With Rise Of Painkiller Abuse, A Closer Look At Heroin

English: Pre-war Bayer heroin bottle, original...
English: Pre-war Bayer heroin bottle, originally containing 5 grams of Heroin substance. (Photo credit: Wikipedia)

 

The number of people who had used heroin in the previous year increased between 2007 and 2012, from 373,000 to 669,000. Meanwhile, federal data from 2011 finds that nearly 80 percent of people who had used heroin in the past year had also previously abused prescription painkillers classified as opioids.

 

via With Rise Of Painkiller Abuse, A Closer Look At Heroin : NPR.

 

Indescribable horror turned into advocacy

Bill White appears to have started blogging!

His most recent post touches upon an issue that is close to my heart.

People in recovery and their family members are leading what is rapidly becoming an international recovery advocacy movement, but there are faces and voices notably absent from the frontlines of this movement:  the families who experienced death of a loved one from addiction before recovery was achieved.  These family members are now seeking each other out for mutual support and are adding their voices to calls for enhanced access and quality of addiction treatment and recovery support services in local communities.

He then introduces a video made by a bereaved father, Jim Contopulos, in memory of his son, Nick.

The following is attributed to Jim and reportedly from his eulogy for Nick.

For those of us here today, who have had a “front  row seat” to this disease over these past 13 years, or even to those sitting further back and have continued,  as it were, to hear “reports form the front line” we can confirm without any hesitation that addiction is truly a “cunning, powerful and baffling” disease.

Some of us sitting here today know nothing of Nick other that this courageous struggle, and it is my hope that as we allow Nick to “speak” through the songs he loved; the movies he loved; his love for animals; his love for children, especially his love for his daughter Hailey; his irreverent humor; his love and admiration for his sister Vanessa, his mom and myself; his strong desire for justice as well as his struggles with addiction coupled with mental illness, what’s known as a dual diagnosis, that you will have a much larger context for his life.

Perhaps with this better understanding, Nick would ask you simply to love, rather than judge; the addict, the mentally ill the diseased, the imprisoned, the homeless, the poor, the unlovable and the lonely, because Nick himself was, at one time or another, all of these.

None of us sitting here today wants only to be remembered for our failures and certainly not Nick, which is why he so loved the final verse to the song “These Days” by Jackson Browne, which says. “don’t confront me with my failures, I have not forgotten them”.

The worst part of this work is the terrible loss of life, often young lives. Among the parents that are left behind are some of the bravest and most admirable men and women I have ever met.

liv.townhall-2Diane Montes turned the loss of her son, Brian, into a mission to prevent deaths and support families going through a similar loss.

It was the evening of June 29, 2006, when Diane Montes returned home from work and went to her son’s room to speak with him. When she opened his bedroom door, she witnessed “an indescribable horror.” Brian Montes, a 22-year-old education major at Michigan State University, was lying dead on his bed. Police told the grieving mother that her son died from heroin use.

The family later learned that the fatal dose was mixed with the pain-killer Fentanyl, which caused respiratory failure. Brian’s family had not been aware he had a drug abuse problem. They later found out he had only been using heroin for 6 weeks when he died.

After Brian’s death, Diane and her husband Andy learned that there were more Livonia teenagers and young adults using heroin than they had ever imagined. Diane talked to a number of people who said they knew of young heroin users who either died, were hospitalized, or sent to drug rehabilitation. In addition, it was reported that Livonia police suspected the drug could have played a role in a dozen deaths in Livonia over the previous year.

Diane looked for information and support in Livonia but found little. She learned of the Royal Oak Save Our Youth Task Force, a group of school, police, medical and political leaders focused on spreading word about the dangers of heroin and other drugs and how users and families can find help. The Royal Oak group formed in response to a number of drug deaths in that community.

On October 18, 2006, Diane convened a community meeting to try and build community support for a Livonia Save Our Youth Task Force. Over 140 people with questions and stories to share attended that initial meeting. From that meeting, a group formed and the first meeting of the Livonia Save Our Youth Task Force was held on November 15, 2006.

Since 2006, Livonia Save Our Youth continues to grow and expand. In 2012, the name was changed from “Task Force” to “Coalition” to reflect the longevity of the group and intent to continue its mission and activities in the community.

I’ve called on Diane over and over again to ask if she’d be willing to speak with a parent who just lost a child. She’s never hesitated to make her self available to them.

Mark Rudolph also lost his son, Ryan, in 2007 and has been relentless in building a coordinated community response to the problem of addiction in his “safe” suburban community.

He made this video in memory of Ryan. (The voice mail he included at the end is heartbreaking and horrifying.)

mark anna beach animatedMore recently, I met Mark S. who lost his son, Andrew, just one year ago.

He’s been sharing his difficult journey on his blog and in his podcast. He recently marked Andrew’s birthday with a 12 hour podcast to raise money to provide treatment for others.

DSC00291Here’s his introduction to that 12 hour podcast.

[audio http://traffic.libsyn.com/talktherapy/Hour_1_of_12_Hour_Podcast_Mark.mp3]

These are just a few of the people I’ve met who have turned their tragedy into a heroic journey. Sadly, we’re in the midst of another wave of overdoses.  I hate this part of the job but I am so grateful to have met people like Diane, Mark and Mark.

Heroin Shortages Drive Deadly Alternatives

English: Pre-war Bayer heroin bottle, original...
English: Pre-war Bayer heroin bottle, originally containing 5 grams of Heroin substance. (Photo credit: Wikipedia)

 

Though the federal government is participating in marketing buprenorphine as having low addiction potential, buprenorphine is being identified as a growing problem overseas:

 

Responses to the drought varied by country, with drug users in each developing their own preferences for heroin alternatives, according to reports from the European Monitoring Center for Drugs and Drug Addiction (EMCDDA.)  In Norway, users turned to buprenorphine, a semi-synthetic often used to treat heroin addiction, but intoxicating and addictive in higher doses.  In Hungary, cathinones gained popularity. That substance – an ingredient in the drug mixes known as “bath salts” in the U.S. – is part stimulant, part opioid. Slovakia, too, went for uppers – there, methamphetamine use surged. In Bulgaria, a mysterious substance known as “white heroin” cropped up; reports vary regarding its makeup.

Buprenorphine also swept the country of Georgia, which previously never had much of a heroin problem.

Lasha – whose name has been changed to protect his identity – first tried the drug when he was 15, on the 2007 Georgian New Year. He easily scored the drug through older acquaintances  he had met the day before, and his new friends crushed up a tablet of Subutex, a name brand of buprenorphine, and injected him with it.

Lasha’s first high was a nightmare. “Every five minutes I got sick and it didn’t stop until the morning. I had nothing in my stomach and some strange liquid was coming out,” he said. “I thought I would die.”

But two days later, he did it again. ”The same thing happened,” Lasha said. ”I was going crazy… I wanted to feel the real pleasure that was felt by my friends. I wanted some more.” So a week later, Lasha injected the drug a third time.

”I felt it at last. The warmth came from my feet up to my head,” he said. “I was God. I was cool. I could do everything possible and impossible.” By the time the high wore off, Lasha was hooked. ”It finished and again I felt like a nobody,” he said. ”I immediately missed that feeling and wanted to inject once more…I became the classic junkie.”

Thousands of users befell the same fate in Georgia, where a third of the drug users who now seek treatment are addicted to synthetic opioids. Georgian drugs reforms in 2007 cracked down on traditional narcotics but did nothing to stem the misuse of perscription drugs. “It was effective for catching drug dealers, but drug users found an alternative way — artificial drugs,” explained Georgian drug counselor and anthropologist Tamaz Mchedlidze.

 

 

The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

2012′s most popular posts #9 – What Vietnam taught us

Da Nang, Vietnam. A young Marine private waits...
Da Nang, Vietnam. A young Marine private waits on the beach during the Marine landing, August 3, 1965. (Photo credit: Wikipedia)

 

I seem to have noticed an uptick in book, news and blog references to heroin addiction among returning Vietnam vets. (A Google news search suggests that this perception is accurate. I suspect it’s because it offers a narrative that’s consistent with the current monoculture.) It’s claimed that this offers important lessons about addiction and behavior change.

 

In May of 1971 two congressmen, Robert Steele from Connecticut and Morgan Murphy of Illinois, went to Vietnam for an official visit and returned with some extremely disturbing news: 15 percent of U.S. servicemen in Vietnam, they said, were actively addicted to heroin.

Soon a comprehensive system was set up so that every enlisted man was tested for heroin addiction before he was allowed to return home. And in this population, Robinsdid find high rates of addiction: Around 20 percent of the soldiers self-identified as addicts.

Those who were addicted were kept in Vietnam until they dried out. When these soldiers finally did return to their lives back in the U.S., Robins tracked them, collecting data at regular intervals. And this is where the story takes a curious turn: According to her research, the number of soldiers who continued their heroin addiction once they returned to the U.S. was shockingly low.

“I believe the number of people who actually relapsed to heroin use in the first year was about 5 percent,” Jaffe said recently from his suburban Maryland home. In other words, 95 percent of the people who were addicted in Vietnam did not become re-addicted when they returned to the United States.

This flew in the face of everything everyone knew both about heroin and drug addiction generally. When addicts were treated in the U.S. and returned to their homes, relapse rates hovered around 90 percent. It didn’t make sense.

 

Studies of this cohort do offer some important lessons, in particular, that exposure to opiates does not create addicts on a large scale. But the lesson is not this:

 

It’s important not to overstate this, because a variety of factors are probably at play. But one big theory about why the rates of heroin relapse were so low on return to the U.S. has to do with the fact that the soldiers, after being treated for their physical addiction in Vietnam, returned to a place radically different from the environment where their addiction took hold of them.

 

These stories often ignore the fact that:

 

there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.

 

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

 

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

 

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

 

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

 

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

 

It’s worth noting that this can cut in both directions. There’s a tendency to respond to problem users (people who drink too much, but are not alcoholics.) and dependent non-addicts (most pain patients or these returning vets) as though they are addicts. This results in bad treatment for those people, bad research and it manufactures resentment toward treatment, mutual aid groups and recovery advocates.

 

Changes in brain gray matter in abstinent heroin addicts

English: Middle frontal gyrus. 日本語: 中前頭回。前頭葉にあ...
English: Middle frontal gyrus. (Photo credit: Wikipedia)

A few years ago, Bill White called for research on the neurobiology of recovery. (He noted that all of our research efforts have been focused on understanding addiction without any research on understanding recovery.)

Well, some Chinese researchers have made a contribution. Good news for heroin addicts.

Background

Previous neuroimaging studies have documented changes in the brain of heroin addicts. However, few researches have detailed whether such changes can be amended after short-term abstinence.

Methods

We used magnetic resonance imaging (MRI) to investigate gray matter volume in 20 heroin-dependent patients at 3 days and at 1 month after heroin abstinence; 20 normal subjects were also included as controls.

Results

Decreased gray matter density in frontal cortex, cingulate and the occipital regions were found in heroin users after three days of abstinence. In contrast, after 1-month abstinence, no significant difference was found in superior frontal gyrus between heroin addicts and controls, but changes in other brain regions, including right middle frontal gyrus, left cingulate gyrus and left inferior occipital gyrus, still remained.

Conclusion

Our findings illustrate that abnormal gray matter in some brain regions of heroin addicts can return to normal after one-month abstinence.

The truth is dangerous

Michele Leonhart official photo. Found at http...
Michele Leonhart  (Photo credit: Wikipedia)

How hard is it for the DEA to have an honest conversation about drugs? Below is testimony from the director. Note the incoherence.

“Is crack worse for a person than marijuana?” Polis asked Leonhart.

“I believe all illegal drugs are bad,” Leonhart answered.

Polis continued, asking whether methamphetamines and heroin were worse for a person’s health than marijuana.

“Again, all drugs, they’re illegal drugs,” Leonhart started, before being cut off by Polis.

“Yes, no, or I don’t know?” Polis said. “If you don’t know, you can look this up. You should know this as the chief administrator for the Drug Enforcement Agency. I’m asking a very straightforward question: Is heroin worse for someone’s health than marijuana?”

Leonhart ducked again, repeating, “All illegal drugs are bad.”

Since assuming the head position at the DEA, Leonhart has made controlling prescription drug abuse the top priority, a stance she had laid out so aggressively that it led one Democratic senator to block her confirmation.

I imagine she’s concerned about getting trapped, but come on! Reasonable people can disagree on drug policy, but only if we don’t respond to disagreement by being unreasonable.

What Vietnam Taught Us

A Marine at Vietnam Memorial on 4th July 2002
A Marine at Vietnam Memorial on 4th July 2002 (Photo credit: Wikipedia)

I’ve noticed an uptick in book, news and blog references to heroin addiction among returning Vietnam vets. (A Google news search suggests that this perception is accurate. I suspect it’s because it offers a narrative that’s consistent with the current monoculture.) It’s claimed that this offers important lessons about addiction and behavior change.

In May of 1971 two congressmen, Robert Steele from Connecticut and Morgan Murphy of Illinois, went to Vietnam for an official visit and returned with some extremely disturbing news: 15 percent of U.S. servicemen in Vietnam, they said, were actively addicted to heroin.

Soon a comprehensive system was set up so that every enlisted man was tested for heroin addiction before he was allowed to return home. And in this population, Robinsdid find high rates of addiction: Around 20 percent of the soldiers self-identified as addicts.

Those who were addicted were kept in Vietnam until they dried out. When these soldiers finally did return to their lives back in the U.S., Robins tracked them, collecting data at regular intervals. And this is where the story takes a curious turn: According to her research, the number of soldiers who continued their heroin addiction once they returned to the U.S. was shockingly low.

“I believe the number of people who actually relapsed to heroin use in the first year was about 5 percent,” Jaffe said recently from his suburban Maryland home. In other words, 95 percent of the people who were addicted in Vietnam did not become re-addicted when they returned to the United States.

This flew in the face of everything everyone knew both about heroin and drug addiction generally. When addicts were treated in the U.S. and returned to their homes, relapse rates hovered around 90 percent. It didn’t make sense.

Studies of this cohort do offer some important lessons, in particular, that exposure to opiates does not create addicts on a large scale. But the lesson is not this:

It’s important not to overstate this, because a variety of factors are probably at play. But one big theory about why the rates of heroin relapse were so low on return to the U.S. has to do with the fact that the soldiers, after being treated for their physical addiction in Vietnam, returned to a place radically different from the environment where their addiction took hold of them.

These stories often ignore the fact that:

there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty.

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

It’s worth noting that this can cut in both directions. There’s a tendency to respond to problem users (people who drink too much, but are not alcoholics.) and dependent non-addicts (most pain patients or these returning vets) as though they are addicts. This results in bad treatment for those people, bad research and it manufactures resentment toward treatment, mutual aid groups and recovery advocates.