Tag Archives: heroin

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Chronic pain #I forget

The CDC has a new set of recommendations for chronic pain.

I will write about them. I have to read them first. Hurts too much, right now, the election, and all the pandemic fighting. Stress people and you see what they are really like.

My church has melted down into a huge fight. I was in a chorus singing instead of being in a meeting. Apparently there is a group that says brown people have “taken over” the national organization of the church. Um. Hello. That is discrimination. Does the color of the skin matter if it is a good leader? Why are people insane? I filled out a county survey on drug use today. I know we have methamphetamines and heroin in our high schools because patients have told me. But then I get to the race question. What race am I? I checked OTHER and wrote HUMAN. The race bullcrap is NOT SCIENCE. I haven’t done any genetics testing. I DO NOT KNOW WHAT RACE I AM THOUGH I LOOK WHITE.

It is important for medicine in that there is proven discrimination with less screen health services offered to “brown” people, whatever the heck “brown” people means. I wish the heavens would turn us all the same color over night. Or perhaps blind us. That is not nice of me and I do not care.

I am glad that this horror came out in my church. Because now the discrimination is out in the open. And the committee has sent out a message saying NO. We WILL stay part of the national organization. We WILL not give in to this discrimination. AND I SAY HOORAY AND BLESSINGS ON THEM.

Here is the new CDC set of recommendations for chronic pain: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm . You can read them yourself.

I read to this sentence so far: “Approximately one in five U.S. adults had chronic pain in 2019 and approximately one in 14 adults experienced “high-impact” chronic pain, defined as having pain on most days or every day during the past 3 months that limited life or work activities (5).”

Part of me is horrified and part of me is calm. Because pain is a part of life. Pain, love, joy, fear, it’s all part of our emotional evolved systems to survive, right? If God is love, God is also pain and fear. It is not a split. It is both.

This song is a love song. But to me, it’s a love song from heroin to a woman. One lovely day, a place where there is no pain. There will be pain on the return, the withdrawal. I have patients say, “You need to get me pain free.” My reply was “I will not get you pain free. Pain free is dead. Or at least, they can no longer tell me if the next form hurts.” In this song, “she won’t let on, that the feelings have got so strong.” Addiction, opioid overuse.

I took the photograph of Elwha yesterday. He is my relaxation mentor.

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Avoid death by fentanyl

Some of the West Point Cadets overdosed on March 12, 2022 are still on ventilators. They took what they thought was cocaine. It was laced with fentanyl and they all nearly died.

Not only that, but two of the bystanders who did not use the drug, but did cardiopulmonary resuscitation, CPR, also succumbed. They stopped breathing because they got a heavy dose of fentanyl giving CPR.

Fentanyl is being laced into ANY illegal drug, and being 50 times stronger than morphine, it can kill you by making you stop breathing. Also, fake pills are made. Do not buy pills on the street. And I don’t care if it is your friend. Remember that when someone is really addicted, the addiction is running the show. They need the drug more than your friendship. People will lie, steal and sell drugs. Protect yourself:

Please read the website at

https://www.cdc.gov/stopoverdose/

If you or a family member uses illegal drugs, please get naloxone to have at home. If the shot is given in time, very soon after the person stops breathing, it can save their life.

Here: https://www.cdc.gov/stopoverdose/naloxone/index.html

If you give someone a dose of naloxone CALL AN AMBULANCE. Because it is short acting and the opioid may take back over. The person may need to be on naloxone iv! You must get them to an emergency room as fast as possible.

Our local Health Department was giving out naloxone shot kits in the last few years for free. Our local police carry naloxone. If you are on prescription opioids, you should be offered a prescription for naloxone and your family should be instructed on how to use it.

And teach your children well. I interviewed my patients for years on the age they started smoking. Most of my patients started at age nine. One woman said age seven. We have to start talking to children about drugs and risk and not smoking anything by third grade. That is the horrific reality.

And Bless the punk band The Offspring for reaching out to opioid overuse people and saying, “Get help. You can do it. Please do not die.”

The Opioid diaries live by the Offspring.

And they too are inimitable.

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Update on Addiction 2022: Mouse Cocaine Addict Studies

Recent experiments on mice are giving us interesting information on addiction, and suggesting that l-dopa may be able to control/mitigate addiction. This lecture about how dopamine works in addiction using a mouse model (poor mice) blew me away. The mice fell into two categories: maintenance users and vulnerable addict rats. The study of the dopamine postulates a reason for the difference.

20th Annual Drug Conference Washington State from 2019

Notes from lecture 3: Paul Phillips PhD
Dopamine Neurotransmission in Substance Use Disorders: from Preclinical studies

For a long time there were no agreed upon animal models: rats don’t steal money from other rats to buy drugs. However, rats do get addicted and this can be studied.

There are features in rats, rat behavior and rat brains that might translate to humans.

1. Basic discoveries about dopamine neurotransmission in substance use disorders is discussed.
A neurotransmitter study checking every ten minutes in brain examines two areas: dorsal and ventral striatum. Dopamine is increased in the area between cells from the administration of substances “first time use” in animal models: cocaine, alcohol, methadone, cannabinoids, nicotine, amphetamine, morphine. This is the first clue re addictive drugs, whether there is an increase in dopamine intraneuronally. The endpoint is that direct effect on dopamine receptors, which has a different brain mechanism for each drug. Cocaine blocks the receptor that reuptakes the drug into the neuron. Methamphetamines and amphetamines reverse the reuptake pump, makes the receptor spit it out. Gaba neurons act to inhibit dopamine neurons, normally mu receptors on the gaba interneurons and the opioids block those. Ethanol has another mechanism of action. It changes inhibitory activity, lowering the inhibition of the gaba interneurons. Nicotine REALLY messes with multiple receptors and multiple cells, but main effect is increase of dopamine in the striatum.
Increased dopamine in human brain relates to the feeling of being high: brain PET scans show amphetamine and dopamine bound less, reduction in the binding. Subjects were substance abusers. Subjective questioning of how high they felt correlated with the amount of dopamine released on the PET scan. Methylphenidate was used in that study. Canada study: cocaine increases dopamine in human brain by PET scan.
Addiction does lead to changes in the brain, on both PET scans and functional MRIs.
PET scans measuring dopamine binding in the brain show that the baseline in brains of substance abusers differs from non-abusers. The levels of dopamine receptors is lower in the substance overuses and there is lower binding than controls: heroin, alcohol, meth, cocaine (and obesity and ADHD…..). (This has been known for opioid overuse and chronic use for a while: the brain cells withdraw receptors, so the same dose does not reduce pain because there are less receptors. The change in receptors appears to vary in different subjects. Recovery is very slow.)
The role of dopamine has been confusing. It is known that it is involved in the cue evoking cocaine “craving”, but is also involved with — satiety. This has been confusing and contradictory — what does dopamine do but also the dynamic structural signaling.

2. The animal studies demonstrate that the dopamine signals are phasic.
Rat studies measure changes in dopamine minute to minute electrochemistry for sub-second dopamine detection in vivo, which means we can measure changes in dopamine in real time. There is an identified output signature for dopamine levels, measure in 8.5 millisecond, ten measures per second.
The rats were voluntarily taking cocaine. The cocaine was available in a liquid with a light that would come on when it was available, for two hours daily. The animal presses a lever when the light cue is on and gets an infusion of drug. With the ten measures per second, the first and smaller dopamine response in the brain is before the lever is pressed. That is, there is a rise in dopamine BEFORE the rat presses the lever. If stimulated dopamine, the animal would go press the lever. Then there is a larger reward dopamine signal when the drug hits.
Dopamine is the chicken and the egg: signal to USE and signal that has ARRIVED.

3. Changes that take place with drug use
There is a signal change over time that correlation with features of addiction.
The mice had an implanted brain electrode, tinier than human hair, 7 microns, biocompatability — don’t make the brain attack it as a foreign object so rat brain keeps working. The study involves tyrosine hydroxylase, a precursor of dopamine. A food pellet response of the tyrosine remains the same at 1, 2, 6 months so can monitor substance abuse brain changes. These are cocaine addicted rats. They get cocaine via a nose poke of a button when it lights up. Pellets, not iv (they learn that faster). There are 2 ports to nose poke: active and inactive. The signal that cocaine is available and the pellet is active: a light comes on for 20s and then drug arrives. Can take again after 20sec. The rats titrate cocaine use: not continuous. They pace cocaine use, wait for it to wear off. Over time, drug use 1 hour access daily… slow increase, relatively stable.
When the access is bumped up to 6 hours access daily… rats do increase use — first of 6 hours, escalation of drug use faster — in humans development of tolerance.
With 1 hour cocaine availability, the dopamine response to the cocaine in the rat brain is lower by the 2nd and 3rd week, slowly decreases, then with 6 hours of access the loss of dopamine is very robust, happens faster, dopamine signal gets smaller every time.
Rats long access: were there individual differences? Yes, metric, nonescalated vs escalated groups so like humans. 60 escalated 40 didn’t and stayed stable. So essentially I named these “Vulnerable addict rats” and “Maintenance rats”.
Which group most motivated to take cocaine? The study ups the price of cocaine for rats, how many times are you willing to receive the drug? The escalating animals made more responses, “worked harder” for the drug. The escalator brains, Vulnerable Addict Rats, had just about a complete loss of dopamine signal by three weeks.
The nonescalators had more stable dopamine responses, retained some dopamine brain function.
The greater the loss of dopamine, the more the animal escalates the drug use.
The Vulnerable Addict rats would use cocaine to the exclusion of food, water, sex and sleep and died early.
This is a feedback loop. The rats get a success signal when the drug is taken — but over time don’t get the success signal because dopamine receptors are gone — so take more. In the Vulnerable Addict escalators, the dopamine signal of anticipation goes down in response to the cue, the drug effect takes a little longer but the pharmacological response to drug actually remains.
They tried giving l-dopa, a parkinson’s drug and if treat, the rats get a restoration of the dopamine cue — pharmacological response didn’t change — how does this affect behavior? A daily shot of l-dopa and the animals on the l-dopa have less escalation. (wow!) The l-dopa didn’t affect the nonescalators/maintenance rats. When they remove the l-dopa in the vulnerable addict rats, the animals jump to higher use and so the brain changes are happening even when it is masked by the l-dopa but does not stop the brain changes.
They ask the question: can you reverse escalation? With the the l-dopa, they use less.
Dopamine signaling to take drugs (the anticipation cue when the light goes on) decreases in animals that escalate drug taking, but does not change in animals with stable drug taking.
Restoring dopamine signaling with l-dopa can prevent or reverse escalated drug taking.
This dopamine signaling….

4. Mechanisms — drug cue elicits dopamine.
So this is about triggers. This is a paired drug cue: the light signals that the drug is available. If a non-contingent drug given to animal, the light still elicits drug seeking. Using a naive animal: pair reward with cue, over time the cue will increase dopamine.
(hmm. Facebook. blogging. Instagram. “You have mail”. )
The initial addiction has a short access time. One hour out of 24. When this is changed to long access, some animals escalate vs non escalation — as take more and more drug, the response to the drug taking cue gets larger in the escalators/Vulnerable Addicts. Presentation of cue — by investigator vs animal:
If elicits drug seeking than the dopamine response gets larger to the cue over time.
If the cue is given but other choices of liquid, then the dopamine response gets smaller in some rats — so terminating drug seeking. The Vulnerable Addict Rats had a larger and larger dopamine craving cue spike, the longer they were off the drug. The the increase in the cue drives craving and decrease drives seeking — so both bad.
The conclusion in the rats is that craving for drug, related to cues, is dependent to length of time off drug. The longer the rats were off the drug, the larger the dopamine spike when the cue light comes on. The measure of cue behavior gets worse …. 60 day study in rats, this is not physiological withdrawal, is prolonged way beyond the withdrawal.
1. noncontingent
wait a day or wait a month
work harder to get drug, harder a month out
reaction to drug cue presentation, enhanced over time
at start of drug small signal to drug cue
long access then cue gets bigger
same a day after stop drug
but huge in a month after no drug — huge dopamine response

(my thought was then swearing. how do we treat this?)
In chronic drug use the cue signal shrinks which reinforces drug use AND stopping increases the cue response which ALSO reinforces.

5. Implications for treatment
treating rats
They discuss a virus with promotor that affects dopamine cells, light activated ion channel, cells release dopamine when light stimulated
only activates release of dopamine, to understand mechanisms.
For the self administered nose cue …. In the nonescalator maintenence rats, dopamine cue response stays fairly robust, stimulate those cells and no change.
In the escalator/vulnerable addict rats… if do a virus stimulation of dopamine in the brain, more dopamine to cue boosted, so they use less cocaine and look like the non-escalators.
5th cue less dopamine than 1st cue: if put dopamine back then maintains the drug seeking.

What underlies the decrease in dopamine release?
When the animals use cocaine, dynorphin goes up (kappa antagonist).
They injected a kappa receptor blocker — animal no longer escalate (not in humans at this time, don’t understand well enough) treating animals that are escalating, so the bad addict/vulnerable rats.
Most animals don’t escalate — but pretty serious amounts of drug cocaine so not abstinent.

For future
Dopamine diametric changes: dopamine may reduce consumption but might increase craving, so it is difficult to treat.
l-dopa — treatment — some studies, looking for abstinence, does NOT produce abstinence. Does not make abstinence worse. Says that promise seen relates to the status of the subject — helps with people who are still using (some) but doesn’t help increase or prolong abstinence. So could reduce harm but not abstinent….politically unpopular. Happier with turning alcoholic into a social alcohol user, but that idea is less popular/politically ok with cocaine/opioids (and especially meth).

They are studying mouse nosepokes for alcohol — reduced intake when the rats are on l-dopa.

There is a functional agonist for kappa receptors == buprenorphine, might have effects on drug consumption, speculation across different drugs.

Dynorphin is a stress related peptide, so does that signaling produce escalation of drug taking? So other stress drugs — like corisol, CRF, plan for more studies.

Question: Stress related hormones– babies in stress in utero and in stressful childhood have less dopamine receptors and need more dopamine for pleasure, susceptibility to drug addiction (ACE scores) so is still really early studying neurotransmitters.

Dr. Question: why do people do better with agonist therapy than abstinence in opioids vs other drugs? Answer: we don’t know….. yet.

further information:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1920543/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC80880/
https://archives.drugabuse.gov/news-events/nida-notes/2017/03/impacts-drugs-neurotransmission
https://nida.nih.gov/

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Songs to raise girls: Bessie the Drunkard’s own child

I am posting this from another site, originally posted November 2016. I am posting it because of a comment on a paper in my town about “homeless drug dealers”. It’s not the drug dealers that are homeless, it’s the addict. Ok, you can definitely have an addict dealer… But I worked hard to treat any kind of addiction, not only because of the patient, but also the family and especially the children. And every patient was a child once….

This is another temperance song that my mother taught me, learned from her father. Both of my mother’s grandfathers were Congregationalist Ministers in Iowa.

Out on the stormy night sadly I roam.
No one to love me, no dear pleasant home.
Dark is the night and the storm rages wild.
God pity Bessie, the drunkard’s own child.

Chorus:
Mother, O why did you leave me alone,
No one to love me, no dear pleasant home.
Dark is the night and the storm rages wild
God pity Bessie, the drunkard’s own child

We was so happy til father drinked rum.
Then all our trials and troubles begun.
Mother grew weary and wept every day.
Brother and I were too hungry to play.

Barefoot and hungry we wander all day
Looking for work, but “too small” they all say
On the damp ground to lay my head
Father’s a drunkard and Mother is dead.

Thus the two wandered, ’til one stormy night
Brother and sister both faded from sight
Then gazing at them, sadly I said
“Father’s a drunkard and Mother is dead.”

Cheerful, right? Again, I know the tune and only have the chorus memorized. My parents quit singing it in front of me so that I wouldn’t sing it at Show and Tell.

And small children shouldn’t hear this sort of thing, right? I don’t know. I learned an awful lot about the dark side of the world and danger from these songs. I found them helpful. I think they influenced me to be careful….

And think of the refugee children and children everywhere. This is still happening.

here: http://www.pdmusic.org/1800s/66fadamid.txt
and here: http://mudcat.org/thread.cfm?threadid=57166
The tune I learned is slightly different and darker than this: http://mudcat.org/@displaysong.cfm?SongID=6196
And some overlapping words with a different tune: https://www.youtube.com/watch?v=7ooDfYaH08E and https://www.youtube.com/watch?v=9KGiFkcxOus

The photograph is my maternal grandfather, F. Temple Burling, sitting on his grandfather’s lap. His grandfather was Morris Temple. My grandfather taught my mother this song and she taught me.

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Liars and the lying lies they tell

This blog post: hanging from a telephone wire intrigues me.

Why do the liars lie?

I disagree with Ms. Kennedy.

The liars lie for the same reason that addicts lie. They are not lying to you or to me. They are lying to themselves FIRST. They want to believe what they say.

“My marriage is perfect.”

“I love all my children the same.”

“I never make an error.”

“I talk to my mother every Sunday morning because we are so close and love each other so much.”

“I can see right in to your head.”

“I don’t care about anything.”

“I am happy all the time.”

Whew. A totally easy list to come up with and I could go on and on and on…. and so could you. When someone says something like this… I am always (fill in blank) or I never (fill in blank)… stop. Think. They want to believe it. They might like you to believe it too. They might even kind of know that it’s a lie and very convincing one but the best liars have convinced themselves.

I saw it in clinic all the time. Over and over and over.

It’s the glitter that gives it away. When they come in all glittery and sparkly and their eyes shine and they are too beautiful for words and they charm your socks right off…. check your wallet. They are an addict or a manipulator or they WANT SOMETHING FROM YOU. And there are people who just do it automatically. They lie all the time.

Whatever. When someone reminds me of my mother or my sister… or the other extremely well trained enablers on the maternal side of my stupid family…. ooooooo. The person has my full focused attention. Which thing is the lie? What do they want? What are they going to try to get out of me?

When I trained in buprenorphine treatment, the guy (enabler) that I was dating was horrified. “You can’t treat addicts!” he said.

“Why not?” I asked.

“They LIE.”

I laughed. “ALL patients lie. There are studies. They lie about whether they are taking their blood pressure medicine. They lie about how much salt they are eating. They lie about exercising. The first question I ask if someone’s blood pressure is too high, is “Are you taking the medicine?” More than half the time I get a sheepish, “Yeah, well, no, I ran out of it two weeks ago.” “Yeah, well, then I can’t tell if it’s working or not, can I? And you’ll have to redo the stupid labs once you have taken it for two weeks and come back for another check.” “Ok, ok, I get it.” If you lie to your doctor, well, you might get hurt. Tell them about the pills your friend gave you, tell them about the supplements, and that infected toe? Might help if you tell the truth about it. Even though it was when you um inserted well we were just, like he has an infected um. That is important information and changes which antibiotics I use plus now I want to check for chlamydia and gonorrhea and same sex male so we gotter talk about HIV prophylaxis and this is a 15 minute clinic visit? I am now running late and annoyed. You need another visit in 1-2 days or else I gonna hospitalize yo dumb self.

And WHY do people, and especially people in addiction, lie to themselves?

Damage. ACE scores. Adverse Childhood Experience Scores. They wish that they were that close to their mother. They long for a perfect marriage. They were beaten in secret by the perfect father. The famous man, their grandfather, sexually abused them. The list is endless.

And how do we help? The person I just stopped dating told me that his children said to him “My picker’s broke.” Our pickers are not really broken. We are attracted to the people who can teach us.

In the book Passionate Marriage, the author writes about how we are attracted to the people who have what we lack. What we want to learn. What we are afraid of. What we need to learn. I needed to learn how to really look at anyone I date with my full on intuition right away and also that it is seriously Not Nice of me to get curious, activate my inner scientist and stick around. I recognize the projection on me at some point and then the scientist in me is intrigued. Really? The most recent one said that inside me there is a sweet innocent joyous tiny girl.

Well, I thought. No, not really. There certainly is a baby. But it’s a baby honey badger or a baby Iron Bitch Alien Lizard. Don’t care what you call it. But it is about as sweet as a pissed off porcupine or skunk. Polecat. Octopoggles done got us! Squirting ink and sliding into an impossibly small space and escaping from the acquarium over and over until the captors let me go…..

And that was actually the moment I should have spoken up. Calmly. Kindly. “Um, no. I was never a sweet innocent joyous tiny girl. I was bathed in antibodies to tuberculosis in the womb and no doubt alcohol and my parents were newly married and I came out saying, “What is happening now? Some new torture? Augh! Bright lights! Is there food? I am really really hungry. Feed me or I will eat YOU.” And then I lost my mother for nine months so that I would not catch tuberculosis from her and die. I didn’t really understand it. I thought people kept giving me away and that you couldn’t trust those evil adults.

In the end this is all actually necessary, says the Passionate Marriage author. WHAT? WHAT? Well, in a truly loving relationship, both people will withdraw the projection. The projection is the “falling in love” where the person is golden, perfect, your true love. No, they aren’t. But you love that aspect of them that you want/need/can’t do. True love is when you withdraw the projection and you see the real person and you love them.

It isn’t easy. But people do it. Birds do it, squirrels do it, trees do it, even elementary bees do it… let’s do it… let’s fall in love.

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Resources on opioid addiction

This is a list of resources on opioid addiction that I am putting together for a talk to a community advocate group this Thursday.

The big picture:

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic, January 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

CDC 2018 (It’s not getting better yet.) https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html


Snohomish County:

Snohomish County:

http://mynorthwest.com/878895/snohomish-co-opioid-crisis/

https://drkottaway.com/2018/03/03/reducing-recidivism-snohomish-county-sheriffs-office-and-human-services-program/

http://www.heraldnet.com/news/state-house-backs-snohomish-county-opioid-help-center/

http://knkx.org/post/snohomish-county-jail-now-offering-medically-assisted-detox-inmates

Washington State Pain Law

https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/OpioidPrescribing

https://www.doh.wa.gov/YouandYourFamily/PoisoningandDrugOverdose/OpioidMisuseandOverdosePrevention


Is it genes that make people addicts? (The short answer is genes are a minimal contribution. It is society and patterns learned in childhood and adulthood.)

Adverse Childhood Experiences (put people at way higher risk for addiction):
https://www.cdc.gov/violenceprevention/acestudy/index.html


Books that helped me understand addiction (in my teens):

It will never happen to me by Claudia Black (about the patterns children take in addiction households to survive and cope with childhood)

Manchild in the Promised Land by Claude Brown (a black male writes about his childhood in Harlem when heroin hit the community. He was in a gang at age 6.)

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Causes of death: which does your doctor treat?

What is the number one cause of death in the United States? The heart. You know that.

You might know the number two: all the cancer deaths put together.

Number three is lower respiratory disease: mostly caused by tobacco.

Number four. Can you guess? Number four is accidents. Unintentional deaths. In 2012 number four was stroke, but unintentional deaths have moved up the list, here: https://www.cdc.gov/nchs/fastats/deaths.htm. The CDC tracks unintentional deaths, here: https://www.cdc.gov/nchs/fastats/accidental-injury.htm. And what is the number one cause of unintentional death right now? It is not gun accidents. It is not car wrecks. It is not falls. It is unintentional overdose: usually opioids, legal or illegal, often combined with other sedating medicines or alcohol. Alcohol, sleep medicines, benzodiazepines, some muscle relaxants. No suicide note. Not on purpose. Or we don’t know if it is on purpose….

And does your physician try to prevent accidental death? Do they talk to you about seatbelts, about wearing bicycle helmets, about smoke alarms, about falls in the elderly, about domestic violence, about locking up guns? About not driving when under the influence? Do they talk about addiction and do they treat addiction?I think that every primary care physician should treat the top ten causes of death. I am a family medicine physician and I try to work with any age, any person. I treat addiction as well as chronic pain. I have always tried to talk about the risk of opiates when I prescribe them. I treat addictions including alcoholism, methamphetamines, cocaine, tobacco and opioids. Legal, illegal and iv opioids, from oxcodone and hydrocodone to heroin. That doesn’t mean I can safely treat every patient outpatient. People with multi drug addiction, or complex mental health with addiction, or severe withdrawal must be treated inpatient. But I have taken the buprenorphine training to get my second DEA number to learn how to safely treat opiate overuse. I took the course in 2011. I was the only physician in my county of 27,000 people who was a prescriber for two years. Now we have more, but still the vast majority of physicians in the United States have not taken the training even when it is offered free.

I don’t understand why more physicians, primary care doctors, are NOT taking the buprenorphine and recognition and treatment of opiate overuse course. Most are not trained. Why not take the training? Even if they are not prescribers, they will be much better informed for the options for patients. People are dying from opioids daily. Physicians have a DEA number to prescribe controlled substances: I think that every physician who prescribes opioids also has a duty and obligation to train to recognized and intervene and be informed about treating opioid overuse.

A large clinic group in Portland, Oregon made the decision last year that every primary care provider was required to train in buprenorphine. One provider disagreed and chose to leave. However, everyone else is now trained.

We as a country and as physicians need to get past fear, past stigma, past discrimination and past our fixed ideas and step up to take care of patients. If a physician treats alcoholism as part of primary care, they should also be knowledgeable and trained in treatment of opiate overuse.

Ask YOUR physician and YOUR local clinics: Do the providers prescribe opiates? Are their providers trained in preventing, recognizing and treating opiate addiction? Do they treat opiate overuse? Do they understand how buprenorphine can save lives and return people to work and to their families? Are they part of the solution?

For the Daily Prompt: provoke.

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Reducing recidivism: Snohomish County Sheriff’s Office and Human Services Program

The last two days have been at the 20th Annual Fundamentals of Addiction Medicine Conference in Washington State, 15 lectures. Everything from science trying to understand addiction via studying dopamine in ratbrains to the last presentation: Snohomish County started a program two years ago that pairs a social worker with a county sheriff or deputy to work with the homeless.

The county is trying to stop the revolving door of homeless to arrested to jail to homeless. 95% of the county homeless are addicted to heroin and some to methamphetamines. They don’t access services when they are “dope sick”. They describe heroin as being 10x worse than the worst influenza. I think of withdrawal from opioids as having all the pain receptors turned as high as they can go and screaming at once.

The sheriff and social worker go to the camps. They get to know people and offer services. They have helped over 100 people get their identification replaced. When someone is arrested, their homeless encampment is often stolen. No honor among thieves, you say? The rat studies address that: in addiction the brain puts the drug first, in front of food, water, sex. Some rats will access the drug until they die, just like people. I think of it as the person losing their boundaries to the drug. The conference used the phrase “incentive salience” — dopamine is released when the person or rat is cued that the drug is now available and again when the drug arrives. More on that in another write up.

At any rate, the clients do not get to appointments. So the deputy and social work start at the beginning: they make the appointment, go knock on the tent that morning, remind the person to get dressed, take them to get food and coffee and then take them to the appointment. Then they return them to their camp.

After two months, the first sheriff and social worker were so successful that the program was expanded.

They have 206 chemical dependency evaluations.
232 have gone to detox. The detox is 3-5 days. They are taken straight from there to inpatient treatment, 30 day minimum, but ranging from 30-90 days. After treatment, clients are taken straight to sober housing, with a 6 month supported stay and intensive outpatient treatment.
85% get through the detox.
59% graduate from the treatment
50% go on to sober housing and intensive outpatient.
Their first clean and sober client is two years out.

50% of the homeless who agree to the program getting to sober housing is huge. Recidivism and incarceration drop, so it is making a true difference.

The program is expanding. They have a Community Court set up, much like Juvenile Drug Court, modeled after a program in Spokane. If the person agrees to drug treatment, they can do that instead of jail. This is for minor offenders. The sheriff says that once the homeless person is incarcerated, everything is stolen. They then steal food and supplies for a new camp when released and it happens again. If the client completes the program, low level charges may be dropped. They are setting up a service center right by the court where the clients are sent immediately to talk to a chemical dependency person, to get medical treatment, dental emergencies, centralized services because these people do not have transportation.

The social worker is in kevlar and heavy clothes as well and is never to go in the encampments without the law enforcement officers: it’s usually private land so it would be trespassing anyway.

This was an absolutely inspiring presentation. It starts with outreach and intervention, and gives people choices. They will soon be opening a temporary site, up to 15 days with medical support and beds, for when a client is ready but the social worker needs to arrange the detox, the treatment, the housing. Sometimes when a client is finally ready, there are no beds. And they don’t want to send them to detox and then back to the streets. The sheriff says that he was “volutold” for the program, but he, the deputy and the social worker are all clearly inspired by the program and enjoy their work and that it is making a difference.

 

Any write up on addiction fits today’s Daily Prompt: messy.

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Why care for addicts?

Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

I took the photo of my daughter on Easter years ago.