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Patients who had recently withdrawn from opiates also had high levels of the stress hormone cortisol (adrenaline).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  The recently withdrawn group also had pronounced sleep disturbances, while sleep in the extended care group was similar to controls.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.

NY Times / Suboxone redux

English: Suboxone tablet - both sides.
English: Suboxone tablet – both sides. (Photo credit: Wikipedia)

 

I thought I was done, but here are a couple more smart takes. Both support maintenance but appreciate the article raising awareness of important problems.

 

From The Institute Blog:

 

And as the articles (and the comment section) demonstrate, the use of buprenorphine to treat addiction and prevent substance use-related harms is messy.  Interlacing text and video, the NYT pieces illustrate those complexities skillfully.  Here are three points to keep in mind as you read:

1) Medication-assisted treatment reduces overdose deaths.

2) It is necessary and good that buprenorphine treatment is investigated and reported on.

3) Drugs are double edged.

 

From RecoverySI:

 

To sum it up briefly: Some really bad research was used to convince docs that there was an ‘emergency’ need for more potent opioids to treat chronic pain, and that when used properly, these new, more potent opioids presented little or no danger that the user would become addicted.

That turned out to be BS. Surprise.

The result: We’re in a drug epidemic with no South American cartels or Afghan drug lords to vilify. And with some elements in Big Pharma, and some docs, figuring how to get rich off it.

Right– that’s the same combo that got us here.

It’s my belief that many physicians, even the uncommonly brilliant and passionate ones, can have a major blind spot when it comes to the meds they prescribe. Somehow, they convince themselves that a medication is safe if they prescribe it.

 

It’s worth pointing out that they, also, are not making recovery arguments for maintenance.

 

 

Suboxone diversion?

Ah subutex!
Ah subutex! (Photo credit: nicolasnova)

A recent study looking at diversion of buprenorphine finds that:

While 9% reported recent street-obtained buprenorphine use, only a small minority reported using buprenorphine to get high, with the majority reporting use to manage withdrawal symptoms.

The use of street-obtained buprenorphine primarily to avoid withdrawal fits with Dawn Farm’s experience, though the percentage would be much higher than 9%.

We know that the experience in Europe has been different. For example, a 5 year study there found:

In 2007, 60.2% of the respondents claimed heroin or morphine as their first injected drug. This percentage had declined to 51.3% in 2010, but in contrast the incidence of buprenorphine as the first injected or abused drug by the study population increased from 30.5% (2007) to 44.4% (2010).

Why the difference? Well, a few possibilities come to mind:

  • That Europe adopted the drug earlier than the US.
  • That the brand most widely used in the U.S. includes naloxone, which is less desirable as a street-obtained drug.
  • That the American study was done in 2008, and things have changed rapidly since then.

The big question is whether we’ll see the kind of misuse that Europe has seen.

[Hat tip: Substance Matters]

Buprenorphine compliance rates

Choose you evidence carefully by rocket ship
Choose you evidence carefully by rocket ship

The following abstract popped up today.

The purpose of the study was to look at factors associated with completion of the 6 month, primary care based program.

What struck me was the completion rate–35.7%. For all the crowing about ORT, this seems really low. (And, they said this completion rate is consistent with prior studies.) This is particularly underwhelming when the researchers identify physical injury as a predictor of completions and speculate that this is related to chronic pain. These subjects constitute 71.7% of completers. So…when you omit those with injuries, the completion rate drops to 24%.

Primary care patient characteristics associated with completion of 6-month buprenorphine treatment

BACKGROUND: Opioid addiction is prevalent in the United States. Detoxification followed by behavioral counseling (abstinence-only approach) leads to relapse to opioids in most patients. An alternative approach is substitution therapy with the partial opioid receptor agonist buprenorphine, which is used for opioid maintenance in the primary care setting. This study investigated the patient characteristics associated with completion of 6-month buprenorphine/naloxone treatment in an ambulatory primary care office.
METHODS: A retrospective chart review of 356 patients who received buprenorphine for treatment of opioid addiction was conducted. Patient characteristics were compared among completers and non-completers of 6-month buprenorphine treatment.
RESULTS: Of the 356 patients, 127 (35.7%) completed 6-month buprenorphine treatment. Completion of treatment was associated with counseling attendance and having had a past injury.
CONCLUSIONS: Future research needs to investigate the factors associated with counseling that influenced this improved outcome. Patients with a past injury might suffer from chronic pain, suggesting that buprenorphine might produce analgesia in addition to improving addiction outcome in these patients, rendering them more likely to complete 6-month buprenorphine treatment. Further research is required to test this hypothesis. Combination of behavioral and medical treatment needs to be investigated for primary care patients with opioid addiction and chronic pain.

“It works!”, Ctd

This is "effective"?
This is “effective”?

A new study of buprenorphine implants find that implants work as well as oral dosing and outperform placebo.

What does that mean?

If I’m reading it correctly, it means that the average subject receiving the implant tested positive for opioids 68.8% of the time compared to 86.6% for the placebo subjects. (If I’m misreading it, set me straight.)

I don’t know about you, but that not how I’d define success for myself or a family member.

This speaks directly to the importance of asking, “what does ‘effective’ mean?”

Another article argues for morphine maintenance for opioid addiction.

If ORT is the direction the field is heading, why not? If questioning the assertion that ORT is the most effective treatment based on quality of life differences is a bogus argument*, why not morphine maintenance or heroin maintenance?

*  Note that I’ve argued that physicians health programs are the gold standard and that they should replicated and offered to all opioid addicts. I did not say that they standard abstinence-based treatment was superior or should be imposed on anyone. In fact, I’ve repeatedly argued that the standard abstinence-based treatment offered opioid addicts does not provide the appropriate quality, duration, intensity or dose.

Recovery for life?

Writing Desk 2008

Our friend Bill White has been blogging. This is great news! To my mind, he’s been the most important voice in addiction treatment, recovery and research of both. His writing is very accessible and he bridges experiential knowledge and empirical knowledge.

He’s also been amazingly prolific. The downside of this is that his body of work can be overwhelming. It looks like he plans to use the blog highlight important findings/stories/lessons with links back to the source documents. 🙂

His most recent post is on recovery for life:

“When does recovery today predict recovery for life?”  After investigating all of the scientific evidence I could locate on this question, I have regularly responded that this point of durability seems to be reached at 4-5 years of continuous recovery, meaning that less than 15% of those who reach that point will re-experience active addiction within their lifetime (with opioid addiction potentially being closer to the 25% mark).

Methadonia

When Methadonia was first released, there was quite a bit of hand wringing over whether the film inaccurately presented methadone maintenance treatment in a negative light.

Cassie Rodenberg, at The White Noise, who has been spending time with and blogging about homeless addicts in the Bronx says [emphasis mine]:

Some on the streets find methadone worse than an original heroin addiction, while others find the maintenance system workable. The documentary “Methadonia” interviews those in NYC recovery. For those curious, this is the closest thing I’ve seen to those I speak with every day, an accurate portrayal of life for low-income residents struggling with heroin addiction and recovery. Take a look for the stories.

What’s interesting is that anyone who’s spent time around heroin addiction has seen what we see in Methadonia, yet advocates insist it is not the reality of methadone. Yet, the reality they discuss is invisible to us. If we’re to believe them, it has to be on faith.

2012′s most popular posts #8 – Another Reaction to Hazelden’s Adoption of Suboxone

Perhaps I’m the Wrong Tool by Tall Jerome

Mark Willenbring, a former Director of the Treatment and Recovery Research Division of the National Institute on Alcohol Abuse and Alcoholism/National Institutes of Health weighs in on Hazelden’s embrace of Suboxone

Hazelden’s new approach is a seismic shift that is likely to move the entire industry in this direction. I told Marv that it was like the Vatican opening a family planning clinic! However, although this is a major positive step, they continue to be wedded to a strictly 12-Step approach along with the medication. I don’t see this ever changing. Hazelden has always seemed to operate like a Catholic hospital: science was ok as long as it didn’t conflict with ideology, and when it did, ideology won out.

His post betrays the trope that 12 steppers control the treatment world.

What are the beliefs driving his celebration of buprenorphine maintenance? In another post he offers what he believes should be the informed consent statement offered to opioid addicts entering treatment. [emphasis mine]

The only treatment proven effective for treating established opioid addiction is maintenance on a medication such as Suboxone or methadone, often with adjunctive counseling. Studies show that maintenance treatment reduces illness, mortality and crime, and is highly cost-effective. Therefore, it is the first-line treatment and the treatment of choice. There is no evidence of effectiveness for abstinence-based treatment.”

Wow. “The only treatment proven effective“? “There is no evidence“?

Mark Willenbring is a doctor. What kind of treatment would he receive if he became an opioid addict? Would he get Suboxone maintenance?

No. He would not.

Why? We don’t treat doctors with Suboxone maintenance. They get abstinence-based treatment.

Wait, what!?!?!? They get treatment for which there is “no evidence of effectiveness”?!?!?!?

Actually, there’s evidence that they have great outcomes with abstinence-based treatment.

All of the finger wagging about maintenance as the treatment approach with the strongest evidence-base raises some important questions:

  • Why do the most culturally empowered opiate addicts with the greatest access to the evidence base reject this evidence base with respect to their own care and the care of their peers?
  • What does this say about the evidence and its designation as an evidence-based practice? That this evidence doesn’t offer a complete picture?
  • What does it say that health professionals get one kind of treatment and give their patients another?
  • Why are some addiction physicians and researchers so indignant when others question their advocacy of a treatment approach that they and their peers refuse to use on themselves?
  • Does this advocacy of a medicalized approach have anything to do with the fact that they are indispensable in this medicalized approach?

 

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.

 

Another Reaction to Hazelden’s Adoption of Suboxone

Perhaps I’m the Wrong Tool by Tall Jerome

Mark Willenbring, a former Director of the Treatment and Recovery Research Division of the National Institute on Alcohol Abuse and Alcoholism/National Institutes of Health weighs in on Hazelden’s embrace of Suboxone

Hazelden’s new approach is a seismic shift that is likely to move the entire industry in this direction. I told Marv that it was like the Vatican opening a family planning clinic! However, although this is a major positive step, they continue to be wedded to a strictly 12-Step approach along with the medication. I don’t see this ever changing. Hazelden has always seemed to operate like a Catholic hospital: science was ok as long as it didn’t conflict with ideology, and when it did, ideology won out.

His post betrays the trope that 12 steppers control the treatment world.

What are the beliefs driving his celebration of buprenorphine maintenance? In another post he offers what he believes should be the informed consent statement offered to opioid addicts entering treatment. [emphasis mine]

The only treatment proven effective for treating established opioid addiction is maintenance on a medication such as Suboxone or methadone, often with adjunctive counseling. Studies show that maintenance treatment reduces illness, mortality and crime, and is highly cost-effective. Therefore, it is the first-line treatment and the treatment of choice. There is no evidence of effectiveness for abstinence-based treatment.”

Wow. “The only treatment proven effective“? “There is no evidence“?

Mark Willenbring is a doctor. What kind of treatment would he receive if he became an opioid addict? Would he get Suboxone maintenance?

No. He would not.

Why? We don’t treat doctors with Suboxone maintenance. They get abstinence-based treatment.

Wait, what!?!?!? They get treatment for which there is “no evidence of effectiveness”?!?!?!?

Actually, there’s evidence that they have great outcomes with abstinence-based treatment.

All of the finger wagging about maintenance as the treatment approach with the strongest evidence-base raises some important questions:

  • Why do the most culturally empowered opiate addicts with the greatest access to the evidence base reject this evidence base with respect to their own care and the care of their peers?
  • What does this say about the evidence and its designation as an evidence-based practice? That this evidence doesn’t offer a complete picture?
  • What does it say that health professionals get one kind of treatment and give their patients another?
  • Why are some addiction physicians and researchers so indignant when others question their advocacy of a treatment approach that they and their peers refuse to use on themselves?
  • Does this advocacy of a medicalized approach have anything to do with the fact that they are indispensable in this medicalized approach?