2014’s top posts: #8

Opioid addicted brains recover and residential more effective than medication for young opioid addicts

keep-calm-and-heal-your-brainSeveral years back, Bill White pointed out that we’ve learned an enormous amount about the neurobiology of addiction but know nothing about the neurobiology of recovery.

This week, a small study focused on just that:

The researchers performed several tests to assess changes in the “brain reward system” during early recovery.  After drug withdrawal, many people with opioid dependence have “persistent changes in the reward and memory circuits”—they may experience heightened “rewards” or “pleasure” in response to drugs and related stimuli, but greatly reduced responses to naturally pleasurable stimuli (such as good food, or friendship).

Dr. Bunce explains, “This is thought to occur because opiates are potent stimulators of the brain’s reward system; over time, the brain adapts to the high level of stimulation provided by opiates, and naturally rewarding stimuli can’t measure up.”  Such dysregulation of the natural reward system may contribute to the high risk of relapse during recovery.

The test results showed several significant differences in the reward system between groups.  A test of startle reflexes showed that patients with recent drug withdrawal had reduced pleasure responses to “natural reward” stimuli—for example, pictures of appetizing foods or people having fun.

In brain activity studies, patients with recent drug withdrawal showed heightened responses to drug-related cues, such as pictures of pills.  In the extended-care patients, these increased responses to drug cues—in a region of the brain called the prefrontal cortex, involved in attention and self-control —were significantly reduced.

Patients who had recently withdrawn from opiates also had high levels of the stress hormone cortisol (adrenaline).  In the patients who had been drug-free for a few months, cortisol levels were somewhat reduced, although not quite as low as in healthy controls.  The recently withdrawn group also had pronounced sleep disturbances, while sleep in the extended care group was similar to controls.

All of these changes—brain and hormonal responses to drug cues and natural rewards, as well as sleep disturbances—were correlated with abstinence time.  The more days since the patient used drugs, the lower the abnormal responses.

The study supports past research showing dysregulation of the reward system during early recovery from opioid dependence.  It also provides evidence that these responses may become re-regulated during several weeks in residential treatment—a period of “clinically documented” abstinence from opioids.

That’s a potentially important step forward in addiction medicine research, Dr. Bunce believes.  “It shows that if the patient remains in treatment and off drugs for several months, the body’s natural reward systems may have the capacity to return toward normal, making it easier for them to remain drug-free outside the treatment setting.”  With further study, tests of the natural reward system might provide useful, objective markers of recovery—clinical tests that help to evaluate how the patient’s recovery is proceeding.

It is a small study, but it challenges the notion that the brains of opioid addicts are damaged in a permanent way that requires opioid maintenance treatment.

Another recent study compared one year outcomes for 12 step facilitation residential treatment and office-based buprenorphine treatment.

A study from the Harvard-affiliated Massachusetts General Hospital (MGH) Center for Addiction Services found that a monthlong, 12-step-based residential program with strong linkage to community-based follow-up care enabled almost 30 percent of opioid-dependent participants to remain abstinent a year later. Another recent study found that 83 percent of those who entered an office-based opioid treatment program had dropped out a year later.

“Our results suggest that abstinence-focused, 12-step residential treatment may be able to help young adults recover from opioid addiction through a different pathway than the more typical outpatient approach incorporating buprenorphine/naloxone treatment,” said John Kelly of the Center for Addiction Medicine in the MGH Department of Psychiatry.

. . .

“Our study emphasizes the importance of strong linkage between residential treatment and continuing care,” says Schuman-Olivier, who also is with the Outpatient Addiction Services at Cambridge Health Alliance. “Right now there is a huge gap between residential and community services in many health systems. Yes, residential treatment can be costly, but with an opioid-dependence epidemic that has led to frequent overdose deaths, it’s important to think about what works, not just costs. We have evidence that outpatient treatment for opioid dependence is not as effective in young adults as it is in older adults, so we need alternatives to protect this vulnerable population.”

Now, 30% is not what we’d like to see, BUT the average duration of residential treatment in this study was only 25 days. (It did not describe the continuing care that the patients received.) These outcomes are also much better than recent studies on buprenorphine retention with young patients and drug use outcomes.

OD Awareness and both/and approaches

NARCAN-KITYesterday was International Overdose Awareness Day. Where do we stand?

This crisis has brought some good policy changes. Naloxone distribution programs are spreading fast and good Samaritan laws are spreading too. These policy changes will undoubtedly save lives, and that’s important.

There’s also no doubt that there are a lot of deaths that these programs won’t prevent. Consider the death of Phillip Seymour Hoffman. As is common, he appears to have died while using along, which casts doubt on any suggestions that naloxone and good Samaritan laws would have saved him. Even for those they save, they don’t offer a way out of their suffering and a lives that they hate.

fr2plus-overview-main-450x330How are we doing in terms of access to treatment of adequate intensity and duration? We don’t have much in the way of statistics for that, but it’s save to say that we’re not doing so well. We’ve got models that work really well, but we only use them with health professionals, lawyers and pilots.

Too often, we’ve had one faction calling for more treatment and another calling for harm reduction.

Naloxone is not enough. And, even access to quality treatment of adequate duration and intensity were improved, we couldn’t engage and successfully treat everyone.

We need a both/and approach rather than an either/or approach. Let’s increase access to naloxone and make sure that every rescue is followed by the kind of care an addicted health professional would get.



Learning from the AIDS epidemic



The American Journal of Medicine has an interesting commentary examining parallels between the AIDS epidemic and the opioid epidemic.

While the early history of government inaction, public fear, and stigmatization of HIV/AIDS is a shameful stain on this country’s conscience, 30 years later we have achieved tremendous victories, and the disease has transitioned from a veritable death sentence to a chronic condition for which most live a normal life, many with just a pill a day. The collaboration of affected communities, the public health system, physicians, and ultimately, government agencies to advance scientific understanding and disseminate an effective model of care provides lessons applicable to our current opioid epidemic.

To effectively address opioid addiction in this country, we need a comprehensive campaign for prevention, diagnosis, and treatment. Standard-of-care treatment models must be developed and disseminated based on existing evidence. Enhanced education of the medical community is necessary, and educational resources for addiction in medical training should be equivalent to that of other chronic diseases. While the intertwined issues of educational opportunity, employment, safe housing, and poverty must be acknowledged, remedying social determinants of health is not a prerequisite for implementation of effective treatment. Lastly, we could learn a lot from the HIV/AIDS campaign of “nothing for us without us” and involve patients with addiction in the design and implementation of programs meant to serve them.

There are immediate steps that can be taken to address the catastrophic death toll from unintentional overdose. Routine distribution and training in the use of naloxone, an opioid antagonist, is an effective and scalable intervention that is proven to save lives. Efforts to reformulate pain medications and decrease the availability of painkillers through physician education, prescription drug-monitoring programs, and crackdowns on “pill mills” also are important in preventing future addiction. However, we must be cognizant of those already addicted who, as the availability of pharmaceutical opioids declines in the absence of effective treatment, may turn to illicit opioids thereby introducing many other problems.

Ryan_2From the perspective of a provider who has worked with a few AIDS patients, it seem that the sea change moment was the passing of the Ryan White CARE act when we started making very expensive care available to low income AIDS patients, regardless of their insurance or ability to pay.

The average annual cost of HIV care in the ART era was estimated to be $19,912 (in 2006 dollars; $23,000 in 2010 dollars).3 The most recent published estimate of lifetime HIV treatment costs was $367,134 (in 2009 dollars; $379,668 in 2010 dollars).4

What would happen if we passed legislation that allowed all addicts to access the same kind of treatment that addicted health professionals get? How would the cultures of addiction treatment and addiction change. How would cultural attitudes toward addiction change? If there was a way out? For everyone?