Socety is still out of touch with the reality of addiction

(My latest Addiction and Recovery column.)

By Bob Gaydos

Philip Seymour Hoffman
 ... on the cover of Rolling Stone

        The congenital disconnect between much of society and the reality of addiction reappeared recently with the death of actor Philip Seymour Hoffman, apparently due to an overdose of heroin.
The Oscar-winning actor was found dead in his Manhattan apartment with a needle in his arm and bags of what was believed to be heroin nearby, according to police. Almost immediately, the familiar reactions were heard: How could he? He was so talented, so  admired, so wealthy, had so much to live for. He had been to rehab and he was sober more than 20 years. How could he risk it all for a fleeting high? And with heroin no less. Who does heroin today?
Apparently, aside from Hoffman and the late Amy Winehouse, a lot of people. And not just the down-and-out addicts who were once the stereotype for what some considered to be “serious” addiction, as opposed to what, one presumes, were considered less serious forms, like addiction to alcohol or cocaine. Addiction pecking order aside, today’s heroin user is just as likely to be your neighbor’s teen-aged son or daughter as a famous actor or singer.
The Substance Abuse and Mental Health Services Administration, which tracks drug use in this country, says a recent survey showed a more than 100 percent increase in the use of heroin in the United States between 2002 and 2012. Slightly less than half a million people were regarded as heroin dependent. How pervasive is it? The states of Maine, New Hampshire and Vermont (so much for stereotypes) report serious problems with heroin addiction and overdoses and deaths as a result of heroin use. Heroin use is up in Pennsylvania, Illinois, Ohio, name a state.
          Much of this increase is tied to the abuse of prescription pain killers, such as Oxycodone, Oxycontin, Vicodin and Percocet, which are opiates, like heroin. Concern over the over-prescription of such drugs and the growing use of them by teenagers who simply took them from their parents’ medicine cabinet, has made it more difficult to get the pills and to crush them for snorting. This makes them more expensive. In comparison, heroin on the street is much cheaper.
        And, quite possibly, much deadlier. Police are examining the many bags of heroin they found in Hoffman’s apartment, among other reasons, to learn if the heroin had been cut with another substance -- a dangerous synthetic heroin” that has emerged -- or if it were too pure. Heroin is not only one of the most addictive drugs, it reacts quickly on the brain, sometimes giving the user insufficient time to react to a bad batch.
Does any of this explain why Hoffman -- famous and sober -- decided to try heroin? No. Relapse, as professionals in the substance abuse field explain, starts in the addict’s brain, with changes in attitudes, behavior, a relaxing of diligence. Dr. Nora Volkow, director of the National Institute on Drug Abuse, in commenting on Hoffman’s death, said, “You need continued awareness of the possibility of relapse. No matter how long you’ve been clean, if you take the drug, you’re at high, high risk of relapse.” Meaning, if you think you can take “just one more hit,” you’re probably delusional and definitely risking your life.
Addiction is considered a chronic, incurable disease because once the brain is reintroduced to the addictive substance -- alcohol, heroin, cocaine -- it can quickly return to its old ways. Addicts often say that when they started using their drug of choice after a period of abstinence, they were right back where they left off, or worse. This is why abstinence and continued treatment, be it therapy or a 12-step program, is recommended for recovery. A change in lifestyle and constant awareness are the keys, the experts say. Over time, the approach may gradually change, but as Volkow reminds, an addict can never forget what he is. And society would do well to remember as well.

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Stepping down, slowly, from suboxone

(MyAddiction and Recovery column.)

By Bob Gaydos

Five years ago, hooked on heroin and pain pills, Mary (not her real name) says, “I was depressed, malnourished, angry and I had just gotten out of jail. That was my turning point. I could continue downhill or change my life.”
Mary decided to change her life. Today, she is clean and sober, married, has a son and is attending classes at SUNY Orange. She says she owes much of this change to another drug -- suboxone -- which allowed her to kick the pain pills and heroin. Taking suboxone, which cost $200 a week and was not covered by her health insurance, was still cheaper than the drugs she was using, she says.
Now, she’s at another turning point. She’s weaning herself off suboxone. “I’m scared,” she admits. I feel when I’m on it, I’m safe. I don’t know if it’s the A.A. meetings or suboxone or both.”
Dr. Rodolfo Nazario, who calls suboxone “a miracle drug,” would say both. Nazario says some kind of outpatient program is also necessary to “deal with the psychological part of the disease.” Even then, it’s no easy transition. Despite his decade of treating patients with suboxone, Nazario says he has been able to wean “very few” off it. And, as he and Mary both emphasized, withdrawal from suboxone can be “horrible.” Which may explain Mary’s fear.
She has first-hand experience of using it in other than the prescribed manner. Two years after starting the suboxone treatment, Mary had a craving for heroin. She stopped taking suboxone for three days, then got heroin. She used it for two months, then one night decided to go back on suboxone before being in withdrawal from the heroin. That is not the prescribed method of treatment. “I felt the heroin on one side of my head, suboxone on the other,” she says. “I had seizures, sweating, vomiting, shaking. I was speaking a different language.”
She hasn’t tried that approach again. From 2 1/2 pills a day five years ago, when she first saw Nazario, Mary is down to half a pill (4 milligrams) a day. She’s following doctor’s orders. Thus far, she says, everything has been fine. “I’ve never gotten high from it,” she says. “I’ve heard you can. I don’t know how.”
In fact, the secret of suboxone, according to those who recommend and prescribe it, is that, while it is a morphine-like substance that provides an addict with a feeling of “normalcy,” it’s impossible to get high on it. Now widely prescribed to treat opiod dependence, suboxone is actually two drugs in one delivery system. Buprenorphine does the same thing for the brain that opiates do, thus the feeling of “normalcy.” The second drug, naloxone, prevents the high that comes from the opiods reaching brain receptors. For safety reasons, the delivery system itself has changed from tablets to a film that is placed on the tongue.
While a strong proponent of it, Nazario has no illusions about taking patients off suboxone. He says some patients do not have the willingness to try weaning off the drug. “I try to step them down slowly,” he says. “Some can take more withdrawal than others. We aren’t here to be martyrs anymore. If they don’t have the medicine, they suffer. They need the drug just to get by. I encourage them to try to get off. If they can’t, they can’t. The important thing is, the patient isn’t doing  anything illegal and is performing well.”
“My goal,” says Mary, “is to get off the suboxone, maintain my sobriety, keep going to AA meetings. I consider myself an addict. I don’t drink. I feel fine. No cravings, no side effects. I’ve been doing it very slowly.” Her doctor and people in recovery would say that’s the way to do it. I’ll keep you posted.

*  *  *

Doctors in New York state must take a special course to be licensed to treat patients with suboxone. When they are accredited, they are limited to 30 suboxone patients in the first year, 100 thereafter.
Dr. Rodolfo Nazario, of Middletown, who has been prescribing suboxone for 10 years,  says, because of the growing abuse of opiod pain killers, especially among young people, “We should be able to treat more.” He says he’s never had 100 patients.
He also is a strong proponent of the new state law that closely monitors prescription of pain medications by doctors. Some of the growing abuse has been attributed to doctors being too willing to prescribe addictive pain medications. “I hate to say it, Nazario offers, “but there are some physicians … I call them licensed drug dealers.”
Nazario also has some harsh words for insurance companies that won’t pay for suboxone treatment, but paid for the Oxycontin and Vicodin: “You make them addicts, but then won’t treat them.”

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These pills are killing more than pain

(The full version of my latest Addiction and Recovery column in the Times Herald-Record.

By Bob Gaydos
Painkiller pills have dominated the news on addictive drugs over the past month:

• A report from the Centers for Disease Control printed in the Journal of the American Medical Association stated that prescription drug overdose deaths had increased for the 11th straight year, with pain killers such as Oxycontin and Vicodin being the chief culprits in 75 percent of the deaths, most of which were not suicides, according to the report.
• A new law, aimed at fighting “doctor shopping” for hydrocodone, an addictive opiate that is the main ingredient in many popular pain medications, took effect in New York state. The law elevates hydrocodone from a Class III to a Class II drug and establishes an electronic database for prescription pain medications, accessible to doctors and pharmacists. It also places stricter requirements on obtaining and filling prescriptions for them, including eliminating automatic refills.
• In the Town of Woodstock, N.Y. , Wayne Longmore was stripped of his medical license after pleading guilty to writing thousands of prescriptions for non-medical use of hydrocodone.
• A Rockland County, N.Y., doctor, David Brizer -- dubbed “Dr. Feel Good” -- was indicted on 55 counts for allegedly selling thousands of prescriptions for painkillers to drug dealers in Rockland and in Manhattan.

All of this adds up to the inescapable conclusion that prescription pain medications -- legal drugs -- have rapidly become a major drug addiction problem, as the CDC indicated. Hydrocodone is especially troubling since it is, in effect, legally prescribed heroin. Those who become addicted to it, whether by becoming too dependent on it while dealing with legitimate pain issues or, as with many young people, by stealing it from their parents’ medicine cabinets, sometimes turn to heroin itself, because it is cheaper than the pain medications.
Several issues arise from this conflux of stories. Among them:

• The medical community needs to do a much better job of teaching its members about the risks of prescribing addictive pain medications too readily. Individual doctors need to do a better job of monitoring their patients’ use of the medications, while also making sure not to make life even more painful for those who truly need the medications.
• Society needs to rely less on legislation to deal with drug addiction and focus more on getting better educated on the subject. For example, New York’s new law, while well-intended as a way to fight addiction to painkillers by reining in pill-liberal doctors, may also increase the cost of the drugs to consumers and will probably make life more difficult for those, such as cancer patients, needing regular pain medication prescriptions. It is also likely to send some people to the streets to buy cheaper heroin instead. Also, parent groups have complained that, while the state has focused on cutting off the easy flow of pills, it doesn’t have enough drug rehabs to treat young people addicted to prescription medications.
• Treatment specialists say parents need to pay closer attention to their prescription medications at home and not assume that their teen-aged children will not steal them. They urge parents to talk to children about the dangers of abuse and of mixing the pills with other medications, a major factor in the deadly drug overdoses.

So, more laws? More education? More treatment? As society continues to struggle with finding the best approach to reducing addiction to pain medications, perhaps the most important thing everyone can do to reduce the number of fatal medication overdoses is learn to recognize the signs of addiction to prescription painkillers:

• Continued use of the drug, even after the pain has ceased.
• Complaining about vague symptoms to get more medication.
• Lack of interest in treatment other than medications.
• Using prescription pills prescribed for others
• Physical withdrawal symptoms when doses are missed.
• Flu-like symptoms, such as joint and muscle aches and insomnia.
• Mood and behavior changes, such as becoming agitated or anxious.
• Secretive or deceitful behavior trying to obtain the drug.
• Using more than the recommended amount of medication.
• Developing a high tolerance, requiring more pills for the desired effect.
• Withdrawal from family, friends and society.
• Financial problems associated with buying ever more pills.

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