|Can we trust addiction medication?
By Sacha Z. Scoblic, The Fix
No one should be paying $30,000 to go to what amounts to three 12-step meetings a day; a true treatment center should be providing something medically significant. So says Dr. Mark Willenbring, one of the nation’s staunchest advocates for a lot more medical intervention and a lot less spiritual journeying in the rehab and recovery industry. Otherwise, it’s like “going to an oncology center and getting prescribed a macrobiotic diet instead of chemotherapy,” says Willenbring, who is the founder and CEO of ALLTYR, which provides drug and alcohol addiction treatment based on cutting-edge science and research.
Willenbring is by no means opposed to traditional 12-step programs in day-to-day life. He’s all for creating a robust arsenal for battling addiction; he’s interested in anything that yields results. But as you might expect from the former director of treatment and recovery research at the National Institute of Alcohol Abuse and Alcoholism, he is opposed to the prevailing resistance to, and ignorance about, the treatment of addiction with prescription drugs. The available medicines are admittedly limited and only partly effective. But no other approach—from the 12 Steps to psychotherapy to meditation to fire-walking and soul retrieval—has made a notable dent in this disease. Success rates remain low, and to exclude the tool of medical intervention from the treatment toolbox is, Willenberg says, “a crime.”
Medicating addiction remains at best a tricky business. The more intricacies science reveals about the strange brew of compulsion and pleasure, endorphins and dopamine, neuro-this and neuro-that racing about in the human brain, the more elusive any single fix seems. (And no one is even talking cure.) Individually, each brain is unique—like snowflakes. Collectively, our brains are blizzards of synapses and information that make targeting addiction less hit than miss, less science than art.
Unfortunately, what works for one addicted brain—decimating both physical cravings and more slippery psychological urges—may not for another, and what works to mitigate one opiate may not for another. But for Willenbring, who is both a clinician and a researcher, this challenge is cause for tailoring the best treatment to the right patient and, most definitely, not for throwing out the prescriptions with the heroin. We have a few excellent tools at our disposal—some new drugs and some oldies-but-goodies (here’s looking at you, methadone!)—that make the task of at least managing the chronic, lifelong disease of addiction easier and, in the process, save lives.
Disulfiram, better known as antabuse, has about as much user-friendliness as that acrid polish nail-biters shellac their nails with to dissuade them from chomping down. But, instead of getting a bitter taste when indulging the bad habit, disulfiram will cause an alcoholic to have: “headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety.” Disulfiram is all about infusing the alcoholic with deep physical regret once they start drinking; it’s like the morning after a tequila binge when you say, “I’m never drinking again”—only the feeling starts ten minutes in and makes your worst hangover look like a mere cough and sniffle.
Tiparamate, or topmiax, is an anti-convulsant typically used for seizure-control in epileptics. But doctors prescribe it off-label for alcoholism because it can decrease the pleasurable effects from continued consumption of alcohol. This isn’t purely coincidence: Anticonvulsants reduce seizures in part by “decreasing abnormal excitement in the brain.” Where disulfiram punishes with a bang, tiparamate saps pleasure with a whimper.
Then there’s naltrexone, or nalmefene, an opiate antagonist that strives to block the pleasurable effects of alcohol and opioids like heroin and Oxycontin right at the neuroreceptors in the brain that register them, while simultaneously ebbing the cravings for drugs and alcohol altogether. There’s none of the sickness of disulfiram and the diminishing returns (This isn’t getting me high!) are offset by reduced cravings (Meh, who cares). This one-two punch is promising, but studies show only a little over 10% of patients are helped by naltrexone.
And that’s pretty standard when it comes to alcoholism, according to Willenbring. He likens disulfiram, tiparamate, and naltrexone to antidepressants, which have been shown to be much less effective over time than initially expected, requiring switching from one to another or adding on “booster” drugs and otherwise hoping for the best. Willenbring says that, in his experience, disulfiram, tiparamate, and naltrexone “reduce relapse in the neighborhood of 20%.” “Now, that’s not too bad,” he says. “It’s a tough disease, and I’ll take every arrow in my quiver—even if it’s just a leg up.” Magic bullets they ain’t.
If there’s any magic to be had, it may not be in the specific medication used itself but in how we think about their use. Best example? Long-term opiate-replacement therapy. For years, buprenorphine and, for decades, methadone have been prescribed to treat opiate addiction, for everything from heroin and morphine to Vicodin and Oxycontin. Buprenorphine and methadone are themselves opiates—though they are less-addictive, producing a less-intense high and none of the most dangerous side effects. They substitute for the addict’s drug of choice, replacing the effects and limiting the withdrawal.
The newest serious opiate-fighting drug is Suboxone, a mixture of buprenorphine and naloxone, which binds to opiate receptors to mimic the effects of, say, heroin, but then resists abuse by making the addict sick if they try to shoot up the Suboxone. This two-pronged approach has been shown to provide substantially better outcomes in young adult users than in those patients who just received the standard short-term detox and counseling. What’s more, addicts taking Suboxone were “less likely to use opioids, cocaine and marijuana, to inject drugs, or drop out of treatment.”
“These findings should reassure and encourage providers who have been hesitant to offer extended Suboxone treatment,” said National Institute on Drug Abuse Director Dr. Nora Volkow.
Unfortunately, as of 2008, just 8% of all treatment facilities nationally were even certified opioid treatment programs—that is, allowed to administer these medications. That means, of course, that a whopping 92% of treatment facilities offered no opiate analgesics to their heroin patients at all. “So now we have this crime where thousands of addicts are going to abstinence-only-based treatment for opiates,” Willenbring says. “But not one study validates this approach—while there are hundreds of studies demonstrating the effectiveness for Suboxone and methadone.”
Offering severe opiate addicts medication is important because the startlingly acute concentration of opiates found in heroin or Oxycontin create profound neuroadaptations, sometimes permanently impairing the brain’s ability to control use. So for many severe opiate addicts, Willenbring says, simply taking away the addictive substance results in an internal chemical deficiency. And no higher power can fill that hole.
What’s more, when used consistently and for the long term, opiate replacement therapy is in fact very successful. Despite the prevalence of abstinence-only models, patients taking buprenorphine can integrate this drug into their daily routines and live otherwise-drug-free healthy lives; but, according to one study, once off the drug—even after tapering and counseling—close to 100% of patients relapsed. Opiate replacements can literally be the difference between using and not using, between high-quality and low-quality mental health, and finally between life and death. “It’s highly effective, clearly save lives, and stabilizes people,” says Willenbring, adding that contrary to popular myth, these patients are not “high” on their new medications, just normal.Willenbring is a proponent of the long-term use of opiates to treat addiction—possibly even lifelong (if no serious side effects get in the way or if science delivers a new breakthrough). For many people, Willenbring says, it’s a matter of “once you develop dependence, it’s there for life.” That means Suboxone, buprenorphine, and methadone may be the only chemical shield between an addict and relapse. Without the presence of opiate replacements, death rates shoot up to about 50% in severe addicts—mostly from overdoses. Not giving a severe opiate addict meds is “like telling a diabetic to go to a support group,” Willenbring says. When you have an insulin deficiency, a thyroid deficiency, what do you do? You replace it. Sometimes for life. And today that’s the answer so far for managing a chronic lifelong opiate deficiency.
Which isn’t to say, it’s a perfect answer. Maintaining opiate replacement therapy in the long run usually means taking a daily dose in pill form. And that means entirely likely events—like a missed pill, a forgotten prescription refill, or a lost vial—can be the thin line between a patient and a deadly relapse. And for some addicts, the sheer plausibility of forgetting to take a pill would be excuse enough to use again. (Desire for a new way of life? Meet the cunning and baffling addicted brain.) Imagine staying on top of that for the rest of your days.
One new drug, Vivitrol, an injection of naltrexone that lasts 30 days, both eases the daily pressure to take one’s meds and ups the ante on the necessity to remember to do so in awkward 30-day increments. It’s a variation on a theme; not a new story.
As for real, new exciting scientific breakthroughs, don’t hold your breath. The science has slowed down—both in the private sector and in government. This is at least in part due to high hopes for watersheds in brain-imaging science and the human genome—innovations that would explode the science of addiction!—that never quite panned out. According to Willenbring, unraveling the genome—let alone divining helpful solutions to mental diseases like addiction—proved to be spectacularly more complex than scientists first appreciated. (Remember when we were going to decode the human genome in a decade?) Conversely, brain imaging, says Willenbring has been “grossly oversold.” All of those “very seductive pictures” of brains reveal something a bit more ho-hum: When “thinking changes, the brain changes.” Willenbring calls brain imaging the new phrenology.
So, all of the excitement many of us have heard about vaccines for addiction has tapered off. “Industry has pulled back from investing in these medicines because new science isn’t there,” says Willenbring. That’s why there are a lot of useful tweaks of existing drugs—such as Vivitrol or Suboxone—but nothing like a game-changer. “We need more investments,” says Willenbring. “Otherwise we’ll continue to see a bunch of these ‘me too’ drugs.” We can only hope that this dry drug pipeline does not persist as long as it has for the treatment of depression and related mental health problems, which has seen only variations in the Prozac-type class of antidepressants for three decades. Willenbring says that, in his view, the most promising place to look for an addiction advance is in drugs that affect stress-response systems.
Until then—or until some other “next big thing”—three things are certain. One is that, as Willenbring says, “The more we learn, the more complicated it gets.” Another is that the potential market for a cure—tens of millions of people—is only growing. And the third? The deep resistance of many in the recovery community to the medical treatment of addiction will do nothing to bring new and better drugs out of the lab and into the brains of the people who need them.
Read about Senator Rockefeller's proposed legislation
|Petition to the Government of Iran
|Physicians for Human Rights is urging the Iranian government to end the incommunicado detention of Drs. Arash Alaei and Kamiar Alaei, two Iranian physicians who have reportedly been detained in Iran by Iranian authorities. The physicians, who are brothers, were apparently arrested at the end of June, 2008 and their current whereabouts are unknown. The doctors are experts on HIV/AIDS and have worked for many years on HIV/AIDS prevention and treatment activities in Iran and internationally. PHR calls on the government of Iran to disclose their whereabouts, provide them access to lawyers and family, and either to charge them with an internationally recognized crime or release them immediately.
Physicians for Human Rights is urging the Iranian government to end the incommunicado detention of Drs. Arash Alaei and Kamiar Alaei, two Iranian physicians who have reportedly been detained in Iran by Iranian authorities. The physicians, who are brothers, were apparently arrested at the end of June, 2008 and their current whereabouts are unknown. The doctors are experts on HIV/AIDS and have worked for many years on HIV/AIDS prevention and treatment activities in Iran and internationally. PHR calls on the government of Iran to disclose their whereabouts, provide them access to lawyers and family, and either to charge them with an internationally recognized crime or release them immediately.
Dr. Kamiar Alaei is a doctoral candidate at the SUNY Albany School of Public Health and is expected to resume his studies there this fall. In 2007, he received Master of Science in Population and International Health from the Harvard School of Public Health.
His brother Arash is the former Director of the International Education and Research Cooperation of the Iranian National Research Institute of Tuberculosis and Lung Disease.
Since 1998, Dr. Arash Alaei and his brother, Kamiar Alaei, have been carrying out programs dealing with HIV/AIDS, particularly focused on harm reduction for injecting drug users in the war-torn province of Kermanshah, on the West Coast of Iran.
Since 1986, the Alaei brothers have sought the integration of prevention and care of HIV/AIDS, sexually-transmitted infections, and drug-related harm reduction, into Iran's national health care system.
In addition to their work in Iran, the Alaei brothers have held training courses for Afghan and Tajik medical workers and have worked to encourage regional cooperation among 12 Middle Eastern and Central Asian countries. They were key organizers of a tri-national meeting in 2004 in Tehran to discuss harm reduction and substitution treatment in Iran, Tajikistan and Afghanistan. At that meeting, Iran's programs proved to be inspiring role models for the region, according to medical experts who participated in the meeting. The Drs. Alaei's work has addressed the most disadvantaged populations and patients in the country.
You may access the petition at http://188.8.131.52/~iranfree/. Please sign it and distribute it broadly.
The following announcement was sent by the Canadian Harm Reduction Network.
Please visit their website, check it out and support them by becoming a member.
YOUR HELP IS NEEDED!
Addiction Recovery Insurance Equity Campaign
Our new Advocacy section, I am happy to say, has now grown into it's very own page!
COME CHECK IT OUT!!
Support Full Funding for Drug Courts!
The President has requested $69.86 million for the Drug Court
Discretionary Grant Program for Fiscal Year (FY) 2007. field. A
letter to the House Appropriations Committee in support of full
funding for drug courts has been authored by Rep. Neil Abercrombie
(D/HI) and Rep. Tom Osborne (R/NE). We are hoping to have 100
members of the House of Representatives sign this letter before it
is delivered to the House Appropriations Committee in May. We need
Please take a minute to send a letter to your Representative asking
them to sign on to this letter. NADCP is working towards a similar
letter in the U.S. Senate. After the drastic cuts in drug court
funding last year, it is more important than ever that we raise our
voices in unison!
Go to http://ga4.org/campaign/houseapprops to send your letter today.
Blueprint for the States
Policies to Improve the Ways States Organize and Deliver Alcohol and Drug Prevention and Treatment
Gary D. Helmbrecht, MD, FACOG, and Siva Thiagarajah, MD, FACOG
GREAT update for Nepal!
On 30th Oct 2007, Nepal witnessed a grand re-opening ceremony of Methadone Program in Tribhuwan University Teaching Hospital. Amidst controversies, the opening ceremony took place in the Hospital's conference room by the hands of chief guest, Home Minister of Nepal Mr. Krishna Prasad Sitaula.
Witness to the event speculated the ceremony as a historic event taking place in a country where drug users are openly abused by law enforcement and society alike. In a country where anti choice sentiments are still very popular. During his speech the chief guest and Minister of Home Affairs, expressed human prospective towards drug use and tolerant views towards harm reduction and its tools are seen as a major steps towards embracing the humane approach towards drugs problem in Nepal. It's an achievement for drugs and HIV activist of Nepal.
Methadone distribution started from 31st of OCT 2007 with the highly recommended Social Unit operated by NGO in Teaching Hospital premises.
Greater roles of UNODC in Nepal:
The minimum service coverage of below 5 % for drug users in Nepal, Universal access to harm reduction services seems like a far fetched dream.
Recent teaming up of Drug users Network "Recovering Nepal" with UNDP and UNODC for the re-implementation of Methadone program has been encouraging to witness.
Without the support of these UN agencies, such emergency response "the re-implementation of Methadone program" would not have been impossible.
Now, the start of Methadone program and already established Buprenorphine program by Youth Vision "From Margins to Mainstream Project"; the stage has been set for scaling up of these services for wider coverage. The ultimate goal now should be set for universal access to harm reduction services for drug users.
The positive attitude towards harm reduction services by the Government has showed that the future for harm reduction services is very bright for Nepal.
Read other articles about MMT in Nepal.... "Problems in Nepal"
"Kingdom of Nepal"
*Many thanks to Bijay Pandey, a WONDERFUL advocate in Nepal, who contacted me originally and has kept me updated throughout!
CONGRATULATIONS TO OUR DR. MARC!!
The 2007 American Association for the Treatment of Opioid Dependence (AATOD) National Conference recognizes outstanding contributions to methadone treatment by rewarding the Nyswander/Dole Award. MSO is THRILLED to announce that OUR Dr. Marc will be a recipient this time! Dr. Marc Kleinman, Regional Administrator/Clinical Director for Operation PAR clinics in Florida, is a PhD in Clinical Psychology and has worked with Methadone patients for over 30 years. Since we opened our doors here at MSO he has taken time out of his crazy, busy schedule to come here and operate his Real Deal forum ...where he has answered questions and given support to so many. He is also on our Board of Advisors and Directors.
Dr. Kleinman has been instrumental in establishing Methadone Anonymous (MA) groups throughout Florida . He is a member of the Addiction Consult Team for Hospice in South Florida and provides regular training to law enforcement and child protective services investigators. He is my mentor, at the top of my personal hero list, and I am honored to call him "friend".
At each AATOD conference, the award recipients are nominated and selected by their peers for extraordinary service in the opioid treatment community. These successful Award recipients have devoted themselves to improving the lives of patients in our treatment system. Dr. Vincent Dole and Dr. Marie Nyswander were the first recipients of this Award in 1983. The Association has been responsible for bestowing this honor since the first Regional Conference of 1984 in New York .
It is a great honor that this time the Nyswander / Dole “Marie” Awards will be presented by the children of Dr. Vincent Dole -- Vincent Dole III, Susan Dole and Bruce Dole.
Thanks for all you do, Dr. Marc... and...
*Come read the interview with Dr. Marc!*
Unfortunately, Dr. Marc was very sick with cancer and passed away at the end of July, 2008.
Please stop by his Memorial Page and sign the condolence book.
FOR IMMEDIATE RELEASE:
FEBRUARY 22, 2007
CONTACT: Mark Parrino
MEDICINE SAVING LIVES, NOT ENDING THEM
Recent headlines involving celebrities and methadone misuse unfairly undermine the long term safety and benefit of this life-saving medication in treating opioid addiction and reinforce negative public perceptions regarding methadone treatment.
The recent article in USA Today and numerous features in local and national media outlets have focused on the negative outcomes of the misuse of opioids by individuals who are not participating in supervised opioid treatment programs. While some reports do acknowledge the legitimate use of methadone in treating addiction, such references are often marginal. Unsupervised prescription and use of methadone for pain management that puts pills in the hands of uninformed patients, is completely different from the supervised and individualized approach that is practiced in medication assisted treatment (MAT) for opioid addiction.
Numerous scientific studies and evidence-based practices have shown conclusively that methadone, buprenorphrine and other federally-approved opioids have proven to be successful treatment options when used appropriately in clinically-approved settings where medication is monitored by licensed professionals, Mark Parrino, President of the American Association for the Treatment of Opioid Dependence (AATOD), stated. However, the unsupervised use of methadone or other opioids for pain management, obtained illegally or from physicians not specially trained in the use of these medicines, can result in the negative outcomes which surface in the headlines.
AATOD has called for a coordinated national response to reports of methadone associated deaths in line with the recommendations of the U.S. Department of Health and Human Services Report of February 2004. This landmark Report, prepared by a panel of federal and state officials and experts in the treatment of addictions, concluded that health professionals need better training in addressing pain and addiction and highlighted the need to develop a uniform definition in determining cases of drug-related mortalities. AATOD asserts that it is time to move these recommendations forward.
The truth is that medication assisted treatment helps individuals end the cycle of addiction and its associated destructive behaviors reuniting families and enabling patients to become independent and productive members of their communities, Dan McGill, AATOD Public Relations Committee Chair, noted. AATOD encourages and welcomes inquiries from all media outlets to focus on the positive role of medication assisted treatment in the practice of medicine and treatment of addiction.
A very familiar name to this organization/website is Sharon Dembinski. Sharon is our pregnancy guru and my personal hero, but in case you're one of the few that has not seen or heard me telling the world about Sharon......she is a Pediatric Nurse Practitioner, NAMA Certified Methadone Advocate and Lead Developer of the Program "Mother's on Methadone" (MOM) at Kent Hospital in Rhode Island. .....as well as practices at the Discovery House clinics also in Rhode Island in her "spare" time! She also has our Methadone Pregnancy Info and Support page here at the website. Yikes.....did someone say "spare time", lol???
That being said.....on with the alert. Sharon recently discovered an error in TIP 43 on morphine dosing for the treatment of neonatal abstinence syndrome (NAS). She alerted CSAT one month ago to this potential danger and the following is their response/alert. I would also like to take this opportunity to once again thank Sharon for her hard work ......making this her life's passion! Had Sharon not found this error....or....."typo" infant's lives could have been lost. THANK YOU, SHARON!!!