The Medical Model Discovers Heroin Addiction

Jill Littrell, PhD
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Heroin Epidemic

The United States is experiencing an epidemic of heroin addiction and a sharp rise in opiate over-dose death.  Contrary to addicts being introduced to opiate addiction through street heroin, 75% of new addicts became addicted through prescription opiates.  When the OxyContin becomes too expensive ($80/pill), people switch to the cheaper street heroin ($5-10/hit).  Nora Volkow of NIDA, Tom Frieden of the CDC, and Michael Botticelli of the President’s Office of Drug Control Policy have advocated the expansion of methadone programs and buprenorphine treatment to respond to the epidemic.  SAMSHA, the federal agency which regulates methadone maintenance programs, suggests that we call these interventions “Medication Assisted Treatment” (MAT) rather than opiate substitution programs so as not to stigmatize people.

SAMSHA’s New Rules

Methadone programs have been around since the mid-1950s in New York State.  Under the Narcotic Treatment Act of 1974, methadone maintenance clinics became legal in the United States, although states vary in state regulations.  What is new is that SAMSHA has effectively rewritten the rules on how methadone maintenance clinics are run.  Whereas the law of 1974 limited methadone to those who had been addicted for a year, the SAMSHA (2012, Tip 43) guidelines allow for those who are not physically dependent on opiates to receive methadone.  While initially the goal was to wean patients off, SAMSHA (2012) advises directors of clinics when a patient requests a dosage reduction that they should “educate” the patients on the importance of staying on their Medication Assisted Treatment.  There is no duration limit on MAT.  Moreover, there is no longer a limit on dosage.  Given that stress is a reliable precipitant to relapse in drug abusers, SAMSHA discusses increasing dosage during stressful times (see page 77, in SAMSHA’s Tip 43, Medication-Assisted Treatment).

Buprenoprhine is a Partial Agonist?

The newcomer on the scene for treatment of opiate addiction is buprenorphine.  The drug company characterizes buprenorphine as a “partial agonist” at a mu-receptor and an antagonist at a kappa receptor.  In the body, there are 3 types of receptors for opiates: mu receptors, kappa receptors, and delta receptors.  Mu receptors produce the pleasurable effects and the compulsion to use opiates.  Kappa receptors counter the mu-effects.  Upon hearing that buprenorphine is a partial agonist, I wondered “how?”  I’m always amazed at the amount of information available to biologists.  For almost all receptors, someone knows the shape of the receptor, the amino acids in the receptor that a ligand (neurotransmitter or drug) interacts with, the proteins in the body of the neuron that are influenced when the ligand binds, and the downstream effects on the ligand/receptor binding.  So what is making buprenorphine different from methadone, morphine, and OxyContin?  It did not take long to find out.

Turns out that buprenorphine not only interacts with the mu-receptor but also another protein called a “Regulator of G-protein Signaling” which turns off activity at the mu-receptor.  The problem is that tissues and brain areas vary in terms of whether the neuron contains the “Regulator of G-protein Signaling.”  As such, buprenorphine will only demonstrate an effect on some outcome measures but not on others.  Thus it will be a “partial agonist” on some measures but not on others. The case has been made that buprenorphine is less likely to produce an overdose via respiratory depression than other opiates.  However, all bets are off if buprenorphine is used with another drug.  Many people on buprenorphine die when they combine “bup” with alcohol.

Opiate Agonists Are Very Dangerous Drugs

Methadone and buprenorphine compete for the same enzymes as many antibiotics, antidepressants, and antipsychotics for their metabolism (removal from the body). As such the effective dose of methadone is much higher than when people are not on these other medications.  In addition, methadone can result in cardiac arrhythmias because of a change in electrical conduction in the heart (QTc prolongation), although buprenorphine is supposed to be a safe on this outcome.  However, many antidepressants and antipsychotics can also increase QTc prolongation.  With regard to danger associated with cardiac arrhythmias, the probability of an adverse event increments with each additional drug.  Studies of opiate overdoses find that antidepressants, benzodiazepines, and antipsychotic drugs are associated with lethal overdoses.  The SAMSHA guidelines recommend screening for co-occurring disorders.  The Tip 43 guidelines do mention those medications which compete for the same enzymes as methadone but don’t discuss risks associated with multiple medications that increase risk of cardiac arrhythmias.

Dilemma of Other Addictive Drugs in Methadone Maintenance

It has been known for a long time that many heroin addicts do not limit their drug consumption to heroin.  When people are in methadone maintenance, they often don’t quit using cocaine, marijuana, or alcohol.  (In terms of drug interactions, there is some suggestion in the literature that concurrent use of marijuana actually decreases the opiate dosage required to curtail cravings.)  While SAMSHA does suggest that Opiate Treatment Programs screen for other drugs, SAMSHA is unclear about what should happen if the urine tests positive.  (According to SAMSHA instructions, we are to use the language ‘tests positive’ rather than ‘dirty urines.’)  SAMSHA is clear that patients should not be dis-enrolled from the program.  Sanctions can include limiting take-home dosages of methadone.  They also suggest switching the patient to naloxone.

Naloxone, Seriously?

When I read the suggestion to switch to Naloxone, I was really confused.  SAMSHA seems to want to avoid an addict’s use of street heroin at all costs.  Naloxone will displace all opiates (buprenorphine, heroin, morphine, methadone) from the mu-receptor but won’t induce any signaling in the neuron.  In fact, naloxone will displace natural opiates (endorphins) from the receptor as well such that even any placebo effect on pain suppression is lost.  In terms of listed side effects, naloxone causes anxiety, a decrease in pain tolerance, joint and muscle pain, and induces immediate withdrawal signs if taken by someone who is dependent on opiates.  There’s a history of poor compliance among addicts with naloxone.  SAMSHA knows this.  Why would they introduce a drug option that could undermine all their efforts to set up a self-sustaining high compliance program?

To be fair here, naloxone does decrease relapses in alcoholics who are trying to maintain sobriety.  So we can call it “evidence-based treatment.”  Drug addicts are not going to crave their drug(s) of choice when taking naloxone.  The problem is that with naloxone patients aren’t going to want anything else either, such as food, going to work, etc.  (Yes, naloxone has been considered as a potential treatment for obesity.)  Of course the drug companies don’t include measures such as lethargy and apathy when they publish the drug trials, but the impact is clear in the animal literature.

So we’re back to the real problem of what to do about methadone and “bup” patients that use other drugs.  Especially when used in combination with alcohol, methadone and buprenorphine can induce overdose.  Another complicating factor with the SAMSHA’s goal of increasing the numbers on MAT is the paucity of knowledgeable clinicians who approve of MAT in America.  About 45% of the non-physician clinicians in substance abuse treatment in this country are persons in recovery.  They generally are strong adherents to Twelve Step Principles.  The goal for Twelve Steppers is freedom from all mood and mind altering drugs.  They don’t generally approve of MAT.  Historically, physicians in Addiction Medicine often are recovering people as well.  So where are all these substance abuse professionals to staff methadone maintenance clinics going to come from?  The danger in by-passing the current work force and developing a new work-force is that it will take some time for the new recruits to develop expertise in detecting when a client is abusing alcohol and knowing the population.

Methadone for Pain Versus Methadone for Addiction

Ironically, while the government’s response to the opiate epidemic is to increase MAT with more liberal dosing practices, they are also more closely monitoring pain clinic doctors.  At a recent International Opioid Conference I attended in Boston, most of the presenters were doctors working in hospice or pain clinics.  The lawyers talked about pain-management doctors being entrapped by clients working for the DEA and then facing criminal charges and fines.  (The director of prestigious Stanford pain-management clinic was recently visited by the DEA.)  At the conference, the director of the Stanford clinic talked about his clinic’s response to the DEA scrutiny.  They have developed very rigorous screening batteries to detect those pain clinic patients most likely to become addicts; they have developed elaborate informed consent procedures entailing a 20 minute video presentation for all prospective patients; they implemented drug screening procedures with point of care methods followed by laboratory screening involving very expensive assays.  The bottom line is that costs have increased dramatically, further contributing to the cost of medical care, which presently is already the most expensive system in the world.  This all seemed ironic to me, because if given a pain patient is indeed an addict, then the protocol is to refer to methadone or buprenorphine treatment for addiction.  Once the patient becomes a methadone or buprenorphine patient, doctors are to “educate” the patient about the dangers of ever trying to become abstinent.  Moreover, the rationale for methadone is that the dosage is to be sufficiently high so that tolerance develops such that heroin, at any dose, will fail to produce an effect (opiate blockade).

Given that buprenorphine is now in a clinical trial to treat medication resistant depression, we’re probably going to have a lot of people taking opiates.  Then we’ll have many dilemmas over what to do if the patient escalates the “bup” dose without permission or uses an unapproved medication.  Physician may wonder whether they need parole officer training.  But, whatever the outcome for the patient, more money will be spent on drugs, monitoring, and auxiliary personnel.  Thus, the U.S. is embarking on another big experiment with the drug companies and another big increase in the cost of medical care in this country.

* * * * *

References:

Leece, P., Cavacuiti, C., Macdonald, e. M., Gomes, T., Kahan, M., Srivastava, A., Steele, L., Luo, H., Mamdani, M. M., & Juurlink, D. N.  (2015).  Predictors of opioid-related death during methadone therapy.  Journal of Substance Abuse Treatment, in press.

McCance-Katz, E. F., Sullivan, L., Nallani, S.  (2010).  Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a reviewAmerican Journal of the Addictions, 19(1), 4-16.

Zedler, B., Xie, L., Wang, L., Joyce, A., Vick, C., Brigham, J., Kariburyo, F., Baser, O., Murrelle, L.  (2015).  Development of a risk index for serious prescription opioid-induced respiratory depression or overdose in Veterans’ Health Administration patientsPain Medicine, in press.

Zedler, B., Xie, L., Wang, L. Joyce, A., Vick, C., Kariburyo, F., Rajan, P., Baser, O., & Murrelle, L.  (2014).  Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patientsPain Medicine, 15, 1911-1929.

38 COMMENTS

  1. Jill,
    I thought your article was a well written critique of the twisted logic of “treating” opioid misuse with medication assisted therapy. I’ve worked in the addiction field for over 30 years and have had similar concerns. The development of buprenorphine as an antidepressant scares me. It’s formulation in ALKS-5461 is essentially another chemical version of Suboxone. I think of it as the coming of a depression apocalypse. now people treating their depression will develop a dependency to a Schedule III opioid.

  2. Obviously a greed inspired policy, which is quite frightening. And since “75% of new addicts became addicted through prescription opiates” it strikes me as quite obvious the medical community is handing opioids out way too easily, and likely not properly informing patients that they are being given an opioid.

    I know I was prescribed one, but not told it was an opioid drug, instead it was called a “pain medication.” Thankfully, I rarely took it. But it did result in odd thoughts when I did take it. So I sought medical advice from four different doctors, and not one of them told me I’d been prescribed an opioid drug that could cause hallucinations. Instead, I was misdiagnosed with 3 “major mental illnesses” and railroaded into the “system.” I find it shocking that the medical community is unaware of the fact opioid drugs cause hallucinations.

    As it turned out, my PCP was paranoid of a malpractice suit because her husband had been the “attending physician” at a “bad fix” on my broken ankle. And the second opinion doctor wanted to cover up the sexual abuse of my small child for her ELCA pastor and friends. And the two psychiatrists seemingly just like to railroad healthy people into the psychiatric system for profit. Pardon my disgust at the greed and complete lack of ethics of the mainstream medical community.

    • For people who suffer with real pain, an opiod can make their life worth living. I think it’s important not to throw the baby out with the bathwater. I suffered pain with MS that made it difficult for me to sleep and had me thinking that it wasn’t a matter of “if”, but “when” I would seek assisted suicide. Fortunately, I found another solution to lower the pain to the point that I could live with it and gladly stopped the oxy. I think it’s very important not to turn this problem into a witch hung.

        • And peck. Yes, witch hunt is always good to bring up. So’s Carrie Nation and what Mother Nature intended. I suppose my approach was oblique in comment terms. But along this obvious front it connects well enough if you work at it. I hope you are doing better and feeling good, and nice to see you back.

      • I don’t have a problem with a patient being prescribed an opioid ethically, with informed concent regarding the potential for addiction being apart of the informed concent, prior to the patient being prescribed an opioid. But the opposite of this is happening within today’s medical industry.

        And I do have a problem with those main stream doctors prescribing the opioid drugs, without inforrming the patient they’d been put on a mind altering drug, and then misdiagnosing the known adverse effects of the opioids as the invalid DSM “mental illnesses” to cover up easily recognized medical malpractice and medical evidence of child abuse, which is what happened to me.

        • S. E., True. We have to home in on the side of this you’re attending to mostly in your comment, and emphasis on good informed consent is the perfect point to make explicit. The chief problem that is symbolic of the nature of the professional failings that add to the lack of informed consent epidemic has to do with physician’s not really very often at all understanding or caring to keep up to date on the difference between psychological dependence and addiction. One problem would be that all they think counts is what comes to them with their name on it as Dr. Y or X. The humanities sources on addiction like Jim Carroll’s Basketball Diaries and de Quincy’s Confessions of an English Opium Eater also lead you closer to keeping the facts straight, as long as you are not just a liar and don’t care what help you need to be. Since the problem here is really stubborn-ness and too much power, not the dangers of what people decide for themselves if they get information and have freedom to choose their way, responsibly, according to conscionable laws.

        • Hi Someone Else – Just wanting to let you know that I meant to let you see that your statement got me up to speed because of how you connected with the meaning of empowerment in knowledge. I had intended not to explain the big picture so much as put the “other” half of the err on the safe side position into focus in terms that you introduced first. Unfortunately, as much as I love these conversations about controlled substances, that doesn’t keep me getting disgusted with myself when some passing traffic triggers a flashback sequence that sends my motor reflexes into action like it was fifteen years ago with me reacting to evade some riding mishap. This also sort of wipes my mind clean. Your carefully thought out comment hear provoked some good rational considerations of what some callers to an open line NPR show on this issue told me about both the lack of knowledge problem with opiates and doctors, their exaggeration of what suits themselves best to believe, and the view that pain can wait. So, if my statements don’t make literal sense enough, it’s because when my concentration disappeared, I just thought what I knew and said something. Like if you are in a workgroup where nothing exact has to get said. But I meant it. You are an accepting person, and also like to keep the facts straight, so please understand that my intentions were along the lines of that approach to. If we can’t meet doctors as equals with our best ideas and meaningful sources of information, so that they care to think of us as individuals and their equals, too, we are lost. And we can’t get as far with the asymmetry of their power to decide what is best for us versus bringing us to see what our real options are more definitely, and actually counselling us about those without prescribing. We could get the drugs we wanted for ourselves and don’t need their monkeyshines in the way is my position.

  3. Jill,
    Thanks for this. I have to say, I’ve got a slightly different take on this. We’ve funded a M.A.T. program in our county for about 10 years now and have seen more advantages than disadvantages.

    To be clear, there are different ways to operationalize M.A.T. and some are horrible and I wouldn’t recommend. The reason I can agree with the M.A.T. label is that, done correctly, the medication (We use primarily Suboxone) is only given when the person is involved with treatment. From a very practical point of view the drug (Suboxone) allows the person to “not feel sick” and they’re able to participate in treatment, able to work, go to meetings, able to do any number of “socially necessary” things. This information comes from over a hundred client interviews. A successful program however has to have a great working relationship between the prescribing physician and drug/alcohol treatment team. This is something that is not always happening. We’ve not seen the issues you describe of complications with persons on the Suboxone but also abusing other substances (alcohol) though I don’t doubt that happens.

    In keeping with medication optimization principles, folks are started on the lowest effective dose (so they don’t feel “dope” sick) for the shortest amount of time. Most folks are titrated off by two years. Our county, like our State and other States is facing quite a problem with opiate abuse/dependence. M.A.T. is the most effective approach we’re aware of. It’s certainly not perfect and not everyone does well but we’ve yet to encounter a more effective option. If anyone knows of one – please suggest.

    We certainly need to do more on the prevention/education end of things. Getting rid of Pharma’s direct to consumer marketing might help. Teaching the benefits of pain, both physical and psychological, may be helpful so we’re all not so inclined to immediately suppress discomfort. Pain is after all a message sent by our bodies. Listening might not be such a bad idea.

    • Perhaps, the doctors and medical practitioners should be upfront about the fact “pain meds” are opioid drugs with their patients, and confess that opioid drugs cause odd thoughts and hallucinations, rather than denying this reality to cover up their medical mistakes?

      • Someone on drugs, is still on drugs no matter what you call them, Methadone, Suboxone, Subutex, DXM, all drugs are drugs. No matter whether the get them from a psychiatrist, a nurse or a drug dealer.

        When you legally string someone on drugs, that’s what you do. Over time the body doesn’t like drugs, and builds up tolerance. And when tolerance gets high, then, most addicts will get treatment, knowing that next time around they can get high again. This results in lots of OD’s, when people leave treatment early.

        But addicts typically come into treatment, when their use is about, just using to keep from being sick, and not getting high again. Long term addicts those with 30 year histories of Opiate use, typically use programs, to clean up a while, lower tolerance,, and then in a couple of years, start chipping again.

        Usually psychiatrists know very little about street drugs, about Opiate Street life, and how addicts live, and what they do. How easy it is to get prescriptions that can be sold, like Xanax, Klonopin, Ativan.. and many others.

        Usually in Methadone maintenance, people will still use other drugs, making it easier to get loaded, rather than just keep from getting sick. These programs, are notoriously easy to manipulate. There are supposed to check for track marks etc… Do UA’s, etc, but still dirty tests happen all the time. And depending on the situation, programs tend to carry people with multiple dirty tests. Even in probation, they do the same because it means another jail bed, and more paper work. And Drugs are relatively easy to get in prison.

        Its been my experience that with these programs, as time goes on there is less scrutiny of users, activities. Addicts build up trust, and learn how to gain confidence, and once they have it, well it gives them more license.

        I’ve seen lots of programs come and go over the years, but I have yet to see a real understanding of what makes people addicts, Usually what is see is lots of administrators, and program operators making money.. And there are billions of dollars to be made off addicts. And lots supposed ex addicts running these programs.

  4. Very interesting article. I’m wondering if anyone here has experience of working with people using the herb kratom to try and detox off opiates. There have been quite a lot of stories of people using this herb to help them through both methadone and heroin detox. I have worked with a few people who have found it effective. It is also addictive in its own right but appears much easier to discontinue than prescription opiates.

  5. Jill and David

    Interesting article with many provocative points. You might want to read for critique my 2014 blog titled “The Manufacture and Maintenance of Oppression: A Very profitable Business” – you can access it above under writers or here.

    https://www.madinamerica.com/2014/04/manufacture-maintenance-oppression-profitable-business/

    The article leaves out the following important points:

    1) the opiate epidemic has origins in the 5th vital sign campaign promoted in the middle and late 1990’s by the pharmaceutical industry and certain medical leaders in pain medicine. This made it more mandatory for doctors to check pain levels at every visit and opened up doctors to punishment if they failed to prescribe all these “safe and non-addictive drugs” like oxycontin etc.

    2) the fifth vital sign campaign led to a new profitable industry and proliferation of pain clinics around the country where high numbers of pain drugs are dispensed creating the conditions for prescription abuse on a major scale. Clinics that for the most part create new addicts and actually lower the pain threshold for most people who use these drugs for an extended period of time – example “opiate induced hyperalgesia.”

    3) the opiate overdose epidemic (resulting in a huge number of deaths) is also principally fueled by the rise in medically induced benzodiazepine prescription and dependency/addiction. Benzos combined with methadone and suboxone tends to mimic a heroin high. Benzos plus heroin or other opiate magnifies the effect of all the drugs on the individual using them. OVER 30% OF DEATHS from opiate overdoses involves the use of benzos. I believe that most opiate addicts know how to handle their opiates but get into serious trouble when they combine these drugs with other sedative hypnotics, especially benzos – remember Heath Ledger and Phillip Seymour Hoffman.

    4) methadone and suboxone programs are highly profitable and principally a form of social control over a potentially volatile section of the population; they do little to stem the tide of addiction. They don’t call methadone the “orange handcuffs” for nothing.

    5) methadone accounts for 5% of the opiate prescriptions but is involved in one third of the opiate related deaths.

    6) suboxone is a very popular street drug with high amounts of its pills and strips sold to addicts as a way to avoid getting strung out or going to rehab. This may prevent people from hitting a “bottom” and seeking treatment to become abstinent. There is little evidence (that I know of) that people are successfully tapering off after a year. Read the forums online about suboxone and you get a clear sense that the doctors and clinics that dispense this drug do not know how to get people SUCCESSFULLY off of it.

    7) while Twelve Step Programs use to discourage any drug use (including psych drugs) they have (for the most part) in recent years accommodated themselves to Biological Psychiatry, and the use of methadone and suboxone. After all we can’t forget that they are based in a “diseased based” paradigm of so-called treatment.

    8) ANY drugs that perturb the endorphin receptors in the brain would seem to open the door for future mood disturbances and mitigate a person’s ability to experience pleasure, and perhaps have a negative effect on a person’s natural frustration-pain tolerance levels.

    9) all just more reasons for us to fight for major revolutionary systemic changes in society and put psychiatry in the dust bin of history; the sooner the better!!!

    Richard

    • On point number 4) Instead of my saying that “methadone and suboxone… does little to stem the tide of addiction.” I would rather make the much stronger point that these programs do more harm than good and actually create conditions to maintain and expand addiction problems in our society!!!

      Richard

      • But you see, it’s a rationalization. It’s the one that they want for society. If a person gets the drug from the “street”, that person is a drug addict. If they get it from a “doctor”, then they’re sick and in treatment. It’s all about taking something that has a dark and “scary” image in the minds of many people and turning it into something that is more psychologically soothing to them. And, of course, as long as there is money in doing it, efforts will be made to expand it.

  6. Jill- Way to get on the issues front to back. The little mention of correspondence of results in animal studies is the right twist in the research side for all this, too. But that’s definitely not to miss saying that your quick delivery of the inside scoop on the recruitment and retraining measures implied by new regs is particularly great to have spelled out as well. You might believe my side of the story from the Breggin empathic conference in Michigan a couple of months back, and find it relevant considering the DEA side of the story here. That is the most outstandingly impressive story of great counselling work was from a self-trained for the job physician. (Breggin likes to suggest non-professional equivalency is attainable for plenty of counselling work.) Dr. Tom Ryan, pediatrician is steadily and as he tells it, very pleasantly working to counter the ADHD epidemic where he lives, from his position at the most viable entry point for keeping the story straight. He also describes himself as a full-fledged libertarian in the social causes arena. He said the he had simply resolved one night at home with his wife, who is also in pediatrics, to stop giving ADHD prescriptions and start explaining without exception that there was no such thing. He henceforth had proceeded to demonstrate in his offices that kids would listen to him and behave well in front of their parents if he was firm, respectful, and authoritative in their eyes, and his self-arranged promotion and implementation of this therapeutic-engagement measure was sitting at 100% success to date. Of course, the counselling generally had to get directed to not letting the parents lie to themselves about what the child’s sudden good behavior meant. The numbers were still climbing in the middle double digits for him, but he shows no interest in looking back and so he is bound to stand out like a real opponent of the system, more every day. He also assured me that his notion of the corrective way to go with all pharmaceutical abuse is to aim for total information availability and no prescription needed type of access, resulting in no in-office sales of proven efficacy that the doctor then endorses on the spot. Full deregulation, I take it, to keep the doctor tail from wagging the Pharma dog back into their offices over and over. Then the slick undermining of the doctor-client relationship can’t happen as we see it is bound to in the current environment, and also so as to ensure de-mystifying arrangements for any kind of drug dispensing arrangements–mass anti-addiction remedial treatments not excepted. What would that do here? Why is it scary? What kind of solution is the traditional regulatory model of picking and choosing of licensed authorities and the assigning of outlets–according to special privileges for these special people who then get to have their special regulation- worthy franchises?

  7. What you’re describing is insanity. Substituting one drug with another drug is not going to treat addiction. But that is not the problem for pharmaceutical companies – actually getting people off the drugs would be.

    This problem is specific for US by the way. European countries regulate opiate prescriptions very tightly and they are usually given only to terminally ill patients when the risk of addiction is not really an issue. Given the fact that opiates are not very good in treating low-level chronic pain over the long-term anyway it sounds like a reasonable policy.

  8. ” Physician may wonder whether they need parole officer training. ”

    Opiates were not my thing but God forbid I ever have to get “unaddicted” to anything again.

    Call me selfish but I am not willing to treated like a criminal with all that drug testing to save others. You want to drink or take drugs with your medication assisted treatment or at rehab or in outpatient go ahead and do it.

    Drug testing makes people want to drugs more (forbidden fruit syndrome) and prevents them from learning to use all the other relapse barriers they teach.

  9. When you have a prescription, its medicine. When you don’t, its a drug. Ugh. I’m all for keeping people on safer forms of opiates. I mean, a schedule III Rx pill versus injecting heroin? Yes, Rx the pill. In terms of cost:benefits, I would imagine that maintaining people, rather than focusing on 0 drug use, works better and more cheaply.

    I just wish there was a way to empower people, rather than either maintaining them or punishing them. But then everything would have to change, especially our attitudes (in the US), which are still extremely punitive and harsh, compared to many other countries. We’d have to look at social factors that lead to deviant behavior, including drug abuse, and see about…I dunno…adressing them, lol. I think one big reason the medical establishment has been able to take control over more and more of our lives, I think more so in the US than in a lot of other places (I could be wrong…) is that doing so makes some people a lot of $$$ and also effectively turns widespread, socially rooted problems into individual “issues,” so things just keep on going as usual.

    Until and unless lots of people start taking a deeper, more honest look at our society…I guess the best we can hope for is maintaining people on their chemical(s) of choice.

  10. Loved your article.

    “In terms of listed side effects, naloxone causes anxiety, a decrease in pain tolerance, joint and muscle pain, and induces immediate withdrawal signs if taken by someone who is dependent on opiates. There’s a history of poor compliance among addicts with naloxone. SAMSHA knows this. Why would they introduce a drug option that could undermine all their efforts to set up a self-sustaining high compliance program?”

    This is one of the main reasons drug substitution hardly ever works, someone on Methadone, or Suboxone is still addicted.

    The small amount of Naltrexone is easily overwhelmed but increasing dosage levels of Opiates. There are lots of OD’s on Suboxone.

    Treaters don’t get it, they don’t seem to understand that addicts are already suffering because they are short of natural endorphin production internally. Using any opiate keeps this suppressed. One of the problems of having treatment run by psychiatrist, they think that treatment consists of giving out more drugs. Drugs that have different names are still drugs.

    Acupuncture is a much better solution. For detox, because then addicts aren’t given more drugs, in the withdrawal process.

  11. Richard, I don’t agree with your characterization but I get your point. We disagree on this one. I haven’t seen the problems you cite or are cited in the NY Times piece. The MAT program we have utilizing the Drug Suboxone has been useful for many (but not all) of the individual’s in the program by their report. Again, this is a MAT program which means the drugs aren’t given if the treatment isn’t occurring. And the goal is a two-year taper. This is different from a Methadone maintenance program or poorly run MAT program which do exist. I’m all about getting “upstream” and preventing the problem in the first place but give me some additional programs you’re aware of that are showing better results than MAT using Suboxone for persons currently trying to get off opioids.

  12. David

    All methadone or suboxone (opiate replacement) programs offer, or require or highly recommend some type of so-call “treatment.” I see some clients (for counseling) who are in both types of programs despite the fact that the clinic where I work does not provide these opiate drugs.

    The key question in all this is WHAT THE HELL DOES “TREATMENT” ACUALLY MEAN!? Most opiate addicts will take most therapists (and doctors) and eat them and up and spit them out for lunch.

    This is my way of saying that to exist for any length of time in opiate addiction requires very sophisticated forms of survival techniques to continuously procure these drugs and manipulate people around you to believe you do not have a problem or that you are on the verge of solving your problem or that you will die without their financial or domestic help. Opiate addicts often have the deepest levels of a denial system, more complex than any other form of addiction.

    I ‘ve been doing addiction work for over 24 years; 22 years in a city with high levels of opiate addiction; I think I have seen it all, so to speak. And while I believe I have helped many people over the years, quite often I feel like I don’t know what the hell I’m doing when I confront the complexities of what this system offers up as so-called treatment for opiate addicts.

    There is very little appropriate help for opiate addiction in our society. I don’t believe the “treatment” at your clinic is essentially any better than other mainstream approaches that fail most of the time. You sound like you are accepting the “lesser of the evils” and the overall narrative promoted by the leaders of Biological Psychiatry’s status quo. Our society has basically given up on the belief that opiate addicts can achieve abstinence, they have clearly opted instead for other methods of social control using methadone and suboxone; we must oppose this.

    Most programs discourage tapering until a long period has passed without any violations of protocol. Only a tiny percentage can meet these requirements. And then for those few who do taper to a low dose of these drugs there is NO WAY to acquire access to appropriate levels of smaller titrations of these drugs to avoid uncomfortable withdrawal symptoms. This is one reason why relapse rates are so high.

    Today’s mental health system (operating in a profit based economy) turns doctors into greedy entrepreneurs and vulnerable patients into commodities. Some suboxone doctors (with an allowed caseload of 100 patients) can make a half a million dollars a year. Patients without jobs and living in poor communities will also inevitably end up selling some of their suboxone to increase their personal income. This is how it goes within a class based society.

    This entire system must be dismantled in order to create the necessary conditions for real change and successful options for all people experiencing extreme forms of psychological distress, including those with addiction problems.

    Richard

  13. While decriminalization/legalization is necessary, it needs to be backed up with public health announcements explaining exactly why it is needed. Its not in any way condoning the abuse of addictors, it is done bc the alternative, the drug war, has made things infinitely worse on almost every level, to include making all drugs abundantly available to any & all that wants them. We need to pull LE out of the drug biz & that will free up a lot of resources currently chasing their collective tails. When the laws create more harm and cause more damage than they prevent, its time to change the laws. The $1 TRILLION so-called war on drugs is a massive big government failure – on nearly every single level. Its way past time to put the cartels & black market drug dealers out of business. Mass incarceration has failed. We need the science of addiction causation to guide prevention, treatment, recovery & public policies. Otherwise, things will inexorably just continue to worsen & no progress will be made. The war on drugs is an apotheosis of the largest & longest war failure in history. It actually exposes our children to more harm & risk and does not protect them whatsoever. In all actuality, the war on drugs is nothing more than an international projection of a domestic psychosis, it is not the “great child protection act,” its actually the complete opposite. We need common sense harm reduction approaches desperately. MAT (medication assisted treatment) and HAT (heroin assisted treatment) must be available options. Of course, MJ should not be a sched drug at all.