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.

Thursday, January 28, 2016

Dopamine: “The Anticipation Molecule”


by Peter R. Coleman, MD

For a long time, it has been known that dopamine is the pleasure molecule. After all, it is common knowledge that a large amount of dopamine is released in the nucleus accumbens area of the brain when we do pleasurable things - like eat food and have sex.  When the dopamine is released, we experience a strong sensation of pleasure and, of course, we are likely to want to repeat that experience.  We also know that all addictive drugs release massive amounts of dopamine in the nucleus accumbens - way more dopamine than we humans were ever meant to experience.  This heightened pleasure sensation is the biggest reason why people use addictive drugs.
 
But now, more light is being shed on just how complex are our brains and how different parts of the brain interact. Scientists are now also calling dopamine “the anticipation molecule” because it has been shown that dopamine is also released in large amounts when we anticipate a pleasurable experience.  We actually release dopamine in the nucleus accumbens and get a sensation of pleasure by just thinking about having one of these experiences. Actually, just thinking about having a pleasurable experience is not quite enough to release a lot of dopamine. The large amount of dopamine is released when two things happen - we both think about the pleasurable experience and there is a realistic opportunity that we will be able to have the pleasurable experience - true anticipation.
 
We can all relate to this and know that this is true. I’ll stick with the food example.  Let’s say we are quite hungry and someone brings out a plate of warm chocolate chip cookies.  We are suddenly presented with the opportunity to eat one of our favorite comfort foods.  In this situation our brains will actually release a small amount of dopamine and we will experience a thought - “maybe I should have one cookie”.  We start to process this situation and think about the different possibilities. We could refuse the temptation and not have the cookie, or maybe we think that we could have just one.   Our thoughts about the cookies begin to become a little more like a desire.  We analyze the pros and the cons.   Our thoughts are becoming more like a craving.   Our mind starts to swing towards making the decision that one cookie wouldn’t be so bad, and “What the heck - I deserve it”, or “Why not - I can go to the gym later”. As we allow these thoughts to build, we start to imagine what the cookie will taste like and how it will be amazingly delicious.  Our old memories kick in.  At this point, our pleasure center is releasing so much dopamine, we are getting very excited and we can’t wait to eat that cookie. We know how good it is going to be! We feel great!
 
And then, we bite into the cookie, and it happens - the cookie wasn’t that good.  It was an okay cookie, but it was not nearly as good as we had imagined. “The cookie lied to me!”  “Now I am going to get fat, and for what - a lousy cookie that didn’t even taste that good”.  It is amazing to know we actually got more dopamine from anticipating the cookie than we received from the cookie itself.
 
Drug addiction is just the same.  Even patients who are physically addicted to opiates have to go through all sorts of mind games each time they decide whether to use or not. They all know using drugs is bad, horrible, and they should stop.  But, once they have the opportunity to use, the dopamine kicks in so strongly that not using becomes almost impossible. And, frequently, it is just like the unsatisfying cookie - it wasn’t that satisfying.  Addiction is cruel for both the addicts and everyone around them.

Monday, January 4, 2016

6 Ways to Keep your Resolution for Sobriety


by Gabriella Pinto-Coelho

For those struggling with an addiction to alcohol or another substance, the end of the year can be a challenging time. Thanksgiving, Christmas, and New Year’s can bring up old temptations and triggers that can make your goal for sobriety seem out of reach. But now that the overindulgent holidays are past us, we can focus on the possibilities of the New Year that lies ahead.

Approximately 40% of Americans make resolutions, viewing the New Year as a fresh start, a symbolic transition. While setting resolutions can be a great way to get clear and motivated about your goals, only 40% of those who make resolutions actually go on to keep them. This 60% failure to keep a resolution can stem from a variety of things - unrealistic expectations, lack of discipline, loss of motivation, or something else. I personally think that some of the trouble with keeping resolutions lies in our cultural “all-or-nothing” attitude when it comes to resolutions. For example, say you have a friend who has made a resolution to eat healthier. But on a snow day in February, she eats 10 cookies. 

Sadly, many people would throw in the towel at this point, thinking, “Today I went completely against my resolution, so I guess it’s over now.” In reality, keeping a resolution involves a less-than-perfect path. You might have days when you slip-up and others when you feel on top of the world. Doesn’t that sound a lot like the road to recovery? The point is, don’t give up on your resolutions when the going gets tough or when you take a few steps back. That’s life.

There are some other excellent ways to help yourself keep your resolution for sobriety in the New Year.

1.      Focus on what you are gaining from sobriety. When you frame your resolution as simply “not drinking,” you are making a negative statement. Instead, think and talk about your resolution as something like “freeing yourself from addiction.” Reframing your decision in a positive statement allows you to focus on the benefits that you get out of keeping your resolution.
2.      Forgive yourself for past mistakes and focus on making decisions you are proud of. Beating yourself up over what you did in the past will only create more pain and suffering in the present. Offering yourself some compassion and forgiveness will go a long way toward creating the life that you deserve.
3.      Let your friends and family know about your decision so you can develop a strong support system. Gathering the support of trusted loved ones allows you to get the encouragement that that you need as you navigate the road to recovery. It also holds you accountable to your resolution because the force of positive peer pressure can help keep you in check when you feel your motivation waning. Invest in relationships with the people that can be the helping hands you need.
4.      Do something altruistic. Volunteering not only helps those in need, but it can also give you a boost of self-esteem. When you feel good about yourself, you are more likely to take the necessary steps to take care of yourself.
5.      Face your demons in a healthy way. Many people start using alcohol and drugs as a way to escape their troubles. Whether it’s depression, anxiety, past trauma, insecurity, or something else, everyone has their demons.  Rather than self-medicating, make an appointment with a therapist and work through your issues. While therapy can be emotionally challenging, if you can attack the root cause of your addiction, you will set yourself up for long-term sobriety.

6.      Find clarity and meaning. Without drugs and alcohol clouding your outlook on life, you can start focusing on things that give you joy and meaning. Whether you decide to explore your faith, take up a hobby, learn a new language, travel, or something else, find something that gives you a sense of purpose. Living with intention will give you the attitude that you need to accomplish your resolution for sobriety.

Tuesday, December 22, 2015

After 5 Years of Recovery Are Patients Cured?




by Peter R. Coleman, MD

Recently, we have been hearing more and more about the idea that if people can sustain recovery for 5 years, they are (almost) cured. The concept is, just like a cancer diagnosis, if people can be free of their disease for five years, then the chance of the disease coming back is very unlikely - we can almost say they are cured. It is very unlikely that relapse will occur.

This idea appears to go beyond traditional thinking. We all know the saying - "once an alcoholic, always an alcoholic". We also refer to people in recovery as being "in recovery" and not "recovered", because we don't want to forget the fact that relapse is always possible, and recovering people need to protect their recovery. So, this new thinking is very bold, but maybe it is not so different after all.

I attended the American Society of Addiction Medicine (ASAM) annual conference earlier this year and some preliminary research was published that sheds some light on this situation.

A large study is looking at what happens to people if they are able to maintain 5 years of drug and alcohol free recovery. The results of the study so far indicate that if the patients were able to maintain 5 years of drug free recovery, then the relapse rate over the next five years was an amazingly low rate of only 3%. Fully 97% of people did not fall off the wagon. 

These are amazing results and very encouraging. When you think about it, the results are not as surprising as they first seem. If we think of nicotine dependence, another chemical addiction, then we would probably see very similar results. If people are able to stay off cigarettes for five years, they are very unlikely to pick up smoking again. Of course, they can relapse back to cigarette use if they make silly mistakes, but they are unlikely to do so. After 5 years of abstinence, people see themselves as non-smokers. They are no longer affected by triggers and they have learned how to deal with their emotions rather than just smoking cigarettes when they are bored, lonely, or frustrated. 

So, it makes sense that if people can achieve 5 years of abstinence from drugs and alcohol, they will also be unlikely to return to their former addictions.

Is five years the magic number? We do know that it takes a long time for the brain to heal after the drug use stops. I used to say that 12 months was a reasonable amount of time to assume the brain had returned to normal, but when it comes to opiates like prescription painkillers or heroin, I believe it takes a lot longer for all of the brain to heal. 

There is no other explanation for the fact that relapse is so common, even after very long periods of abstinence. The truth is most people who go to jail and are then released, will relapse virtually as soon as they get out. This seems to be true even when people are incarcerated for long periods of time. Clearly, the memory circuits in the brain and the systems responsible for cravings and impulse control have not fully healed.

We are now recommending treatment and follow up for five years. Using Naltrexone implants and injections for this first part of recovery is crucial. Transitioning to lesser levels of support can then be done when clinically indicated. If we treat this disease just like other medical conditions, we are much more likely to have favorable outcomes.

Tuesday, December 8, 2015

7 REASONS WHY GRATITUDE IS THE BEST MEDICINE



by Gabriella Pinto-Coelho

For some, the holiday season can be a time of year filled with love, family, and joy. And for others, it can be a total you-know-what-show. A lot of it depends on your family, and that’s no surprise. Family is the one place where you can regress 10, 20, 30 years without even realizing it. Family is the one place where you can feel simultaneously loved, loathed, hurt, rejected, and accepted. Everything that comes with reuniting with your family - from memories of bad haircuts to reminders that yes, your aunt is still crazy - can create a perfect storm to exacerbate both mental illness and the risks for substance abuse. Sometimes we get so caught up in the dread of returning home and the pressure of buying the best holiday gifts that we forget what the season is really about - love, gratitude, and peace.

Gratitude isn’t just something that’s good for Thanksgiving, Christmas, or New Year’s. Gratitude should be an everyday kind of thing. And if you don’t buy into that because it sounds too kumbaya, then consider the fact that science has proven gratitude might just be really effective medicine (and it just might help protect you from your crazy aunt and your desire to pick up the bottle). Here are seven reasons why gratitude is the best medicine:

1.   Gratitude creates more opportunities for new relationships. Showing your appreciation for someone isn’t just a pleasantry, it can actually lead to new friendships, according to a 2014 study published in Emotion. And it makes sense: if you are kind to someone and they thank you for your generosity, you’re a lot more likely to want to interact with them again. Especially if you have had to prune your group of friends after starting on the road to recovery, making new friends can be a really good thing.
2.   Gratitude improves your physical health. A 2012 study published in Personality and Individual Differences revealed that grateful people report feeling healthier than their less-grateful counterparts. Grateful people are also more likely to take care of their health, exercise more often, and have regular physicals with their doctor.
3.   Gratitude improves your psychological health. Do you want to be happier and less depressed? Practice gratitude! Gratitude is proven to reduce a number of negative emotions like envy, frustration, regret, and resentment.
4.   Gratitude heightens empathy and decreases aggression. A 2012 study out of the University of Kentucky proves that grateful people are more likely to exhibit pro social behavior even when others are unkind. I’m pretty sure that all of us could use a dose of that when it comes to dealing with family members that drive us up the wall.
5.   Grateful people sleep better. Most people know and appreciate the fact that getting adequate, deep sleep is an essential part of being healthy. A 2011 study published in Applied Psychology demonstrated that writing in a gratitude journal before bed can lead to better quality (and longer) sleep.
6.   Gratitude improves self-esteem. A 2014 study in the Journal of Applied Sports Psychology found that gratitude increased the self-esteem of athletes, which is an essential factor in their performance. Although this study focused specifically on athletes, I would argue that most of us do better at whatever we do when are confident in our abilities and have a healthy self-esteem. Gratitude is also shown to reduce social comparisons, like becoming resentful of others for having a bigger house or better job. That sounds like a pretty valuable skill during the gift-buying and gift-receiving of the holidays.
7.   Gratitude enhances mental strength & resilience. Research has demonstrated the power of gratitude in overcoming trauma. A 2006 study in Behavior Research and Therapy found that Vietnam War veterans with higher levels of gratitude were less likely to develop Post Traumatic Stress Disorder. A 2003 study in the Journal of Personality and Social Psychology found that gratitude contributed heavily to resilience after the September 11th terrorist attacks. Practicing gratitude even in the face of grave circumstances can help promote resilience. Those are some really encouraging results given the all that it takes to be in recovery.

The moral of the story? Gratitude is good for everyone, but it might be even more beneficial for those of you on the road to or already in recovery. So when you’re sitting next to your crazy aunt at the Christmas table, do your best to think about all you have to be grateful for (even if it’s just good food at the table).