Video for Patients and Families With Questions About MAT

Dr. Hillary Kunins, a PCSS Clinical expert, dispels the notion that treating an addiction patient with medication is simply exchanging one drug with another. Learn how physical dependence is not the same as addiction. A good video to share with patients and their families who have questions about MAT.

Dr. Kunins is an Assistant Commissioner at the New York City Department of Health and Mental Hygiene where she leads the Department’s Bureau of Alcohol and Drug Use – Prevention, Care and Treatment.

Link to original video here.

View more videos at www.pcssNOW.org.

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Study highlights unmet treatment needs among adults with mental health and substance use disorders

Despite current treatment guidelines, fewer than 10 percent of adults with co-occurring mental health and substance use disorders receive treatment for both disorders, and more than 50 percent do not receive treatment for either disorder. The findings highlight a large gap between the prevalence of co-occurring disorders and treatment rates among U.S. adults and the need to identify effective approaches to increasing treatment for those with these conditions. An analysis of data from U.S. adults with both a mental health disorder and a substance use disorder indicates that only 9.1 percent of those adults received both types of care over the past year, and 52.5 percent received neither mental health care nor substance use treatment.

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The study, based on data collected from the 2008-2014 National Survey on Drug Use and Health, reports that 3.3 percent of the adult U.S. population, or some 7.7 million individuals, suffers from both a mental health and substance use disorder. Those adults with co-occurring disorders who did receive both types of treatment tend to have more serious psychiatric problems and accompanying physical ailments and were more likely to be involved with the criminal justice system compared to individuals who did not receive both types of care. The primary reasons for not seeking care were inability to afford treatment, lack of knowledge about where to get care, and a low perceived need among those with both disorders.

For more information about mental health and substance use disorders, go to: https://www.drugabuse.gov/related-topics/mental-health

Link to article here: Study highlights unmet treatment needs among adults with mental health and substance use disorders

Here’s The Real Reason Why Some People Become Addicted to Drugs

Why do they do it? This is a question that friends and families often ask of those who are addicted.

It’s difficult to explain how drug addiction develops over time. To many, it looks like the constant search for pleasure. But the pleasure derived from opioids like heroin or stimulants like cocaine declines with repeated use. What’s more, some addictive drugs, like nicotine, fail to produce any noticeable euphoria in regular users.

So what does explain the persistence of addiction? As an addiction researcher for the past 15 years, I look to the brain to understand how recreational use becomes compulsive, prompting people like you and me to make bad choices.

Myths about addiction

There are two popular explanations for addiction, neither of which holds up to scrutiny.

The first is that compulsive drug taking is a bad habit – one that addicts just need to “kick.”

However, to the brain, a habit is nothing more than our ability to carry out repetitive tasks – like tying our shoelaces or brushing our teeth – more and more efficiently. People don’t typically get caught up in an endless and compulsive cycle of shoelace tying.

Another theory claims that overcoming withdrawal is too tough for many addicts. Withdrawal, the highly unpleasant feeling that occurs when the drug leaves your body, can include sweats, chills, anxiety and heart palpitations.

For certain drugs, such as alcohol, withdrawal comes with a risk of death if not properly managed.

The painful symptoms of withdrawal are frequently cited as the reason addiction seems inescapable. However, even for heroin, withdrawal symptoms mostly subside after about two weeks. Plus, many addictive drugs produce varying and sometimes only mild withdrawal symptoms.

This is not to say that pleasure, habits or withdrawal are not involved in addiction. But we must ask whether they are necessary components of addiction – or whether addiction would persist even in their absence.

Pleasure versus desire

In the 1980s, researchers made a surprising discovery. Food, sex and drugs all appeared to cause dopamine to be released in certain areas of the brain, such as the nucleus accumbens.

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Rat receiving optogenetic stimulation of the brain using laser light to produce focused and compulsive reward-seeking. 

This suggested to many in the scientific community that these areas were the brain’s pleasure centres and that dopamine was our own internal pleasure neurotransmitter. However, this idea has since been debunked. The brain does have pleasure centres, but they are not modulated by dopamine.

So what’s going on? It turns out that, in the brain, “liking” something and “wanting” something are two separate psychological experiences.

“Liking” refers to the spontaneous delight one might experience eating a chocolate chip cookie. “Wanting” is our grumbling desire when we eye the plate of cookies in the centre of the table during a meeting.

Dopamine is responsible for “wanting” – not for “liking.” For example, in one study, researchers observed rats that could not produce dopamine in their brains. These rats lost the urge to eat but still had pleasurable facial reactions when food was placed in their mouths.

All drugs of abuse trigger a surge of dopamine – a rush of “wanting” – in the brain. This makes us crave more drugs. With repeated drug use, the “wanting” grows, while our “liking” of the drug appears to stagnate or even decrease, a phenomenon known as tolerance.

In my own research, we looked at a small subregion of the amygdala, an almond-shaped brain structure best known for its role in fear and emotion.

We found that activating this area makes rats more likely to show addictive-like behaviors: narrowing their focus, rapidly escalating their cocaine intake and even compulsively nibbling at a cocaine port. This subregion may be involved in excessive “wanting,” in humans, too, influencing us to make risky choices.

Involuntary addicts

The recent opioid epidemic has produced what we might call “involuntary” addicts. Opioids – such as oxycodone, percocet, vicodin or fentanyl – are very effective at managing otherwise intractable pain. Yet they also produce surges in dopamine release.

Most individuals begin taking prescription opioids not for pleasure but rather from a need to manage their pain, often on the recommendation of a doctor. Any pleasure they may experience is rooted in the relief from pain.

However, over time, users tend to develop a tolerance. The drug becomes less and less effective, and they need larger doses of the drug to control pain. This exposes people to large surges of dopamine in the brain. As the pain subsides, they find themselves inexplicably hooked on a drug and compelled to take more.

The result of this regular intake of large amounts of drug is a hyperreactive “wanting” system. A sensitised “wanting” system triggers intense bouts of craving whenever in the presence of the drug or exposed to drug cues.

These cues can include drug paraphernalia, negative emotions such as stress or even specific people and places. Drug cues are one of an addict’s biggest challenges.

These changes in the brain can be long-lasting, if not permanent. Some individuals seem to be more likely to undergo these changes.

Research suggests that genetic factors may predispose certain individuals, which explains why a family history of addiction leads to increased risk. Early life stressors, such as childhood adversity or physical abuse, also seem to put people at more risk.

Addiction and choice

Many of us regularly indulge in drugs of abuse, such as alcohol or nicotine. We may even occasionally overindulge. But, in most cases, this doesn’t qualify as addiction. This is, in part, because we manage to regain balance and choose alternative rewards like spending time with family or enjoyable drug-free hobbies. 185418346

However, for those susceptible to excessive “wanting,” it may be difficult to maintain that balance. Once researchers figure out what makes an individual susceptible to developing a hyper reactive “wanting” system, we can help doctors better manage the risk of exposing a patient to drugs with such potent addictive potential.

In the meantime, many of us should reframe how we think about addiction. Our lack of understanding of what predicts the risk of addiction means that it could just as easily have affected you or me.

In many cases, the individual suffering from addiction doesn’t lack the willpower to quit drugs. They know and see the pain and suffering that it creates around them. Addiction simply creates a craving that’s often stronger than any one person could overcome alone.

The ConversationThat’s why people battling addiction deserve our support and compassion, rather than the distrust and exclusion that our society too often provides.

Article written by: Mike Robinson, Assistant Professor of Psychology, Wesleyan University.

Link to article here: Here’s The Real Reason Why Some People Become Addicted to Drugs

Stretching the Scope — Becoming Frontline Addiction-Medicine Providers

NEJMlogoOn our infectious diseases (ID) consult service, we recently cared for Mr. C., a young man with Staphylococcus aureus tricuspid valve endocarditis, septic arthritis, and empyema that were consequences of his opioid use disorder (OUD). Several years earlier, he had started taking oxycodone at parties, and eventually, when the cost of pills became prohibitive, he’d progressed to injecting heroin. His days were consumed by the logistics of obtaining heroin to stave off the exhausting cycle of opioid withdrawal. Despite his deep desire to stop using, he was initially ambivalent when we offered to start treatment with buprenorphine, which is commonly coformulated with naloxone as Suboxone (Reckitt Benckiser). “Doc,” he said, “you gotta understand that as an addict, the scariest thing right now is the idea of putting another opioid in my body, even if it’s going to help me.”

Although Mr. C. had done well on buprenorphine in the past, accumulating several months of recovery, he felt overwhelmed by the prospect of starting the process again. In the days after his clinical status stabilized and the ID service defined his antibiotic course, we kept visiting Mr. C. on the ward. We confronted the dual imperatives to treat his infection and his OUD to reduce his near-term chance of dying from an overdose or relapsed infection. During our visits, we discussed his resolving empyema, but also his cravings, withdrawal symptoms, and readiness to start buprenorphine treatment. On the day before his discharge, as he faced impending relapse, Mr. C. decided he was ready. That afternoon, we completed an observed buprenorphine induction and made an appointment to see him the following week in the ID clinic for ongoing buprenorphine and antibiotic treatment.

As the opioid use and overdose epidemic ravages the United States, bearing witness to the physical and psychosocial consequences of addiction has become part of many physicians’ daily work. Despite our position on the epidemic’s front lines, the remarkable reality is that we remain systematically undertrained and underengaged in addiction-treatment efforts. Though we have taken steps toward recognizing our profession’s complicity in the epidemic’s roots, most physicians feel paralyzed when it comes to effecting change for individual patients.

The history of medicine is, in part, the history of physicians stretching the scope of their practice to answer the pressing needs of their times. In the face of OUD, a treatable illness with a striking capacity to rapidly and definitively alter the lives of our patients, their families, and the communities we serve, we have been late and ineffective in our response. In recent years, the number of hospitalizations for the medical consequences of OUD has escalated, and in 2015 alone, more than 33,000 people died in the United States from opioid-related overdose.2 Yet rates of active physician engagement in addiction treatment remain embarrassingly low.

At some point, it became culturally acceptable to treat all conditions in a patient except addiction. It’s a diagnosis still frequently and falsely regarded as untreatable — a convenient assumption driven by the stigma against people with this disease. ID specialists have historically been ardent advocates for social justice and public health, championing patients on the margins of society who have stigmatizing illnesses. In the age of the opioid epidemic, treatment of life-threatening infections arising from injection drug use accounts for an increasing proportion of our practice. Far too often, however, infections that we treat resolve while underlying substance use disorders are left to fester.

Under the federal Drug Addiction Treatment Act of 2000, physicians who register with the Drug Enforcement Administration, regardless of their subspecialty, can receive a waiver to prescribe buprenorphine for OUD treatment after undergoing 8 hours of training. According to the Substance Abuse and Mental Health Services Administration, the federal body that oversees the buprenorphine waiver program, there are currently 37,448 physicians with such waivers, representing only approximately 4% of all professionally active U.S. physicians.  Nationally, the distribution of physicians with waivers is grossly uneven, and many suffering communities are left with little to no capacity for buprenorphine treatment. Obtaining a waiver is one concrete action that all physicians can take to help stem the tide of this epidemic. Physicians practicing in clinical contexts in which long-term prescribing is not possible can prescribe a short course of buprenorphine therapy as a bridge to long-term treatment managed by one of a growing number of primary care physicians and psychiatrists.

As a small group of ID fellows and faculty practicing at Beth Israel Deaconess Medical Center, a large tertiary care hospital in Boston, we have pursued this strategy. We offer buprenorphine in conjunction with antibiotics to patients who are hospitalized with infectious complications of injection drug use. We ask patients about injection practices, counsel them about harm reduction, and prescribe intranasal naloxone for overdose reversal, recognizing that OUD is marked by both recovery and relapse. We partner with colleagues in social work to build viable treatment plans to facilitate recovery and eventually transfer addiction care to long-term programs. As we have waited for institutional capacity to increase, we have also started to offer inpatient buprenorphine induction for patients without concurrent infection.

We anticipated some resistance on both the institutional and the provider levels, but in practice, we have largely encountered appreciation, and our work has served as one impetus for a larger hospital initiative to address the opioid crisis. This pilot program was born in our ID division, but we believe it is replicable by any physician group — for example, surgical teams discharging patients admitted with OUD-related complications or psychiatry teams discharging patients with both substance use disorder and mental illness. For all physicians, it is vital to recognize that medication treatment for OUD is a cornerstone of recovery for most patients, and when it’s omitted, high rates of relapse are consistently observed.

We are wading into the turbulent waters of our patients’ lives to see them through to a time when they are clear of their infection and on the continuum of recovery. Though our efforts are still relatively new, we have been changed by the experience. Some of our patients have had relapses or haven’t returned for care. But we’ve also seen remarkable successes — patients who presented in the depths of addiction and illness who have subsequently reconnected with their families, have started to work again, and now use opioids less or not at all. By providing the bridge to long-term addiction treatment, we have observed patients remain in care at higher rates and start to mend their badly damaged sense of trust in a medical system that has long treated them with judgment and neglect.

We are providing this care outside the realm of traditional ID consultation because the crisis demands it. Today in the United States, another 91 people will die from an opioid overdose.5 Under the watchful eyes of physicians, many people survive their acute illnesses only to die in public restrooms, in private homes, or on the street. There are many inspiring examples of physicians and health care communities that have similarly stretched the scope of their practice, and lives have been saved as a result. We believe it’s time for more of us to join the movement.

Two months after being discharged, Mr. C. continues to receive buprenorphine treatment. He gets his prescriptions through a program close to his home, where he attends weekly group meetings and individual counseling sessions. He wholly understands the gravity of his infection; his heart valve has been left severely damaged, and he still feels weak. But he has reconnected with friends and family and is making plans to return to work. He is in early recovery from his OUD and from the chaos, social isolation, and depression that come with it. As we see it, the medical community is also in early recovery — moving past implicit biases, stigma, and fear to connect with our patients and respond to a defining crisis of our time.

Alison B. Rapoport, M.D., and Christopher F. Rowley, M.D.

Link to original article here: Stretching the Scope — Becoming Frontline Addiction-Medicine Providers

Link to audio interview with author: Audio interview

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Dr. Rapoport

Lives Lost: One story of opioid recovery

Lisa is alive today because of new tactics in the fight against opioid addiction.

CANTON, OH Every morning, Lisa dissolves a pill under her tongue. She doesn’t mind the flavor: chalky, like children’s aspirin, with a hint of orange.

The pill is Suboxone, a medication that helps Lisa control her cravings for opioids. After years of abusing prescription pills and heroin, and surviving more than a dozen overdoses, she has been sober four months and counting.

Her bills are paid. There is food in the refrigerator. She spends time with her children.

“I’m happy, actually,” Lisa said. “This is the best things have been in a long, long time.”

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But her story is about more than a pill. Lisa is alive and in recovery because Stark County embraced new techniques to fight an opioid epidemic that has killed hundreds locally and thousands across the state.

Medication-assisted treatment, outreach by police officers, the wide-spread use of overdose-reversing naloxone and peer support all played a role in Lisa’s story.

Lisa is 51 years old and lives in Canton. She agreed to speak with The Canton Repository on the condition her last name not be used because of concerns regarding her past associates.

Lisa almost didn’t make it to this point. By her own count, she overdosed at least nine times that landed her in a hospital. That number doesn’t include the dozen or so times her teenage son waited anxiously at her side to blast overdose-reversing naloxone up her nose.

“He saved my life more times than I know,” she said.

Lisa started smoking marijuana when she was 13 years old. In her 20s, she started using methamphetamine, cocaine and prescription pills. Vicodin was the first opioid she tried. Her mother gave her the pill to ease a headache.

“That was the miracle cure for hangovers after that,” Lisa said.

Sometime later, a pain management doctor prescribed Lisa opioids such as Percocet, Vicodin and OxyContin for migraines and pain related to scar tissue. The doctor didn’t ask about her past drug use, she said.

Lisa had a medicine cabinet full of opioids, but she would blow through a month’s worth of pills in a few weeks. The first pain management doctor ultimately dropped Lisa after she got an opioid prescription from a dentist. She found another clinic, but authorities shut it down.

Drugs such as heroin, cocaine or opioid painkillers flood the brain with dopamine, causing a feeling of pleasure. Food, sex and exercise also release dopamine, but can’t compete with surge from the drugs.

Over time, drug use depletes the amount of dopamine in the brain. Addiction takes hold and the brain’s structure changes.

“They have to seek substances to fill that gap,” said Dr. Jamesetta Lewis, of Mercy Medical Center’s Pain Management Center. “That’s when an addiction develops. They have to get more and more substances to bridge that dopamine gap the brain can’t fill itself.”

Unable to get pills, Lisa used heroin. That was about eight years ago. Heroin was cheaper than pills and stronger. She used every day. When she heard about someone overdosing, she’d try to buy the same stuff.

“I never cared if I died,” Lisa said. “I never cared. I just didn’t care. And if I was going to die, that was the way to do it because it was completely painless. You just go to sleep.”

Addiction consumed her life and hurt those closest to her. Her adult daughter started using opioids. Lisa’s teenage son worried every time he left the house or went to school that he’d return to find her dead or in jail. At night he skipped sleep to make sure she didn’t die.

“Growing up seeing your family do that, it does something to you,” he said.

Ready for help

Two Canton Police narcotics officers knocked on Lisa’s door one day this winter.

Detective Mike Rastetter and a supervisor were checking complaints about drug activity at Lisa’s home. They knew Lisa from all the times she had overdosed.

“She looked skin and bones,” Rastetter said. “She looked really bad.”

Lisa was sick from withdrawal and desperate when they knocked. What she didn’t know at the time was that the department had told officers to look for ways to help people addicted to drugs get treatment.

Lisa told the detectives she was going to die if she didn’t get help. They started making calls. About four hours later, Lisa was in a detox bed at the Crisis Intervention & Recovery Center.

“We were fortunate enough that day that it was available,” Rastetter said.

Medication-assisted treatment

Addiction treatment can take different forms. After a week of detox, Lisa went to CommQuest Services’ Regional Center For Opiate Recovery in Massillon, which opened in 2015 specifically to treat opioid addiction. Since then, it has received 2,500 unduplicated referrals from more than 20 counties.

“We talk about recovery being a process of learning to enjoy life and repairing the damage you did while you were using and improving the overall quality of your life,” said CommQuest President and CEO Keith Hochadel.

Lisa’s treatment plan combined counseling and 12-step meetings with daily doses of Suboxone, a combination of naloxone and buprenorphine, an opioid. Suboxone reduces the euphoria and cravings associated with opioids so a patient can focus on recovery.

The thought of getting high is always in her mind, Lisa said, but she counts to 20 and thinks about something else and the craving passes.

“I can function every day,” Lisa said. “I function.”

Starting this month, Stark Mental Health and Addiction Recovery will use two-thirds of a $741,000 federal and local funding package to expand treatment with Suboxone and Vivitrol, a medication that blocks an opioid from making the user high.

But the local treatment community has realized that treating addiction involves more than medication and counseling sessions. Men and women in recovery need help to rebuild their lives and the best guide can be a person who has walked the same road.

Rebuilding lives

When Lisa started at ReCOR, she had to go to Massillon every day to get her dose of Suboxone. She couldn’t drive and everyone she knew who had a car was using drugs. She was able to get a ride with a peer supporter from Stark County TASC.

Peer supporters are individuals in recovery who are trained to help others addicted to drugs or alcohol.

“You actually know what they’re talking about,” said Nicole Osborne, who oversees TASC’s peer supporters. “You actually know where they’re coming from. You didn’t just read it in a book in school.”

Three times a week peer supporters from TASC visit individuals detoxing at the Crisis Center. Rides to treatment appointments are just some of the help they offer.

People addicted to alcohol or drugs put everything else in their lives on hold, Osborne said.

When she meets a new client, she asks the woman about her “life to-do list,” the things she’s avoided or ignored for months or years. That can be getting a driver’s license, finding a home, clearing up arrest warrants or getting a job.

“You need the basics of life,” Osborne said. “You need to know where you’re going to sleep that night. It’s hard to even think about being sober or not using drugs if you don’t have a place to live or no food.”

Peer supporters also link clients to others who can help them stay sober.

Lisa said teaming with a peer supporter removed any excuses she might have had for not going to treatment.

“You don’t have a reason to say, ‘I can’t do it,’” she said.

Police outreach

Lisa is drug-tested regularly in the ReCOR program and said she goes to 12-step meetings almost daily.

Rastetter stops and checks on Lisa and her family about once a month. Right now he’s trying to find her a job.

The 11-year Canton police veteran said he never thought his job would include navigating the maze of addiction services, insurance and housing assistance. Finding local resources on the fly is a challenge, he said, but it’s getting better.

“It’s worth a chance,” Rastetter said. “If we save two or three people’s lives and they get off heroin, then it’s worth it. It really is.”

Lisa is one of about five people the police have helped get into detox, and the department is trying to assist more.

Taking a cue from communities such as Mansfield, Akron and Green, Canton police started a Recovery Response Team in late June. The team includes police, a caseworker from TASC and a Crisis Center nurse. Every week, the team visits individuals who recently overdosed.

“The jails are not equipped to deal with addiction recovery, and I think that looking at this from a health care standpoint and as a health care crisis is very important,” said Lt. John Gabbard, who oversees the initiative.

The police will still pursue drug dealers, but Gabbard asked for patience from residents who might not understand the new approach toward individuals using drugs.

“Give us a chance to convince you that taking the long-term approach of getting them help will be more beneficial to the neighborhood than trying to evict them into someone else’s neighborhood and not dealing with that problem,” Gabbard said.

Looking forward

Now that Lisa’s life isn’t ruled by a daily hustle for drugs, she has a lot of things she wants to do.

She wants to get a job and more furniture for her home. She wants to drive again. She wants to spend time with her family, including her daughter who is now in recovery.

Her plan is to “do things and make memories,” Lisa said. “Ones that I can remember and ones where everybody’s happy.

Relapse is always a risk, and with opioids, the consequence of one slip can be fatal.

Her kids were proud of her recovery.

“Not everyone is as lucky as her to where you can OD as many times as she did and be alive to this day,” her son said.

Article written by: Shane Hoover, Cantonrep.com staff writer

Link to original article here: Lives Lost: One story of opioid recovery