenarios are that they would fight to maintain their lucrative street trading.

Notes
1. The Government Reply to the Third Report from the Home Affairs Committee Session 2001-02: The Government Drug Policy: Is it working?, p.5
2. Home Affairs Third Report: The Government Drug Policy. Is it working?, Illegal Drugs, Drugs-related property crime. no.36 3.The Government Reply to the Third Report from the Home Affairs Committee session 2001-02: The Government Drug Policy. Is it working?, p.5
4 .Home Affairs Select Committee Report: The Government Drug Policy. Is it Working? Memoranda of Evidence – no.16 (submitted by the Criminal Justice Association)
5. Risk of Legalising Cannabis Underestimated: A Comparison of Dutch and Swedish Drug Policy. Criminal Justice Association, February 2002
6. The Dealers Think They’re Untouchable Now’, The Observer, 24 February 2002 and ‘London’s Drug Crime Hotspots Revealed. Evening Standard. 28 May 2003
7. Better Ways’. The Economist, 26 July 2001
8. Quoted in Home Affairs Select Committee Third Report: The Government ‘s Drugs Policy. Is Working’., no.60

Source: CIVITAS; Institute for the Study of Civil Society
The Mezzanine, Elizabeth House, 39 York Road, London SEI 7NQ
Phone; +44 (0)20 7401 5470 Fax: +44(0)201401 5471
Email; info@civitas.org.uk

The federal government recently announced that the growing potency of America’s most popular illegal drug, marijuana, and the number of kids seeking help to get off the drug (one in five users) worried them so much that they were soliciting new marijuana-research proposals and urging local law enforcement to crack down on those who sell the drug.

The pro-marijuana lobby was furious and immediately charged the feds with fear-mongering and clamoring to protect their (not so glamorous, actually) jobs in Washington. Their cries rested on claims that more potent marijuana is not tantamount to more dangerous marijuana and that the rise in the number of treatment beds for marijuana users is due to criminal justice referrals, not the drug’s harmfulness.

But the evidence shows the government may indeed have it right. The pro-drug movement, fuelled with the motivation to legalize harmful substances and angry at the attack on its values of “drug use for all,” is putting kids at risk by downplaying the known dangers of marijuana.

Although not as destructive as shooting heroin or smoking crack, marijuana use is unquestionably damaging. Today’s more powerful marijuana probably leads to greater health consequences than the marijuana of the 1960s: Astonishingly, pot admissions to emergency rooms now exceed those of heroin. Visits to hospital emergency departments because of marijuana use have risen steadily, from an estimated 16,251 in 1991 to more than 119,472 in 2002. That has accompanied a rise in potency from 3.26 percent to 7.19 percent, according to the Potency Monitoring Project at the University of Mississippi.

More potent marijuana is also seen as more lucrative on the market. Customs reports claim that a dealer coming north with a pound of cocaine can make an even trade with a dealer traveling south with a pound of high-potency marijuana. It makes sense that people pay more for stronger pot because the high is better.

A flurry of very recent research studies – concerning withdrawal, schizophrenia and lung obstruction, for example – have also shown marijuana’s unfortunate consequences. These conclusions were not being reached in the ’70s and ’80s (legalizers often point to the Nixon-commissioned Shafer report, which said nice things about the drug as evidence of marijuana’s harmlessness), because marijuana from that era was weaker and less dangerous than today’s drug. The May 5 issue of the Journal of the American Medical Association reported that the number of marijuana users over the past 10 years stayed the same while the number dependent on the drug rose 20 percent – from 2.2 million to 3 million.

And although a majority of kids in treatment for marijuana are referred there by the criminal justice system, it still remains only a slight majority – about 54 percent. The rest is self-, school or doctor referral.To paint the picture that the reason marijuana dependence looks higher is because of the criminal justice system is disingenuous (especially because most people who use only marijuana never interact with law enforcement as a result of that use).

Some still argue that it’s wrong to arrest kids and force them into treatment. It seems like the government can never win: If it arrests and locks people up, legalizers kick and scream that we’re not giving users “alternatives to incarceration.” If it arrest kids as a way to get them help, and not as a punishment mechanism, all of a sudden the government is giving in to George Orwell.

It’s too bad that pot apologists don’t see what most parents do see: Marijuana is a harmful drug with serious consequences, and mechanisms – even a brush with the law to help a user realize that what he’s doing is harmful – to help stop the progression of use should be seen as a good thing. That’s not government propaganda. That’s common sense.And it may save a few lives.

Source: Kevin A. Sabet recently stepped down as senior speechwriter to America’s drug czar, John P. Walters. A Marshall Scholar, he is writing a book on drug policy and is also a Ph.D. candidate at Oxford University.

Patterns of HIV transmission among different classes of injection drug users have been characterized.

In a recent study from the United States, the “prevalence of HIV and associated risk behaviors were assessed among three groups of heroin users: long term injection drug users (LTIDUs), new injection drug users (NIDUs), and heroin sniffers (HSs) with no history of injection.”

“HIV seroprevalence was similar among NIDUs (13.3%) and HSs (12.7%),” while “LTIDUs had almost twice as high a level of HIV infection (24.7%),” reported D.D. Chitwood and coauthors at the University of Miami. “After including drug use and sex behavior variables in logistic regression models, both drug and sexual risk factors remained in the models.”

“Attributable risk percent (APR) from injection for HIV infection among injection drug users was estimated to be 55.7% for LTIDUs and 5.8% for NIDUs,” published data indicated. “High-risk sex behavior plays an important role in the prevalence of HIV among drug users and accounts for nearly all the infection among NIDUs.”

“Both injection and sexual risk behaviors need to be stressed in HIV prevention and intervention programs aimed at drug users,” the researchers concluded.

Chitwood and colleagues published their study in the Journal of Psychoactive Drugs (Prevalence and risk factors for HIV among sniffers, short-term injectors, and long-term injectors of heroin. J Psychoactive Drug, 2003;35(4):445-453).

Source: Health & Medicine Week March 1, 2004

Today, the Florida Department of Law Enforcement (FDLE) released the Florida Medical Examiners Commission’s Report on Drugs Identified in Deceased Persons. The report contains information compiled from autopsies performed by medical examiners across the state in 2003. During that period there were approximately 170,000 deaths. According to the report, 6,767 individuals examined had drugs in the system.

Medical Examiners collected information on the following drugs: Ethyl Alcohol, Amphetamines, Methamphetamines, MDMA (Ecstasy), MDA, MDEA, Alprazolam, Diazepam, Flunitrazepam (Rohypnol), other Benzodiazepines, Cannabinoids, Carisoprodol/Meprobamate, Cocaine, GHB, Inhalants, Ketamine, Fentanyl, Heroin, Hydrocodone, Hydromorphone, Meperidine, Methadone, Morphine, Oxycodone, Propoxyphene, Tramadol, and Phencyclidine (PCP).

The report reveals a decrease in the incidences of Heroin in 2003 when compared with 2002. This decrease includes cases in which the drug levels found during the exams were both lethal and non-lethal. In addition, the report indicates the three most frequently occurring drugs found in decedents were Ethyl Alcohol (3,467), all Benzodiazepines (1,794), and Cocaine (1,614). The drugs that caused the most deaths were Cocaine, all Benzodiazepines, Methadone, Oxycodone, Ethyl Alcohol, Heroin, Alprazolam, and Morphine.

The three drugs that were the most lethal, meaning more than 50 percent of the deaths were caused by the drug when the drug was found, were Heroin (88 percent), Fentanyl (63 percent), and Methadone (60 percent). The report also reveals that excluding newly tracked prescription drugs, prescription drugs of Benzodiazepines, Hydrocodone, Methadone, and Oxycodone continued to be found more often than illicit drugs in both lethal (60 percent) and non-lethal (55 percent) levels during 2003.

“This report shows that with few exceptions, both illicit and prescription drugs persist in being a continuing and increasing danger to the citizens of the State of Florida,” said FDLE Commissioner Guy Tunnell. “While heroin deaths have decreased over the past year, most of the other illicit and prescription drug deaths remain at an alarming level for the year, although decreases are noted during the second half of the year.”

“The results from this report are evidence of the immense danger associated with drug abuse and more specifically prescription drug abuse,” said Jim McDonough, Director of the Florida Office of Drug Control. “Far too many Floridians are dying from prescription drugs. To address this problem Florida will continue to strengthen its efforts in the areas of prevention, treatment, and law enforcement in order to reduce the unacceptable amount of deaths that result from the abuse of prescription drugs.”

Source: http://www.fdle.state.fl.us/publications/examiner_drug_report_2003.pdf ;May 26, 2004

WA has one of Australia’s highest rates of illicit drug use. The most common drug was cannabis which was used reularly by 16.5 per cent of people aged 16-24. WA also had the biggest number of injecting drug users – almost 20,000 people. After cannabis the drugs most commonly used by young people were amphetamines (8 per cent) and ecstasy (7 per cent) – BUT THE USE OF HEROIN WAS NEGLIGIBLE! ( Two things here: So why would anyone want to set up a Heroin Clinic in WA ?  Prohibition works, albeit through natural drought, with the very hard work of our Federal Police. Illicit drugs were responsible for one per cent of deaths in WA in 2001 and drug-related visits to Perth hospital emergency departments more than doubled from 1993 to 1998.

The one per cent of deaths from illicit drugs is very serious because that means that, contrary to tobacco harm, 36 years of life is lost for each deceased person.

Drugs such as cannabis, heroin and amphetamines cost the State $610 million a year, according to a new WA Health Dept and Drug and Alcohol Office report. So how did we get to be in this shocking mess? I know that it is through an unholy inter-sectoral Partnership with all Health, Crime Research, Law Enforcement and Epidemiology. The evidence of deception and Public Health corruption lies within the 1997 NDS Evaluation by Single and Rohle. At a cost of over $20 million to Australian taxpayers nearly 32 million needles were distributed in “That’s not to say the problem is limited to the United States or North America,” he added. “It’s a problem found in a number of countries around the world.”

Source:To-days “West” reports; March 2004

DRUG misuse is leading more young people than ever before to show up at hospital A&E departments with chest pain.

While chest pain is perceived as being associated with older generations, the increase in heroin and cocaine abuse is becoming more and more evident in hospitals as large numbers of young people present with symptoms mimicking heart related illnesses as a direct consequence of drug misuse.

“We are seeing a big increase in the abuse of cocaine and heroin and we are now also seeing it show up in our hospitals,” said Tony Barden, regional drugs co-ordination with the HSE South East.

“Young people are now coming in with chest pains association with drug misuse. This is an indication of heart and lung damage but we are just in our infancy where damage is concerned. The picture of just how serious the problem is will become a lot clearer over the next 18 months or so.”

Tony Barden says that serious health problems associated with cocaine and heroin abuse will only get worse and lead to more heart and lung complaints among those who use drugs.

“A lot of people are going out and having seven or eight, even 10 pints, and then mixing it with cocaine,” he said. “We need to be moving towards a scenario where we are working on testing for drugs as well as alcohol among motorists.”

The recently published Drugs Misuse Report 2005 showed that while the numbers coming forward for alcohol abuse treatment had dipped, there had been a marked increase in those seeking help for heroin and cocaine.

Data from the Liaison Officer at WRH, contained in the report, showed that 409 people admitted to the hospital after collapsing, hurting themselves or suffering serious ill-health, were then referred onto addiction services.
Source: Waterford News & Star 2nd June 2006

Methadone substitution has long been used as a treatment for heroin addiction. But a new 33-year follow-up study has found that equally satisfactory results are possible without recourse to long-term prescribing of opioids.

Until now there has been no long-term study of people addicted to injected heroin who have been treated without the prescribing of methadone substitute.

This study set out to look at the outcome for patients treated for injected heroin 33 years after they were first seen, and 26 years after they were first followed up. Measures included sustained abstinence from heroin, continued maintenance on methadone and deaths.

86 people with heroin addiction first seen in 1966-67 in a small town in the south-east of England were studied. At the time of diagnosis the patients were aged between 16 and 20, were single and living at home with their parents. They all injected heroin.

All the patients were treated in the local general psychiatric service, which differed from most other UK services for heroin addiction in that it did not prescribe methadone substitute for 23 years after recruitment of the patient group (i.e. until 1989).

The main provisions of the service were immediate help in times of crisis; personal counselling; regular follow-up; an ongoing relapse prevention group; and symptomatic relief with drugs other than methadone.

The first follow-up took place after six years. At that assessment 13% of the patient group were judged to have stopped using any illegal drugs, 51% were still injecting, 6% had died and 12% had experienced alcohol-related problems.

For this follow-up study, 45 of the original patient group were located and their clinical state assessed using multiple sources, including personal interviews with some of them.

It was found that 42% of the group had been abstinent for at least 10 years. 10% were taking methadone and were classified as addicted. 22% had died. 8% of the group could not be located.

The authors of this study compared their results with three other British studies. They found the death rates comparable (15%-20%), but the rates of abstinence and methadone dependency differed.

The researchers comment that it is encouraging that trend studies show agreement that the proportion of people maintaining sustained abstinence rises with time, whilst the proportion of those still addicted declines.

One worrying feature, however, is the high proportion of premature deaths, mainly due to overdoses. As overdose with opioid drugs is often mentioned as a cause of death, there is a need for closer monitoring of these drugs, and regular health screening and intervention to reduce premature deaths.

The advantages of long-term substitute prescribing of methadone are obvious in terms of increased social stability and reduction of crime. However, the researchers were struck not only by the number of premature deaths in people taking methadone, but also by the negative perceptions of life among those who are currently prescribed this opioid.

The findings of this study highlight the need to compare outcomes between people prescribed substitute drugs for addictions, and those who are not.

Reference Nehkant H, Rathod R, Addenbrooke WM and Rosenbach AF (2005) Heroin Dependence
in an English town: 33-year follow-up. British Journal of Psychiatry, 187, 421-425

Need for meth treatment programs growing dramatically

Two new surveys released today by the National Association of Counties (NACo) show that methamphetamine abuse continues to have a devastating effect on America’s communities.

One survey, “The Effect of Meth Abuse on Hospital Emergency Rooms,” revealed that there are more meth-related emergency visits than for any other drug and the number of these visits has increased substantially over the last five years. The second survey, “The Challenge of Treating Meth Abuse,” showed that the need for treatment programs for meth addiction is growing dramatically and lack of funding is an obstacle in meeting this demand.

“There is no question that meth abuse is having a devastating effect on America’s communities,” said Bill Hansell, President of NACo and Commissioner in Umatilla County, Ore. “Some states have enacted legislation that has been effective in reducing the number of local labs that produce meth. But officials in two of those states have said that the number of users has not been reduced. We still have a fight on our hands. The vast majority of meth being used today is being imported into our country. We have to find a way to treat those people that have become addicted and prevent others from becoming addicted.”

Both surveys were conducted in late 2005. The results of the emergency room survey are based on 200 responses from hospital emergency room officials in 39 states. Most of the hospitals participating in the survey are either county owned or operated. The second survey asked 200 county behavioral health officials in 26 states about drug treatment programs and how they have been affected by the meth epidemic.

A factor affecting treatment programs is that treatment for meth addiction is different from other drugs. 54% of the officials reported that the success rate is different and 44% said that the length of time in the program is longer for meth addicts. Meth users seeking treatment require special protocols and longer treatment periods than users of other drugs. said. “We hope that he will recognize the need for more funding for treatment.”

This is the second set of surveys that NACo has released on meth abuse. In July 2005, NACo released the results of two surveys it conducted on the impact of meth. The surveys reported responses from county sheriffs and police departments and from child welfare officials. The survey of 500 sheriffs and police departments showed that meth abuse is the top drug problem facing counties in America.

In an alarming number of meth arrests, there is a child living in the home. Often, these children suffer from neglect and abuse. 40% of the counties where child welfare activities are the responsibility of the county reported that out of home child placements have increased because of meth, according to the second survey released in July.
Source: www.naco.org January 18, 2006

According to the just released 46-nation Council of Europe annual report, both countries have a higher proportion of cocaine users than anywhere except Spain and Ireland tops the League’s Table for ecstasy. About 185 million people worldwide – 3% of the global population – use illegal drugs. Nearly 80% use cannabis, 20% use ecstasy and amphetamines, 7% use cocaine and 3% use heroin. The situation is now so bad that Europe is the most profitable market in the world for production and trafficking of drugs…
Source: The Scotsman, January 25, 2005.

This study examines the extent to which alcohol and drug use is related to violent and nonviolent criminal activity among adolescent males. Based on data collected from 312 youthful offenders at a public juvenile facility, the findings reveal that in comparison to marijuana and heroin, alcohol use is more strongly and consistently associated with both violent and nonviolent offenses. When other factors are introduced into the analysis, the results show that while an adolescent’s criminal history and racial identity are relatively more important in predicting criminal activity overall, the effect of substance use (especially alcohol and marijuana) continues to be present.

Source: Dawkins, M. Adolescence 32(126):395-405, 1997
Availability: Marvin P Dawkins, Department of Sociology Coral Gables FL 33124

New research clearly shows that longer-term methadone maintenance therapy (MMT), combined with some psychosocial counselling, is a far more effective treatment for heroin addiction than is simply the temporary use of methadone to detoxify patients and reduce drug craving, even when the detoxification is coupled with much more intensive psychosocial therapy.

“The findings from this study clearly indicate that methadone maintenance is an effective treatment for heroin addiction,” says Dr. Alan I. Leshner, NIDA Director. “This is yet another indication that MMT should be used more widely as a treatment option for heroin addicts. Currently, only about 20 percent of the 810 000 diagnosed heroin addicts in the U.S. receive this treatment.” Study director Dr. Sharon Hall says, “The goal of this study was to determine whether short-term methadone-assisted detoxification, when enriched with intensive psychosocial services and aftercare, could provide an effective alternative to MMT. Our results show that no matter how ideologically attractive the notion of a time-limited methadone treatment for heroin abusers, longer-term methadone maintenance treatment is far more effective.”

The researchers interviewed 179 heroin- or cocaine-dependent volunteers monthly, for 12 month after their admission to the study. The volunteers were randomly divided into two groups methadone maintenance treatment group and a methadone detoxification group. The MMT group was eligible for 14 months of methadone maintenance, followed by a 2-month detoxification. Participants in this group were required to attend substance abuse group therapy 1 hour per week for the first 6 months of maintenance, and 1 hour per month of individual therapy.

Patients in the detoxification group received methadone only for the first 180 days of their treatment. During their first 6 months of treatment, the detoxification group was required to attend 2 hours per week of substance abuse group therapy; 1 hour per week of cocaine group therapy (if they had tested positive for cocaine when admitted to the study); a series of 14 1- hour, weekly substance abuse education classes; and 4 weekly individual therapy sessions. This group also received 6 months of aftercare services that included weekly individual and group psychotherapy and liaison services with the criminal justice system, medical clinics, and social service agencies, but no additional methadone after the first 180 days of their treatment.

Study results showed that more patients in the MMT group remained in treatment for longer periods of time (438.5 days vs. 174 days) and had lower heroin use rates than did shorter-term methadone detoxification patients. Of the MMT group, 77 out of 91 patients were still in the study at the 12-month mark, while only 57 of 88 methadone detoxification patients were still in the study. MMT also resulted in a lower rate of drug use-related HIV-risk behaviours and a lower level of criminal activity.

Source: Study Director Dr. Sharon Hall, “ Methadone Maintenance versus 180-day Psychosocially-Enriched Detoxification for Treatment of Opioid Dependence: A Randomized, Controlled Trial,”
The Journal of the American Medical Association (JAMA 2000;283 :1303-13 10) March 2000.

Although methadone maintenance is an effective therapy for heroin dependence, some patients continue to use heroin and may benefit from therapeutic modifications. This study evaluated a behavioural intervention, a pharmacological intervention, and a combination of both interventions.

Methods
Throughout the study all patients received daily methadone hydrochloride maintenance (initially 50 mg/d orally) and weekly counselling.
Following baseline treatment patients who continued to use heroin were randomly assigned to 1 of 4 interventions:
(1) contingent vouchers for opiate-negative urine specimens (n29 patients);
(2) methadone hydrochloride dose increase to 70 mg/d (n=31 patients);
(3) combined contingent vouchers and methadone dose increase (n=32 patients); and
(4) neither intervention (comparison standard; n=28 patients). Methadone dose increases were double blind.

Vouchers had monetary value and were exchangeable for goods and services.
Groups not receiving contingent vouchers received matching vouchers independent of urine test results.
Primary outcome measure was opiate-negative urine specimens (thrice weekly urinalysis).

Results
Contingent vouchers and a methadone dose increase each significantly increased the percentage of opiate-negative urine specimens during intervention.
Contingent vouchers, with or without a methadone dose increase, increased the duration of sustained abstinence as assessed by urine screenings.
Methadone dose increase, with or without contingent vouchers, reduced frequency of use and self-reported craving.

Conclusions
In patients enrolled in a methadone-maintenance program who continued to use heroin, abstinence reinforcement and a methadone dose increase were each effective in reducing use.  When combined, they did not dramatically enhance each other’s effects on any one outcome measure, but they did seem to have complementary benefits.
Source: Author Kenzie et al published in Arch Gen Psychiatry. 2000;57:395-404

Back to top of page

Powered by WordPress