Drug of Choice
Feb12

Drug of Choice

When I think about it, there are few terms in the addiction treatment field that are more silly than “Drug of Choice.” As if we get to choose which drug makes the brain go BAM. When you talk to an addict and ask, “What’s your drug of choice?,” what you get is the answer to “What drug that is available to you lately at a price you can afford that makes you feel better with the least side effects?” Quite a mouthful, huh? Would we ask a diabetic if their toxin of choice is sugar? How did they choose sugar? Why didn’t they choose to have an abnormal reaction to arsenic instead of sugar? What a stupid choice! Using the concept of choice, as in which would you choose if they were all lined up, can confuse us and strengthen the stigma and the idea that addicts are normal people who choose to use drugs. If we asked an addict if they chose to have cocaine work the way it works with them or if they chose to have an abnormal reaction to alcohol we’d hear a resounding “no.” “If I had the choice of what my brain reacted to I’d have picked something a lot cheaper and easier to get than cocaine.” Something like wildflowers or dandelions, no doubt. What is it we really want to know when we ask the question? And why? Well, up to now we really haven’t had a good reason. We just needed a word to write down in the “Drug of Choice” box on the assessment. In many cases it meant something, for instance when the person used only one drug. Most of the time however it doesn’t actually mean much with regard to choosing treatment. However because researchers like things that come in boxes there has been a lot of research on “Drug of Choice.” It’s been used to predict treatment outcomes with regard to which treatment is used. One example of such a research question would be, “Do alcoholics or opioid addicts do better when given naltrexone?” By dividing people up by “Drug of Choice” we manage to make one population (alcoholics) which is heterogeneous sound different from another (opioid addicts) which is heterogeneous in a different and overlapping way with regard to neurobiology. It’s really no wonder most addiction research doesn’t make much sense. But still insurance companies ask the question and the government asks the question so we ask the question, as if we get to choose. But modern science actually gives us a new reason to ask a question about “Drug of Choice.” It’s just not the question we’ve...

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Response to Stanton Peele in The Fix
Feb10

Response to Stanton Peele in The Fix

On February 2 of this year, The Fix published a piece by Stanton Peele entitled “Legalizing Drugs Challenges the Addiction Brain Disease Theory.” I’ve never heard anything in my understanding of addiction as a brain disease that has anything to do with the legal status of drugs, so I thought I’d take a look. It’s a pretty difficult piece for me to follow, but then, I’m just a simple brain doctor. He starts by asking the question, “What if more, and more open, use leads to fewer addictive problems?” A salient question having nothing to do with the premise promised by the title, but we can start with that. He doesn’t move directly to the answer though but detours through a societal comment in which “no organization has greater prestige and acceptance in America than Alcoholics Anonymous.” Really? The Boy Scouts? The Red Cross? The AMA? Really? No one sees membership in any organization as more prestigious than membership in AA? No wonder all those Distinguished Fellows of  the American Psychiatric Society recently; they all wanted to join AA for the prestige. And more acceptance? No organization is more accepted than AA? Here’s a test. Go on 10 job interviews all of which are exactly the same except for one thing. In each one mention a different extracurricular activity: bowling, charity work, AA, etc. Let’s see which one gets you the job. But Dr Peele isn’t finished the detour yet. He then states that AA says that “alcohol can be deadly and uncontrollable.” Well, AA says that about alcoholics, but also says that people without the illness clearly can drink with impunity. Further AA goes out of its way to not have an opinion about alcohol in society. That is a position the organization takes so that it can be free of entanglement with outside issues and free to be of the most help to alcoholics seeking a way to stop drinking. I think the detour is now over, and Dr Peele gets to his point. He quotes a blog by Stephanie Castillo writing for Medical Daily as an authority of the scientific foundation of the disease model of addiction. He then tries to hit closer to the mark by targeting the support of NIDA director, Nora Volkow, as a foundation of the science underpinning the disease model. Yet again he quotes, not the science, but an article about The Myths of Smoking Pot written by Ruth Marcus of the Washington Post. After this strenuous foundation showing that there is some disease model of addiction that says that drugs are bad, Dr Peele then moves to destroy this unsupported straw man by showing...

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Response to Dawn Roberts’ Question about Buprenorphine Taper
Jan13

Response to Dawn Roberts’ Question about Buprenorphine Taper

First, let me say this about conflicts of interest regarding buprenorphine taper, because it’s going to come up. I receive no money of any kind from any maker of buprenorphine. I was on speaker panels for both RBP and Orexo in the past but have not been for over a year. I get no consideration from any pharmaceutical company. Ms Roberts asked in her piece in The Fix “Why is there no official medical protocol to detox people off Suboxone?” I’d like to answer that question. The question seems to suppose that getting off buprenorphine after being maintained on it for opioid dependence is entirely about medical withdrawal management. It is not. What happens when most people get off of buprenorphine is that the medication that was suppressing the symptoms of addiction is going away, and those symptoms return. This is separate and distinct from withdrawal symptoms, but most people don’t make this distinction. What are these symptoms? They are symptoms of low dopamine tone in the midbrain. Well more than half of the patients who have ever come to see me for addiction treatment tell me they’ve had these symptoms since before their first drug use, and it was the relief of these symptoms that was, at least in part, what made the drug so useful. An incomplete list of them are: not enjoying things as much as others who are experiencing the same thing (relative anhedonia), poor memory, poor focus, irritability, and difficulty making attachments to others. If these things start to return along with withdrawal symptoms, it’s easy to think the whole thing is from withdrawal. So there will never be a single protocol for tapering buprenorphine, because in most people, the taper will have to be customized with additional specific treatments for the original symptoms. Agonism of the mu receptor, even partial agonism like buprenorphine, causes additional tonic release of dopamine, and this makes people with low dopamine feel better, even if their original problem wasn’t at the mu receptor or within the opioid system. I’ve seen many patients who weren’t able to get off that last 2mg until we added specific medication for the pre-existing symptoms. In addition to the quest for a specific protocol, Ms Roberts seems to imply that the pharmaceutical companies coopted the government in some nefarious plan to make buprenorphine. In a less paranoid world some might say that the people at NIDA and SAMHSA saw the rise in opioid use over the last two decades and worked for a solution to increased cases of opioid dependence that they could implement because they had no control over the DEA approval...

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I’ve Got News for the Washington Post
Nov24

I’ve Got News for the Washington Post

I read today in the Washington Post that 4 in 10 Americans say they know someone with an addiction to prescription opioids. I’ve got news for the Washington Post, and everyone else in Washington. 10 out of 10 Americans know someone with addiction and it usually has nothing to do with opioids. I was recently in Washington and most of what I was hearing about was the “opioid epidemic” and the “opioid problem.” Just today another senator came up with a new bill (I think there are about 7 pending) to deal with the problem. Where were these people 10 years ago when people in my field couldn’t get appointments with congressional offices to tell them this was happening. What’s so special now? Well, I hate to be cynical, but what seems to be happening now is that people are dying, and not just any people, but people who “aren’t supposed to be” dying of addiction. All of a sudden addiction, specifically addiction involving opioids, is getting political attention. And people aren’t talking about addiction, but opioid addiction, as if it’s a special kind of addiction or a new kind of addiction or a new problem. Or 25 years ago when politicians were raving about doctors not treating pain well enough so that JCAHCO started rating badly hospitals that didn’t count pain as a fifth vital sign, my colleagues couldn’t be heard when they told of the dangers of opioids. Now that there’s an “opioid epidemic” those same administrators, regulators and politicians are screaming, “Who could have seen this coming?” Well, the Addiction Medicine doctors did, and tried to tell you. About 5 years ago when politicians were raving about pill mills and Addiction Medicine physicians told them to consider what would happen when they closed the pill mills (opioids being opioids and addiction being addiction) without offering treatment to patients, we were told we didn’t understand. Now that there’s a “heroin epidemic” those same politicians are up in arms screaming, “How could we have seen this coming?” Well, you could have listened. Here’s the truth. We don’t have an opioid epidemic or a heroin epidemic. In the 1990s and early 2000s we didn’t have a methamphetamine epidemic. In the 80s we didn’t have a crack epidemic.  And in the 70s we didn’t have a marijuana epidemic. In the 60s we didn’t have a crank epidemic. And before we started calling them epidemics we didn’t have an alcohol problem during prohibition, or an opioid problem in the late 1800s or a stimulant problem after WWII. What we had was an endemic level of addiction, a genetic primary brain illness,...

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Amazing “New” Research on ADHD and Binge Eating Disorder
May10

Amazing “New” Research on ADHD and Binge Eating Disorder

I’m always amazed when I see media reports of new research that’s touted as a breakthrough in understanding that explains something known for a long time. Today, Medscape led me to this study showing a link between ADHD and Binge Eating Disorder. ADHD and Binge Eating Disorder, or as like I like to call them, addiction before I’ve found a drug and addiction when I’ve found a drug called sugar, seem to be linked. Amazing. Who’d have known. This is where paradigm is important. If you live in “DSM world,” where ADHD is a behavioral disorder and BED is a behavioral disorder they look very different. So I’m sure that to someone in that world, this news is startling. But if you live in a biological world (like ASAM’s definition of addiction) where disease (abnormal functioning of a part or organ) causes symptoms, and those symptoms manifest in behaviors, two sets of behaviors with a common cause being link won’t even move the needle. But being startled, you’ll have to figure out how these things are connected, and the authors report some hypotheses about that. They see both of these entities as impulse control disorders and so they suggest we do some research on deeper causes of these seemingly different disorders of impulse control. Good idea. Welcome to the world after 1988 when that research actually started. From my earliest blog post, I wrote about how the psychiatric world saw addiction as the cortex vs the midbrain with the midbrain wanting to engage in its impulsive behavior and the cortex trying to hold it down. So addiction, and BED and ADHD are all seen as too much midbrain or too little cortex. But the reality is quite different. The midbrain is trophic to the cortex. That means it feeds the cortex. When the midbrain is functioning well the cortex gets signals that it can relax and handle things normally, but when the midbrain is in deficit, the cortex knows that survival is at stake and it will do things that aren’t appropriate to a normal social situation, like move around a lot looking for sources of dopamine, or eating lots of food to raise dopamine, or taking drugs to raise dopamine. You get the picture. It isn’t about the midbrain being too strong; it’s about the midbrain not having enough dopamine tone. That’s what ADHD is about (why it gets better when you give dopamine raising agents like amphetamines); it’s what BED is about (why eating things that raise dopamine by causing increased dopamine release like sugar makes you feel better); it’s what addiction is about (why taking substances or...

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The “Mystery” of Rising Deaths in White Women
Mar15

The “Mystery” of Rising Deaths in White Women

The Washington Post recently published a piece that provides mere taste in understanding the problem of addiction in America, and I wish they’d supply a feast. The title, “The Mysterious Force Behind Rising Death Rates for White Women,” might strike one as a bit racist at first. Why should one wonder at rising death rates for white women when women of color have had higher rates of death for years? But that’s actually not the bone I’d like to pick with the WP. They do point out that death rates for women of color have been higher for years but are improving over time. The article is really about the rise of drug overdoses that contributed to rising death rates in almost half of American counties and how that rise is seen to be much greater in white women. The article points directly to opioids, pointing out that in 1999 the rate of opioid related deaths in white women was 3.3/100,000 while in 2011 it had climbed to 15.9. That is indeed a great rise and worthy of comment. But I wish the WP had dug a little deeper. They go on to link the opioid epidemic to stress and then point out that it is most prevalent in poorer counties, point out that other forms of addiction like smoking and obesity (without noting that they represent addiction), and pretty much call it a day. They miss the real news. The news is this; this isn’t new. Back in the early 20th century you could buy heroin at your local pharmacy and get your syringe from the Sears catalog. It wasn’t inner city minorities that were using the most opioids. It was soccer moms. That is, it would have been, if Americans had played soccer back then. My point is that opioids were Mama’s first little helpers, and it’s not for the reason that the WP suggests. People who use opioids in addiction primarily use them, not to escape, but to function, at least at first. We call opioids narcotics because they put 90% of people to sleep. In about ten percent of people, opioids give energy and motivation and the ability to get things done by releasing dopamine into a midbrain with low dopamine tone. Would it surprise anyone that nicotine and sugar binging do the same thing? The WP article tells us the proximal cause of this startling increase in deaths of white women. Sounds like it’s time to start being anti-opioid and anti-anyone-who-supplies-opioids. Go back and read the testimony to congress before the Harrison Tax act of 1913, and you’ll see the same thing. If it weren’t for those damn Chinese immigrants giving white...

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