What Did He Die Of?

A colleague asked a group of us Addiction Medicine specialists if we had any guesses of what killed a patient who died in his care. If reading a clinical description of a death or the thinking that doctors do after a death to improve care might bother you, stop reading. If not, read on. The patient was in his late 20’s and had been treated for addiction involving opioids with medical withdrawal. Following the withdrawal, his treatment team implanted naltrexone, a long acting blocker of the opioid receptor meant to protect him from overdoses should he resume use of an opioid. He was described as stable on these monthly implants for 5 months after withdrawal and was found dead with no drug paraphernalia around him. At autopsy, there were no physical findings except a white power in his mouth, which turned out to be clonidine, a medication used to counter the anxious activation of opioid withdrawal or stimulant intoxication. Post-mortem toxicology showed he had a high level of naltrexone, higher than usually seen in fact. He was negative for all opioids tested including fentanyl, sufentanyl and carfentanyl. He was positive for amphetamines. The group gave a number of different theories. He had used amphetamine, overshot the mark, became nervous, took the clonidine to calm down which increased a specific electrical pause in his heart, that some amphetamines also increase, and this caused his heart to stop. Or he had taken a heretofore unknown opioid (probably a new, currently undetectable, even more powerful fentanyl analog) which displaced all the naltrexone, raising the level, and stopping his breathing. Or he had used cocaine long enough ago so that it wasn’t any longer in his system, but cocaine’s effect on the heart lasted long enough to interact with what he was taking to cause the sudden stoppage of his heart. All good theories. Complex and speculative, but good theories non the less. But my mind didn’t go down this path. I didn’t think about what stopped his heart in the last moment. I didn’t think about what combination of substances could interact in what way to do what damage. I didn’t think about that, because I don’t see the point. It’s a wonderful academic exercise, but if we know, what will we change? Will we warn people not to use clonidine if they are going to use amphetamine? Will we warn people not to use any new opioids from China until everyone in their neighborhood has tried them and survived? At that point in the life of someone with addiction, when they are using what they need to use to feel normal,...

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The Kissinger Cross and Beginner’s Mind
Jul22

The Kissinger Cross and Beginner’s Mind

The Kissinger Cross I learned about the Kissinger cross from an economist named Jim Rickards (twitter: @JamesGRickards). You may have guessed that the Kissinger Cross was named after former Secretary of State Henry Kissinger, but you might be struggling to figure out what it has to do with addiction. No, it isn’t that it’s his cross to bear. It’s something else all together. Kissinger said that when we enter a new situation we have all the options that exist but we don’t have any information on which option is best. As we learn more about a situation our knowledge rises, but with that knowledge comes a decrease in the options available. Some just don’t look good with that new knowledge. So he said there are two lines to be drawn as time moves on, the down sloping line of options and the up sloping line of information. The more we learn, the fewer options we have, so in the end, we know everything but can’t do anything. What the Kissinger Cross is, is the point at which the two lines cross. We no longer have all the options but we still have a lot, and we don’t know enough, but we know a good bit. It’s a chancy thing making decisions with incomplete information, but life is a chancy thing. What Secretary Kissinger gave us was a system with which to figure out when to act that is graphical, at least somewhat objective, and can be put on paper for clarity of thought. It’s a good idea, but what does it have to do with addiction? Well, it has to do with everything, but that’s not the point of your question, is it? You want to know what the Kissinger Cross has to do with the problem of addiction in our society. Well, it can provide us with a solution, but only if we use it correctly. To illustrate that, you’ll have to come with me on a little thought experiment. A World Without Addiction So imagine that we live in a world with no addiction, or, since you won’t be able to imagine that, just imagine that we’re not from this world. We arrive here and see addiction for the first time. We don’t know anything about it; it’s a completely new situation. We can do anything about it we want. We can shoot people, give them lemonade, pet the dog, or go home. We have all the options in the world, but we don’t know what to do. We’ve never seen addiction before. We don’t know what it is, what causes it, what it costs. We just know we’re...

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The ICU
Feb28

The ICU

The young woman walked out of the ICU knowing she’d never see her friend again. At age 26, this was the second time she’s said good-bye to a childhood playmate in this ICU.  When the first of her friends to die was lying there with a machine breathing for her, there was a constant stream of friends and family coming to say good-bye. Now that her second friend was dead but for the machine pumping air into his lungs, there was the same stream of loving people to say good-bye. Both of her friends had struggled with genetic illnesses all their lives, both had done their best to stay alive, both succumbed. The first one died of cystic fibrosis; the second, of addiction. The friend with CF did everything she knew how to do. Took all the medication her doctors told her to take, ate only the foods her doctors told her to eat, exercised, stayed fit, everything. She had a loving family that got her to the best doctors who gave her the best care. But CF doesn’t have a cure, and it doesn’t have a treatment that does more than extend life into the 20’s. It’s genetic, and it’s unfair, but so is every illness you’re born with. The friend with addiction was really no different except for one thing. When his loving family took him to the best care, he heard that medication wouldn’t help. He heard that he should be able to “recover naturally,” that he didn’t need medication. The best doctors that his family sought out didn’t tell him about evidence based medical treatments for his genetic illness. Instead they told him his illness was caused by drugs and would go away if he just stayed clean and became spiritually fit. So in his 4th or 5th rehab he went to a religious based program to get that spiritual fitness. I don’t know his spiritual status when he died, but I know he couldn’t breathe on his own. I wrote a piece recently about what we die of when we die of something that has a treatment we aren’t offered. The young woman’s first friend died of cystic fibrosis and our inability to treat the illness better. Everyone did everything they could. It’s just beyond us at this point in time. But I’m not sure that the second friend died of addiction. There is a treatment available that has been shown to improve survival rates, but he was told it’s a bad thing to be on. There’s a known neurobiology of his illness, but his treaters were willfully ignorant and disdainful of that knowledge, believing that their spiritual superiority was enough...

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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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“Real Recovery” – What is it?
Dec13

“Real Recovery” – What is it?

I have colleagues that use the terms real recovery or true recovery and, lately, as the use of medications for addiction treatment have become more accepted, I’m hearing it more and more. Frankly, it’s getting annoying. So let me say clearly here and now, I do not know what real recovery is. At least I don’t know what real recovery is for anyone else, not for you, not for my colleagues, not for any of my patients. Is someone in real recovery if they are taking a medicine and not going to meetings? Does real recovery depend on the quality of their relationships? Does real recovery depend on their economic productivity? Does real recovery depend on anything that anyone outside of them can come up with to judge them on? I think not. So how should we define recovery in someone who is living with a chronic illness? Let’s ask nature. Going on From Here There are three ways any of us can go regarding  any aspect of our lives from this moment on. We can get worse; we can stay the same; or we can get better. There just aren’t any other possibilities in the next moment. No matter which direction we go in that moment, unless we cross a permanent line called death, there will be another moment with the same three possibilities. Can we all agree that getting worse is not recovering? Can we agree that getting better is? I hope so, but our field  has swung for the fence for so long, there are many of us who live by the motto, “The good enough is the enemy of the best.” So like beauty, we believe recovery is in the eye of the beholder, or in this case, the mind of the beholder. So many believe that if a person is just improving and hasn’t achieved the beholder’s level of recovery, then it isn’t real. I doubt we’re justified to believe that. What possible business of mine could it be what you think your recovery should be? So if you think your recovery is sufficient with slow improvement, or even just staying steady, who am I to claim that you aren’t in real recovery because you haven’t hit my goal yet? And while we’re on the subject of who gets to decide, can we mention something else that is the individual’s choice? I’m referring to what to measure. I have seen people who were introverts told they haven’t improved their relationships enough because they weren’t more like the extrovert who was judging them. I have seen people told that they weren’t in real recovery because they weren’t living...

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