Thursday, September 29, 2016

Help for Chronic Pain Patients

A lot of the patients who come to us to be detoxed off opiates have never used street drugs. They are chronic pain patients who have become dependent on opiate pain medicine prescribed to them in a doctor’s office.
These are patients who started on narcotic pain medication for significant painful conditions, but they are now stuck on the medicine and unable to stop on their own. It can be a very cruel situation because they are taking chronic pain medicine, but they are still in a lot of pain. Sometimes, they become dependent on the opiate pain medicines because they had to take the medicine for such a long period of time. This caused their body to become very dependent on the painkiller medications.
Sometimes, they had a pre-disposition for addiction, so the opiate pain medicine very quickly set off a physical dependency. In other situations, they had a previous addiction to alcohol or other drugs, and now, they have been prescribed narcotic pain medicines and that quickly leads to them being becoming addicted to this new medicine.
When these opiate pain medicines are taken over a lengthy period of time, they change the brain and the body in ways that are not helpful. Chronic pain is quite different from acute pain. In an acute pain situation, like a broken bone, the brain responds well to the pain by making its own natural endorphins and any pain medicine works well to supplement relief. But, in a chronic pain situation, opiates are often taken over a prolonged period of time. When opiate medicines are taken over a protracted period, tolerance starts building up rapidly so that the same dose of medicine loses its effectiveness, and then, people need more and more in order to receive the same effect.
Unfortunately, when high doses of the narcotic medicine are taken, more side effects start showing up, as well. Worse yet, is the brain’s endorphin system gets suppressed so that the brain loses its ability to make its own endorphins. This typically causes the patient has have less energy, less good quality sleep, and more pain. People often notice they are having a lot more of the same pain they were taking the medicine for, but they also have a lot more other aches and pains.
This can even transfer into emotional pain, as patients taking opiate pain medicines for a long time, often feel more irritable, grumpy, depressed, and anxious. They generally don’t feel very happy. They have low energy. They are usually frustrated and lose much hope for a better future. Of course, they do get some relief from these negative feelings when they take their opiate pain medicine, but they only achieving a short period of relief. The pain medicines quickly wear off and this leaves the patient feeling worse than before.
As a result, the typical pain patient has to still live with a lot of pain. The pain they originally started with is still there and not getting any better. And, the rest of their life feels painful, too. Sometimes, it is very hard for patients to determine if the pain they are feeling is really that bad, or they are just suffering with withdrawal from the opiate pain medicines they are taking. It is difficult for the patients to know if they would be better off without the pain medicine, since it is really not helping relieve the pain.
A number of patients come to us wanting to get off their pain medicine because they have come to believe that that the pain medicines are really not working well, and their quality of life is poor. They are willing to take a risk that the pain they are suffering from, will not be too bad, and in fact, they have starting to believe that they will actually be better off without opiate pain medicines. Our experience has been very dramatic with these patients. Over 90% of the chronic pain patients who have detoxed off their opiates have found that the pain they have is actually less when compared to when they were taking their opiate painkillers.
This month, we have a video of a patient who was in this chronic pain dilemma. And, he was willing to share his story of what his life was like on the painkillers, and then, let us video him as he went through our accelerated detoxification. He has found, like most of our patients, that just a few weeks after the detoxification, his pain is considerably less and his quality of life is dramatically better.

Friday, July 29, 2016

New Suboxone® Limits for Physicians


by Peter R. Coleman, MD
Recently, the U.S. Department of Health and Human Services decided to increase the number of patients that physicians can treat with Suboxone®. Beginning around 2002, physicians who went to a training program have been allowed to prescribe Suboxone® for up to one hundred patients.  This has become an important treatment option for opiate-dependent patients and has undoubtedly led to many patients stabilizing their lives and committing to long-term recovery.
When determining rules for Suboxone® treatment, the government intentionally chose a design that was different from methadone programs.  Methadone was approved as a treatment for opiate addiction around 1970.  Because it is an addictive and abused drug, it could only be given out in licensed clinics. Restrictive regulations were put in place, including required daily attendance at the clinic, and supervised consumption of medications. In some ways, the regulations contributed to the problem.  It is difficult for patients on methadone to travel or hold a job, and they are regularly exposed to other actively using drug addicts.  
In order to avoid the same consequences, rules for Suboxone® were designed to allow a physician in private practice to prescribe Suboxone® type products for up to one month or longer.  There were, however, no requirements for counseling, drug testing, or any other case management services.
The Suboxone® program has been somewhat successful and has allowed many patients to change their drug addiction/dependent lifestyle.  However, because there are very few regulations, we are experiencing an influx of clinics which provide prescriptions for Suboxone® with minimal psychological help for the underlying addiction.  Some of these clinics only take cash, spend minimal amounts of time with the patients, and do little more than supply drug addicts with their drugs.  Without these clinics providing any other resources or encouragements to transition to a sober life, it is sometimes hard to tell a difference between them and people on the street who sell their products for cash.
Thankfully, the latest regulations will be an improvement to the industry.  The regulations have fairly strict requirements for physicians to be able to prescribe Suboxone® for more than 100 patients.   Providers must be an Addiction Medicine Specialist with extra credentials, and they have to be in a qualified practice setting. The qualified practice has to accept insurance, provide case management, and be available for emergencies.   These are major improvements that will hopefully change the Suboxone® process and enhance access for patients who need treatment.

Tuesday, June 28, 2016

Medication-Assisted Treatment - MAT

by Peter R. Coleman, MD

Recently, the New York Times ran an article proposing that most opiate addicts should receive Medication Assisted Treatment (MAT).  I couldn’t agree with them more.

Success rates for patients with opiate addiction who are not treated with any form of MAT are horrible.  An important study I have quoted for many years made this abundantly clear. The study was out of Seattle.  It followed 124 patients who went into a hospital to start their recovery from opiate addiction.  About 26% were not even able to complete the detoxification. The others were all offered good treatment options - 28 day inpatient rehab, outpatient counseling, recovery residences, etc.  After 3 months, there were only 4 successful patients. This equates to a success rate of only 3%. And, all of these patients were motivated. They went into a hospital to get clean. But, there is something about opiate addiction that makes relapse so much more likely than other addictions.  Hence, the need for MAT.

The challenge is many physicians have little or no experience with naltrexone therapy, so when they think of MAT, the only options they think about are methadone and Suboxone®. (Even the New York Times article recommended MAT, but the article did not once mention naltrexone).  Methadone has been used since the 1970s.  Experience and numerous studies show that methadone does cut down on crime rates and street drug use.  But, most patients do not like being on it, and of course, it is much more addictive than heroin.  It is also more difficult to detox off methadone than it is to detox off heroin. The other MAT that most physicians think of is Suboxone®.  Suboxone® has been approved as a treatment since abut 2002. When it was first approved, it seemed like it could be a miracle cure. Patients reported reduced cravings and they used less street drugs.  But over time, we have found there is quite a lot of abuse of Suboxone® and the long- term success rates are not particularly high.  In fact, a recent study in the American Society of Addiction Medicine (ASAM) journal followed a group of adolescents who were started on Suboxone® while in an inpatient unit. Within only 2 months, half of them had relapsed and discontinued treatment. At the end of 12 months, only 10% of the group were abstinent – hardly a perfect treatment.

Naltrexone is the other MAT that is now gaining more acceptance in mainstream medicine. For some time, naltrexone has been available as an oral tablet which lasts for about one day.  It is effective if people take it, but in the real world, most people do not take it for more than a day or two.  In some settings, particularly when probation officers observe people taking oral naltrexone, it can be effective.  But, it is almost never effective if it is not being actively supervised.  In fact, there is some thought that the act of taking the oral naltrexone could actually be a trigger, and thereby increase relapse rates.  Some patients report that taking daily oral naltrexone actually reminds them they could use if they really wanted to and they sense their cravings go up.

Naltrexone does work if patients are “forced” to take it over a long period of time.  If the naltrexone is medically put into patients and they can’t “not take it”, it is extremely effective.  For over 18 years, we have been using two-month naltrexone implants and our patients love them.  Because they last a longer period, our patients rapidly accept the reality that they can’t use and they do better getting on with their lives.  Most report their cravings completely go away.  Over the last several years, Vivitrol® has become available as a one month injection, and it too, is very effective.  Because it is FDA-approved it is usually covered by insurance, and so a lot more doctors are more familiar with it.  In fact, a landmark study was just published in the New England Journal of Medicine (NEJM).  In the study, Dr. Lee and his colleagues followed about 300 patients who were involved in the criminal justice system.  Half of the patients received monthly shots of Vivitrol for 6 months, along with some counseling.  The other half only got the counseling.  The patients who received the Vivitrol® had a 57% success rate with no relapse, which is a remarkable finding.  This is so much better than the 3% rate for patients without MAT. The other interesting result of this study was that the patients in the Vivitrol® group had no overdoses, while the patients in the group that only received the counseling, had 5 overdoses.

It is exciting for me to be working in a treatment system where we are able to use the naltrexone version of MAT in all of our patients. After every opiate detoxification, we insist on either a 2 month naltrexone implant, or Vivitrol® injection.  At TCI, we see incredible success with our patients. Since we recommend that our patients stay on naltrexone therapy for 12 months, we have the opportunity to see most of them back for follow-up visits. Our patients and their families are very grateful.  

One of our biggest issues now is convincing patients to stay with treatment. They often feel so good; they start thinking they can stop the MAT. The evidence is clear: naltrexone should be continued for at least 12 months.

Friday, May 27, 2016

Online Porn May Damage Teenage Brains

by Peter R. Coleman, MD

The internet is a marvelous thing. It can bring us information at lightning speed and help us learn things, get places, and entertain ourselves. Some of us older folks can remember life before the internet, but it is hard for anyone to imagine life now without the internet. But new inventions can have unintended consequences.

There have always been some people who enjoy sexual arousal and new inventions have often been used to feed that appetite. Soon after photographs were invented, some enterprising fellows began to make pornographic pictures. When moving pictures were invented around 1900, it was not long after that there were pornographic movies being made and watched. And, so it is with the internet. From the earliest days of the world-wide web enterprising people started to make money by providing pornography online.

There has been, and always will be, a ready market for pornography – it excites the Dopamine part of our brain that is biologically wired for sex and survival. We are born with a natural strong desire for sex, and anything that excites that part of our brain has a strong influence on us. Did you ever notice that beer and car TV commercials almost always involve seductively clad women?  Online pornography has taken this to a new level. The numbers are staggering. In the US alone, there are over 100 million visitors to adult sites every month. It has been calculated, just in 2015, there were more hours spent on one particular pornography website than the number of hours that Homo Sapiens have been in existence!

The problem is all of this online pornography is not so good for us. The worlds of pornography and addiction actually intersect. The common denominator with these things is that, just like addictive drugs, online pornography hyper-stimulates the pleasure centers in the brain – it stimulates those parts of our brains more strongly than the brain was ever meant to be stimulated. We all know that the reason that drugs like oxycodone and heroin are so addictive and so damaging, is because they hyper-stimulate the pleasure center of the brain. Addictive drugs release so much Dopamine that people experience such a pleasurable effect, they continue to come back for more, even when there are serious negative consequences. High image visual pornography does the same thing. It presents images in such a powerful way that the pleasure center gets hyper-stimulated. And, this high image pornography is very available. Many, perhaps the majority of teenagers, have figured out how to get an unlimited supply before they are 14 years old. It is so readily available that even when “tolerance” inevitably sets in (getting bored with the current images), it is very easy to switch and watch something new.
There are three problems with overstimulating the pleasure center with drugs or pornography. The first problem is the hyper-stimulation releases all of the Dopamine available, so that afterwards, there is none left. When there is no Dopamine left, regular things don’t seem as pleasurable any more.
The second problem is over-stimulation of the pleasure center resets our expectations about what is pleasurable. Online pornography can actually ruin some truly pleasurable things in life. Drugs and online pornography hyper-stimulate our brains so much that regular life starts to seem “not enough”. We see people in early recovery from drug addictions, find themselves feeling depressed and bored with life. Normal pleasures like spending time with family, watching movies, eating a good meal, being in nature, and participating in sports, have all lost their relevance. Online pornography does the same thing. Many young men are reporting that normal healthy relationships don’t get them very excited. There has now been identified a new condition called PIED – Pornography Induced Erectile Dysfunction. There are reportedly many people affected and there are whole organizations set up to help people who have this condition. The concept is once your brain has become used to the unrealistic, graphic and never ending images of online pornography, regular sexual relationships are not sufficiently stimulating. And, some men are reporting long lasting erectile dysfunction. They say they would like to be sexual with their partners, but they find themselves not very interested. This leaves many women feeling confused and feeling inadequate. Online pornography is poisoning a lot of relationships.

The third problem is even worse. Teenagers have developing brains, and when these brains are exposed to this hyper-stimulation from on-line pornography it has the potential to cause long lasting or even permanent developmental problems. During childhood, adolescence and even early adulthood, our brains are developing. Young adults are creating new brain cells and new pathways. The pathways that get used a lot are deemed to be more relevant and these pathways become stronger. If the pleasure center is overstimulated, it can fail to develop its full size, and actually end up smaller.  There is some evidence this is happening in some teenage brains exposed to online pornography.  The damage may even be permanent – we just don’t know yet.

One question which is being asked is whether online pornography is any more dangerous than print magazines. The answer lies in the difference between cocaine powder and crack cocaine. They both have the same basic ingredient, but crack cocaine gets into the brain much faster and more powerfully, and it releases much more dopamine. Crack’s effects on the brain are much more severe.

The internet, with highly graphic, instantly available videos, has created an ongoing experiment with our teenagers. The results are not yet fully known, but ultimately, could have significant and devastating consequences.

Monday, April 11, 2016

Expecting Miracles

By Joan R. Shepherd, FNP 

I’m not saying that miracles can’t and don’t happen anytime and anywhere, but seeing miracles is a daily occurrence in my job.

For instance…this week James* came in to get his second naltrexone implant. April did the implant, but she grabbed me on his way out and said, “I knew you’d want to say hello to James.”

Now I’m getting older and a lot of times it takes me a minute to remember who I’m looking at. That’s what was going on as I looked at this handsome, smiling young man in front of me. He grinned kind of sheepishly and said, “ Sorry I gave you guys such a hard time during my detox.”

And then I remembered. James was terrified of the Accelerated Opiate Detox process. He had heard some horror stories about the ultra rapid detox done under anesthesia, but even more than that, he was terrified to give up his dope. It had become a very reliable friend to him. He had a three-week old son at home, and he knew he wanted to be the kind of dad this little one deserved. So he took a deep breath and went through with it.

Checking on him the first couple weeks after he was done, James was struggling with anxiety and sleeping issues. We encouraged him, gave him some tips, urged him to continue with the therapist we’d helped him find and assured him what he was feeling was normal.

And now, here he was, two months later. The 145 pound, 6 foot, acne-ridden guy that was with us in January was transformed. James has put on 15 pounds. His skin is clear, his smile is huge.  He proudly flashed us a picture of his son.

That’s a miracle.

Look for another miracle story in the next couple days.

Joan R. Shepherd, FNP

*I don’t use anyone’s real name, and I change details that might identify a patient.

Monday, March 28, 2016

The New Fentanyl Epidemic

by Peter R. Coleman, MD

Just when you thought the heroin epidemic was bad enough, now we are seeing a new and even worse epidemic - Fentanyl.   We started to hear about Fentanyl since it has been a contributing factor in many recent overdose deaths. 

In its prescription form, Fentanyl is known as Actiq, Duragesic, and Sublimaze. Street names for the drug include Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, as well as Tango and Cash.

Over the last year or two, there have been many clusters of fatal overdoses in communities all over America - often 10 or more people dying in one community in one weekend. And the cause has been found that people who were buying heroin on the street was mixed with Fentanyl.
Fentanyl is a synthetic opiate, just like Percocet, oxycodone, heroin and all of the others - except it is even more powerful, and even more deadly. Fentanyl is 50 times more powerful than heroin. It acts quickly and it seems to shut off the breathing control centers in the brain even more than other opiates. Fentanyl has been used with medical patients for over 30 years. It is very fast acting, and very powerful, so it is used routinely in anesthesia to put patients to sleep.  It does its job of putting someone into a complete coma very efficiently, but if the patient is not intubated and on a breathing machine, it stops them from breathing and the patient dies very quickly.
Now, Fentanyl is readily available on the streets, and it is causing a lot of fatal overdoses. Last year, just in New Hampshire, Fentanyl killed five times more people than heroin (158 Fentanyl overdoses versus 32 heroin overdoses).  Fentanyl is now available on the streets because drug cartels in Mexico have figured out an easy way to increase production. There are some reports that it is even easier and cheaper to make than heroin. Illegal labs in Mexico are producing the drug in record quantities, and it is turning up in drug busts in America in record amounts.
Fentanyl seems to be even more addictive than other opiates. Fentanyl is about 100 times more potent than Morphine. It is so addictive because it acts very quickly in the brain. There is now a lot of evidence that the faster a drug acts and causes a Dopamine release in the brain, the more it is addicting. Fentanyl is extremely fast acting. It is the drug of choice for most anesthesiologists who themselves have a drug addiction.  Most of these physicians will tell you that the drug was so strong and so pleasurable that they became completely dependent and lost all control within a week or two of trying it once.
Fentanyl is also more dangerous because it is so potent. While heroin is measured in milligram doses (1/1000 of a gram), Fentanyl is measured in micrograms (1/1,000,000 of a gram). It is almost impossible to measure the dose accurately, because the quantity of powder is so small. It would be difficult even for a trained pharmacist with accurate scales and equipment to measure a dose of Fentanyl accurately. The thought that addicts are buying a white powder on the street, they have no idea of the concentration or purity, and then, they have to calculate how much to take so they get a safe dose is truly frightening. Even worse, now when Fentanyl is mixed in with heroin, the drug user will most likely have no idea of the presence of Fentanyl.
I am very worried about this drug and what is likely to happen. There are a many reports when street addicts hear about this more powerful drug, that is causing overdoses, they are trying even harder to get their hands on it. They want a powerful high and they want a drug that is stronger, so it will be less expensive. They all believe that they will be able to control it and they won’t use too much. They have no idea what they are getting in to. Even trained anesthesiologists have a high rate of fatal overdoses when they use this drug. Now that Fentanyl is easier to produce, there is a high demand on the street, and use is increasing, the situation is only going to get worse.

Monday, February 29, 2016

Probuphine® - A New Buprenorphine Implant

by Peter R. Coleman, MD

Titan Pharmaceuticals has been developing their long lasting Buprenorphine implant for about 10 years now. They have been trying to get the FDA approval for many years. They have made a lot of progress and have come close to getting FDA approval a couple of times, but this month they got another delay. The FDA has some reservations about allowing this drug on the market, and wants at least another 6 months to study all of the ramifications. Right now, we are living through a serious epidemic of opiate addiction. There are reportedly 2.5 million people in the US with an opiate addiction and fatalities are at an all-time high. It is clear that we need to have multiple tools at our disposal to combat the disease. It may well be that Probuphine will be an effective tool.

Probuphine® is an implant which contains Buprenorphine, the active ingredient in Suboxone®, Subutex and Bunavail®. The implant is inserted under the skin and delivers a dose of the medicine for about 6 months. Buprenorphine tablets and film have been available since 2000 and they have become a very popular treatment - about 1.5 Billion dollars in sales last year. Buprenorphine products relieve a lot of the withdrawal and cravings for opiates - so patients like taking this medicine. But, one of the problems with any product containing Buprenorphine is that the drug is highly addictive. Buprenorphine relieves the withdrawal and cravings for opiates because it attaches to the same opiate receptors similar to heroin and OxyContin®. In fact, it binds so tightly that most patients have more trouble getting off Suboxone® than they do getting off heroin. The withdrawal symptoms off any Buprenorphine product last so long that most patients go back on their drug or they go back to using street drugs.

Two other problems that have become very apparent with Suboxone® and the other Buprenorphine products - diversion and misuse of the drug. Many patients will admit they frequently divert their medicine. They sometimes use less of the drug than they are prescribed, or they sometimes skip some doses in order to sell their “extra” doses to other people. There is quite a street value for Suboxone® because it is cheaper than heroin and prescription opiates. It can tide heroin addicts over if they can’t find or afford their drug of choice. Some people also misuse their Buprenorphine products by injecting them. More commonly, people misuse their treatment by skipping a few days so that they can then feel a stronger high from using heroin - not exactly what was intended by the FDA when they approved these medicines to help patients get into recovery.

Probuphine® has the potential to relieve both of these problems. Once patients receive their implants they will not be able to skip doses or sell their medicine, and it will be lot harder to override their treatment. There are other potential benefits from this treatment. A six-month implant will make it more likely that patients remain in treatment for at least 6 months. It has also been said that an implant can break the cycle of having to take a pill each day. This may help patients feel more normal and less like a drug addict. There is also less likelihood of children accidentally taking the medicine and suffering from an overdose.

The big question of course is what are the downsides of this treatment, and the truth is that at this point, we do not know. We won’t know all of the problems with Probuphine® until it is used in clinical practice, and I think this is why the FDA is being quite cautious about allowing its introduction.

One issue is the amount of Buprenorphine that are delivered - are they appropriate levels, and are they consistent over time? In fact, the implants deliver quite high doses of Buprenorphine initially, but over the 6-month life span of the implants, the amount delivered drops off somewhat. It is not clear if this presents a problem. There could be a problem because the loser doses of Buprenorphine will cause an increased number of relapses as the dose goes down. Alternatively, it could be a good method of weaning off the Buprenorphine as patients recover. Another issue is what happens if people use extra drugs - either more Suboxone®, or street drugs. In the earlier studies, patients who got implants were also allowed to use extra Suboxone® tablets for cravings - which many people did. But using extra doses of Suboxone® while on the implant defeats the purpose of the implant, as far as diversion goes - people will still have “emergency” doses around that they can sell or use themselves. Another question is how effective the treatment is. In the original studies, only about 65% of the patients completed the 6 month program, so there was a high dropout rate. Also, in the early studies, most patients continued to abuse opiates. In fact, around 60% of the patient with implants still continued to use street opiates. It is clear these implants are not a cure for addiction.

Another issue concerns what to do after the treatment is over. The implants have to be removed after the 6-month period and questions remain about how easy they will be to remove. Another question arises for the patients who don’t come back to have the implants removed and what effect it will have on their long term health if the implant stays in for an extra year or two.
Finally, it is not clear what will happen to patients when they want to stop their implant treatment. After the implant loses its effectiveness, patients will definitely go into major withdrawal. Withdrawal off Buprenorphine is much worse to recover from prescription opiates or Heroin. Presumably, the intention will be for the patients to transition back to oral Buprenorphine products and then detoxify from those.

Here at TCI, we are seeing more and more patients who get onto Suboxone® or other Buprenorphine treatment and are unable to stop taking it. They cannot stand the long and intense withdrawal symptoms coming off these products.  Fortunately, our Accelerated Opiate Detox program works very well for these patients.

So, it may be that Probuphine® implants do have a place in the treatment of opiate dependence.  There are a lot of questions, and as mentioned, we will likely have to wait for the product to be released before we really see how well it helps and what are the related problems. At TCI, we have been using Naltrexone implants, as opposed to Buprenorphine Implants, for more than 17 years. These Naltrexone implants block all opiates and dramatically reduce cravings, helping patients stay off opiates. I have to say that when I look at the research on Buprenorphine implants, I am more and more confident and satisfied with our treatment protocols. Our patients usually report no cravings at all. They are able to concentrate on their therapy and their recovery program. Many are able to use the Naltrexone implants to achieve long term recovery.