Disease, Ignorance, and Cruelty
Feb19

Disease, Ignorance, and Cruelty

I want to tell you a story about disease, ignorance, and cruelty. To make it interesting, we’ll make you the protagonist. The year is 1665, and you live in London. You’re trying to stay away from people because plague is sweeping through the country, and more than a quarter of the people you know have already died. In spite of your efforts, you wake up one morning feeling weak. Your body hurts. It’s hard to move. You know immediately what’s wrong, or fear you do, and you know there’s no hope. You don’t know anyone who has become symptomatic who has survived though you’ve heard a few rumors that there are such people. You’re eventually able to get up to void your bladder and notice large swollen masses in your groin. You throw up, and the effort has worn you out. You crawl back in bed, and later that day, you die. But what did you die of? I am confident in saying that you died of disease. In this case the disease was bubonic plague, a very virulent illness caused by a bacteria called Yersinia pestis. Now the year is 2000 and you live alone in Arizona about 2 hours from the nearest town. You’re out in your garden digging and you find the skeletal remains of an animal. You think nothing of it. A few days later you wake up feeling weak and feverish. You think it must be the flu because your body hurts and you have a terrible headache. You get out of bed and when you get to the bathroom you throw up, confirming for yourself that it’s the flu. You have a lot of survival gear in the house because you live far away from help. This includes antibiotics like doxycycline, but you know that they don’t help the flu, so you just go back to bed. You try to stay hydrated but it doesn’t work out. By the time you start considering this might be more than the flu you can’t get out of bed. After falling into unconsciousness later that day, you die. But what did you die of? I’d say you died of ignorance; you died of a lack of information. You didn’t know plague bacteria can live in the ground. You didn’t know it could be found in your area. You didn’t know you had plague. You didn’t know you had the cure 20 feet away. You died not knowing that you died of ignorance. Now the year is 2016 and you aren’t living alone. You’re a microbiologist living in a group of other scientists in Arizona. You go out...

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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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What’s Up in Tennessee? Redux
Feb11

What’s Up in Tennessee? Redux

About a year ago I wrote a blog titled What’s Up in Tennessee? looking at the unenlightened state policies that I thought would make that state’s addiction problem, particularly addiction involving opioids, worse instead of better. It’s been a very popular blog post getting me more comments than almost any other I did last year. Well it’s time to take another look, because Tennessee just stepped in it again. Here’s a recent press release from the State of Tennessee: FOR IMMEDIATE RELEASE Thursday, February 10, 2016                 CONTACT: Mike Machak                 OFFICE: 615-532-6597   Heroin, Buprenorphine Drug Busts on the Rise in Tennessee Tennessee Bureau of Investigation data shows prescription drug seizures declining   NASHVILLE – Tennessee’s nearly half-decade long effort, dedicated to limiting easy access to prescription pain medications and similar opioid-based narcotics, has been successful. Since 2012 the state has seen a steady decline in the use and abuse of these substances commonly prescribed by family physicians. 2015 drug seizure data from the Tennessee Bureau of Investigation (TBI) shows a significant drop in law enforcement confiscations of prescription opioids, ie: pain pills.   Steep Decline of Prescription Opioid Drug Seizures: 2012 – 2014         6,988 Opioid seizures in 2012 4,696 Opioid drug seizures in 2014 *Opioid seizures exclude buprenorphine and heroin; data does not reflect amount of drug seized   This success coincided with Tennessee’s Prescription for Success initiative, launched in 2014. While beneficial in reducing demand for prescription drugs it has resulted in some unintended consequences. Today, the growing appetite in most Tennessee counties is for heroin and the painkiller replacement medication buprenorphine, known under brand names Subutex and Suboxone. They’re now widely prescribed as therapies to ease opioid withdrawal symptoms and cravings. “It’s troubling to see these ‘so called’ painkiller replacement therapies dispensed by unlicensed clinics getting patients hooked and dependent on another drug, just as they were to prescription pain pills, “said E. Douglas Varney, Commissioner for the Tennessee Department of Mental Health and Substance Abuse Services. “Our statewide, multi-agency Prescription for Success strategy did an excellent job of reducing demand for prescription pain opioid medications. But once again I’m very concerned about what’s emerging in our state.” Tennessee Bureau of Investigation data on recent drug seizures for heroin and buprenorphine shows both substances surfacing as new illicit drugs of choice in Tennessee.   Heroin and Buprenorphine Drug Seizures Rising: 2009 – 2014 82 Heroin seizures in 2009 has increased to 341 seizures in 2014 437 Buprenorphine seizures in 2009 has grown to 1,085 in 2014 *Data does not reflect amount of drug seized   “There were very few heroin seizures by law enforcement in 2011 and 2012,” said Commissioner...

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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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In Defense of the Geographic Cure Seekers
Jan19

In Defense of the Geographic Cure Seekers

A geographic cure is when someone in active addiction looks around at the wreckage of their lives and figures out that everything would be better if they pulled up stakes and lit off to a fresh start somewhere else. According to recovery wisdom, this doesn’t work, because it is predicated on the assumption that we will be leaving the problem behind. Further, because to believe that we’ll leave the problem behind is a denial of the repeated evidence that the problem is within us, the person trying a geographic cure is crazy. I’m not here to tell you that a geographic cure works. It doesn’t work for addiction. But, I am here to explain why it isn’t as crazy as it sounds, and why it makes perfect sense to the person trying it. Anyone who has been reading this blog or has read QAA will remember that lowered reward center dopamine tone is one of the manifestations of the human famine signal. Specifically, dopamine tone going down over time as a result of continued using is a pretty good proxy for food running out. That’s especially true when the brain gets other signals that caloric intake is low because we actually have been eating less because of active drug use. So what is the rational thing to do in a famine? Well, for us it might be to go to the grocery, but for our ancestors, that wasn’t possible. We are a nomadic species, or we have been for most of our history. Our brains being hard wired to assume that the problem is the environment, and to move to a new spot during a famine, isn’t such a bad survival mechanism. Sure it doesn’t make sense if you have some control over your environment, but our species has only had that ability for around 10,000 years, and to the degree we take for granted today, only for a few generations. If our ancestors had helicopters or satellites we might have evolved differently, but for 99.9% of our history, the only way to see over the horizon was to walk there. It makes perfect sense to the brain with addiction that if you’ve used up the resources in this area the best thing to do is to move somewhere else. There’s a reason most humans think the grass is always greener on the other side of the fence. It isn’t a thought from our cortex; it’s a drive from our midbrain, “This place doesn’t have enough sources of dopamine tone – GET OUT!” So next time you run into someone thinking about a geographic cure, remember that it makes perfect sense to them and...

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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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