…by Percy Menzies…
I met Percy, a treatment provider and policy person, in Minnesota about six months ago. We have had some spirited discussions since then. In his view, the culprit in the opiate crisis is access — drug availability — a position that’s put him in direct opposition to Johann Hari and others who favour decriminalization/legalization. He is also a champion of naltrexone…an evidence-based treatment we don’t hear much about. Here’s what he’s got to say:
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Access to drugs is by far the strongest factor contributing to the spread of addiction. The unprecedented quantity of heroin being produced by Afghanistan, Burma and Mexico is causing a sharp increase in heroin addiction and deaths in bordering countries including the US. Addiction rates are rising in Europe, Asia, Africa and many other countries. The access is almost certain to grow as more opium poppies are grown in these countries. The heroin problem in the US is compounded by the huge increase in the use of prescription opioids to treat chronic pain. Indeed, the US consumes in excess of 80% of the world’s legal opioids! We have not seen a problem this big since the days when morphine was an unregulated drug and used indiscriminately.
How do we grapple with this growing problem? A little history before we attempt to answer the question. The treatment of opioid addiction is overwhelmingly dominated by opioid substitution treatment (OST) based on a hypothesis that opioid use causes permanent changes to the opiate receptors necessitating prolonged opioid use as a form of harm reduction. Using an opioid to treat an opioid addiction is tricky and works best when access is controlled. It started when President Nixon in the 1970’s reversed the long-standing policy against maintenance treatment with opioids and authorized the opening of methadone clinics. Heroin addicted patients were required to go to the clinic each morning to ingest a carefully controlled dose. This highly restrictive and controversial program was planned as a temporary measure and served a dual purpose. It protected society from the criminal activity of drug addicts and at the same time provided heroin addicts treatment.
If opiate substitution treatment is the only way to go, could we develop or look at existing opioids that could be administered in a less restrictive environment? Buprenorphine, a powerful, but safer opioid, developed in the 1970’s as an injectable drug for the treatment of acute pain, emerged as the best candidate. The oral formulation as a sublingual tablet was found to be highly effective in curbing the cravings for opioids. Although abuse was an ongoing problem, buprenorphine emerged as a safe, effective medication that could be prescribed by a physician. Researchers believed that adding the opioid antagonist naloxone (better known by the trade name Narcan) would deter patients from injecting the sublingual tablet.
The introduction of buprenorphine in 2002, better known by the trade names Subutex and Suboxone took a rather convoluted path. The approval occurred when the nation was in the throes of a man-made epidemic of prescription opioid use. To prevent buprenorphine turning into “pill mills,” physicians were required to obtain a DEA-waiver and there were limits on how many patients could be treated at any one time – 30 the first year and 100 thereafter. Too few physicians bothered to get the exemptions, and although the sales of buprenorphine soared to in excess of $2 billion per year, we have not seen a drop in reduction of heroin use or overdoses. Why? Too few physicians with the required exemption and too few treatment slots for buprenorphine, the experts told us. After much debate and lobbying, the compromise is to increase the access by allowing physicians to treat up to 200 patients at a time.
We are facing an unprecedented epidemic. Why not remove all restrictions on the use of methadone and buprenorphine and throw open the floodgates for OST? Why not treat addictions as we have treated chronic pain in the past? Will this solve the problem? Not by any stretch of the imagination. It will only exacerbate the existing problem as the pool of opioids will greatly increase along with abuse and diversion. We have to offer patients treatment options including non-opioids.
Marc Lewis in his very thoughtful post on visiting a harm reduction facility in Belgium observed: “Methadone provides a solution to heroin epidemic, but not a great solution. Something is still seriously wrong here, and this form of treatment, connection and care can make it livable. But only just.” Marc’s observation that many patients in the clinic he visited balanced their methadone dose with heroin obtained on the street also applies to buprenorphine. As long as there is access to heroin, treatment options centered on buprenorphine or any other opioid are going to be problematic.
My clinics have treated thousands of patients addicted to prescription opioids and heroin by offering them clear treatment options. We refer them to methadone clinics when appropriate; offer buprenorphine as a detox and maintenance medication when necessary; and when they want to be completely abstinent from all opioids, we start them on naltrexone. A monthly injection of naltrexone (called Vivitrol) is a highly favorable alternative to continuous opioid addiction, especially when street drugs are mixed with OST. Our patients can always go back on buprenorphine or methadone if they change their minds. For many patients it is refreshing to know that they don’t have an incurable disease, and a spectrum of treatments options gives them a fighting chance to feel empowered and to quit using drugs. Even if only 15-20% of patients are likely to benefit from naltrexone/Vivitrol, is it not ethical to offer it as a treatment option? Especially for patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.
Access is the major culprit in the spread of addiction and a major contributor to relapse. Increasing access to opioids as part of treatment may help some people, but it is only going to worsen the big picture.
Percy Menzies holds a Master’s degree in pharmacy from India and is the president of Assisted Recovery Centers of America, a clinic based in St Louis, Missouri, that treats in excess of 400 heroin addicts a month through evidence-based treatments.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Mr Menzies opinions are not uncommon and are being expressed by medical professionals and in the media on a regular basis. Unfortunately these views are not supported by the science, and hold more problems than solutions. While I do not think the points raised should be summarily dismissed because they do seem, at first glance, attractive and valid, they need to be rebutted. As such I will provide a formal, considered response within the next couple of days.
I am indeed looking forward to Shaun’s response to my blog. It is these kind of discussion devoid of any invectiveness that is going to advance our field.
Blocking any receptors in the brain, to me, is not a long term option. Sure a person can come to live with the side effects of this type of treatment BUT what does it take away from the “Big picture” of life and life’s expressions and how we see things? Medication, Medication, Medication! Sure there are certain people with a chemical imbalance that could benefit from certain medications, BUT again I believe we can train the brain to ride the tracks of what we are given, through science based treatment of recovery. Or we can learn to live and thrive with what we give, without any outside influences. I have seen too many stuck on the roller coaster ride of needing, wanting, gotta have there meds. Stuck in a world of dependency, relying on medication ALONE to do all the work, with little to no desire to do any other type of therapy.
Richard, I agree with you. Using an opiate like Suboxone or methadone to detox someone might lessen their withdrawal effects but it is not a cure. And long term maintenance programs using methadone or other opiates is only treating the symptoms thereby leaving the addict dangerously close to their next relapse. It is not a long term solution to opiate addiction. To be dependent on a different legal chemical instead of the ones purchased on the street is still dependency. An addict entering detox and then recovery is like a person driving a car who hits a patch of fog. The fog disorients them and it might seem to the driver like it will never end. However, the fog is temporary and it will eventually lift when the driver gets to the other side. In the same way the addict entering detox has to understand that his pain, discomfort and sickness will diminish on the other side of detox. Then comes the hard work…recovery, where they will learn how to live without self-medicating away their pain and emotions whenever they get stressed or frustrated. If the addict’s base-line stays the same, (needing medicine to get through the day) then they will almost certainly end up back on that base-line shooting up whenever stress or disappointment overwhelms them. In recovery an addict’s base line must change. I consider myself a former heroin addict because the last time I shot up was over four decades ago. Early in my recovery my baseline changed, and so did the rest of my life. I have learned to accept pain as a part of life. I no longer have to take a pill whenever I am uncomfortable or feel some emotion that I don’t like. In the past twenty years I have had several surgeries as a result of several motorcycle accidents. Several times I left the hospital with a 30 day supply of opiates. People in recovery warned me not to take them or I will relapse. Much to their surprise I only took them as prescribed for one or two days, then threw away the rest of them. My baseline as an addict was to never feel pain or discomfort or stress. Back then whenever I felt any of those things I would self-medicate with anything I could get my hands on. Actually I would take twice as much as I needed to make sure it worked. Today…I don’t see myself as an addict. My baseline has changed. I have learned to live with pain as my friend.
Lew, This is very insightful. I think of addiction as a powerful belief structure or strategy: I believe this will make me feel better. Unless one is psychotic, beliefs usually correspond to reality, at least to some degree, and they correspond with strategies for how one lives. That was the case with opiates for me. They did make me feel better, until they made me feel much worse.
But like you I found that I could live with changes in mood that previously had made me anxious enough to crave escape. I’m perhaps not as advanced as you. When I’ve been on pain meds (a few times this past 5 years) I’ve sometimes needed to wrench myself away again. But I can do it, whereas I never could in the old days.
Still, some people have an incredibly hard time transforming this fundamental “strategy” or belief: I need to put something inside me…and having a tablet of Suboxone in the morning makes them feel they can make it through the day. We should be conscious of the many approaches to improvement. There are more than one.
The first sentence of this article uses the phrase; “the spread of addiction”, which is similar to the term: “the spread of a disease”, which is of a certain mindset of what addiction is.
Another mindset could be suggested if you plug it into another field.
For example:
“the spread of disco”, the spread of Electronic music”, “the spread of action-hero movies,”
“The spread of_______ , etc..
The point being;
Is access to these things the strongest factor contributing to their spread?
Blame the drug again – and ignore all the social and other factors present – and yet the answer is to give another drug, one that’s far harder to come off – seems a bit odd that. the disease model will not go without a fight and in the long run it hurts drug users – why not just implant all drug users with an anti-drug chip. accessibility may be an issue but not in the way described here.
To clarify,
A new model for addiction will be over-arching, and be capable of including ALL the various beliefs that help certain groups of people, including the belief that addiction is a disease.
The other good news is, that the Medical/Scientific/Recovery fields will no longer have “take a side” on the various beliefs that will always exist about addiction and recovery.
I agree with Shaun- thoughtful and wrong. Look forward to his response
To me it has never made sense to treat one chemical problem with another long term with few exceptions; diabetes is a good example.
The whole mess is derived from the wrong and harmful disease model – this just a case in point.
And illustrated by Carlton- who brought a laugh as I thought of the big epidemics (rapid spread) of Black Plague and Spanish flu..
“” OOOO dont touch that addict you might catch it !!!””
I do, too. I once wrote this on another site and have never gotten an answer: “It is hard to believe that Suboxone, alone among the opioids, has no long-term risks from tolerance, drug interactions, side effects, or as-yet-unknown brain damage. Does suboxone have dangerous side effects if taken long-term (or if taken short-term)? Is there a danger to mixing it with other medications? (i.e. will patients have to limit their use of other vital meds? ) How about with alcohol or benzodiazepines, aside from overdose potential? Does tolerance develop, as it does with other opiioids? If so, how much must be prescribed for it to be effective for pain treatment? How healthy and happy are people who have been on Suboxone (or methadone) for ten or twenty years? Do they suffer from irregularity, sexual dysfunction, memory problems, depression? It seems the possible downsides of MAT are hardly ever addressed–except by patients or critics of ‘substituting one addiction for another.'”
Since I keep hearing–only recently–that opioid dependence causes PERMANENT brain damage, I’d like someone to explain what the damage is and what scientific evidence there is that said damage is permanent. It seems to be a matter of opinion rather than science. Is it, or is there really some research to support (or refute) this position.
When opioids are taken as prescribed, it can be used to manage pain safely and effectively. But if it is abused then it can lead physical dependence and often becomes an addiction. This can cause neurological effects, including coma and permanent brain damage. Opioid addicted people find it very difficult to completely get off from it. In Canada, many of them seek the help of rehab centres like the canada drug rehab(http://www.canadadrugrehab.ca/Canada-Detox-Medical-Alcohol-Drug-Rehab-Programs.html ) to get back to a normal life.
Dr. Vincent Dole, a nutritional scientist who did the initial study on methadone for heroin treatment in the 1960s justified life-long treatment on the basis of the ‘metabolic syndrome theory’. He claimed that opioids cause permanent changes to the opiate receptors and therefore these patients need methadone, similar to a diabetic patient needing insulin. Asked how he could explain this theory. His response: Start a heroin patient on methadone and take the patient off the methadone and he/she will relapse to using heroin because of the ‘metabolic’ need for the opioid! Sadly, this is repeated over and over and patients are resigned to be on methadone for years and years.Now we are saying the same about the other opioid, buprenorphine. Surprisingly this syndrome does not apply to well-to-do patients like physicians, business executives, airlines pilots etc! The federal government spent millions of dollars developing naltrexone as the first non-addicting medication to protect patients from relapsing when they returned home from residential treatment. The first few months are the most vulnerable for the patients as they are likely to encounter a myriad of cues and triggers associated with past drug use. This phenomenon is called Conditioned Abstinence or the Deprivation Effect. The longer you are deprived of your most favorite thing, stronger the desire to use it. Naltrexone is that ‘helmet’, ‘training wheels’, that protected you from accidental or impulsive use of opioids. Over a period of time, the drugs do not have the same lure (extinguishing the conditioning) and the patients can stop the naltrexone. For some it may be a few months or for others a year or two depending on risk. Most physicians like anesthesiologists have to be on Vivitrol for two years because they are going back to using opioids for their patients, We have patients who are released from jails and prison and live in high drug and crime areas. The State of Missouri offers Vivitrol for two years. Once the brain is rewired away from the drugs, the naltrexone can be stopped. Why this visceral opposition to a clear third option for patients who want to be opioid free? For many it may come as a surprise that naltrexone was approved by the FDA to treat heroin addiction in 1984 and for the treatment of alcoholism in 1994. Yes, naltrexone is very effective to treat alcoholism.
I am not from the medical or recovery field but I did recover from decades of an addiction, (alcohol), and in hindsight, this sentence popped out;
“Once the brain is rewired away from the drugs [The naltrexone can be stopped.]”
It is unsettling to realize there are well meaning people that may elect themselves, or assign people to “re-wire” other people that may experience an addiction during their lifetime.
In hindsight, although both thoughts and behaviors did indeed change during the recovery process, the key change during the recovery process was the matter of the heart, or how one feels about things.
These changes should only occur internally by the individual.
For instance, if you realize you want/need to change how you want or love something or someone, what do you do?
Being chemically “re-wired “ would be unsettling for most people, particularly if done by someone other than ones-self.
I dont think I was born an addict but having hindsight into my behavioral environmental and emotional susceptibilities I realize that I certainly learned how to become one… just as I learned not to be one.
My sense is that that addicts often tend to self medicate the wrong issue and that open ended reliance on a pharmacological substitute is just a furtherance of these behaviors.
That said, in the short term nothing wrong with a short term respite in order to see the forest through the trees (the big picture).
A quote comes to mind when I read this :
Such subtle covenants shall be made
Till peace itself
is war in masquerade .
John Dryden
I’m not a man to promote “Adhominum attacks ” but you have a vested interest in what you write :
You are the president of Assisted Recovery Centers of America :
This is copy from the web sit Addiction pro America :
“A prominent Philadelphia-area real estate developer who has transformed brownfields into vibrant commercial and residential communities is spearheading an initial $200 million of investment into around a dozen new addiction treatment centers, saying he wants to elevate the treatment of addictions to the same level of quality and hospitality that he sees in treatment of other chronic illnesses such as cancer.
J. Brian O’Neill’s first key hire for the organization that will be branded as Recovery Centers of America is Deni Carise, PhD, who has shaped clinical transformation at two of the largest for-profit and nonprofit substance use treatment chains and will leave CRC Health Group at the end of this month to become the new for-profit venture’s chief clinical officer.”
I think you have $200,000,000 for profit reasons to take the position you do . I also wonder why after anything that is “Evidence based ” there are no citations ? Day one , thing one folks learn is that one must back up claim of “Evidence based” with the evidence .
I live in Vancouver , British Columbia , Canada . Home of the first Safe Injection site in North America called “Insite” , it also hosts a detox and recovery program called “Onsite” . A sperate program , started by the Catholic Church that goes by the name of Providence Health Care gives folks hydromorphone (Dilaudid®), it’s in clinical trials:
The Study to Assess Longer-Term Opioid Medication Effectiveness (SALOME) is a clinical trial that will test whether hydromorphone (Dilaudid®), a licensed medication, is as good as diacetylmorphine, the active ingredient of heroin, at helping people who suffer from chronic opioid addiction and who are not benefiting sufficiently from other treatments.
I guess what I’m trying to say is that you’re motives are specious and self involved , maybe listening to your client more often will save lives .
Thanks
Donnie Mac / 16
Brilliant.
Also I thought I was the only person who still used the word “specious”. It’s right up there with “insidious”.
Donnie,
A point of clarification. I have nothing to do with Recovery Centers of America operation. Indeed, they are in violation of the the ARCA trade name registration. I am vehemently opposed to these forms of treatment as they do not address the major cause of relapse – Deprivation Effect. The bulk of the treatment should occur in the patient’s ‘home’ environment, while being exposed to a myriad of cues and triggers associated with past drug use.The past attempts to use surrogate opioids has not worked. I am sure you have read about morphine, heroin, cocaine (not an opioid), hydromorphone being used to treatment opioid addiction without much success. The challenge is to prevent diversion of these drugs as is happening with buprenorphine. Naltrexone was developed as a non-addicting, non-divertable ‘post-exposure prophylactic’ to give patients a fighting chance to remain opioid-free and eventually be completely of all drugs -opioids and non-opioids. What is so wrong with this approach?
Mr. Mezies, I have never heard of cocaine being used to treat opioid addiction, but there is good, solid clinical evidence of the efficacy of heroin and hydromorphone (dilaudid) to treat opioid dependence, not only in Switzerland, where it’s been used the longest, but in a growing number of European countries running such trials, and more recently, in Vancouver, there was at least one recent successful study involving dilaudid. I don’t understand what you’re basing your conclusion on. As for preventing diversion, the answer is providing adequate, albeit appropriately controlled, access.
Gina,
Here is a direct quote from an outstanding book by Dr. Howard Merkel and I would urge you and others to read it.
” It is impossible to give an accurate number of how many morphine addicts were unwittingly turned into cocaine addicts by well-intentioned physicians during this era; similarly, alcoholics were often prescribed morphine to the point of addiction and later, cocaine and even nicotine to help kick their drinking habits. At the dawn of doctors’ recognition of addiction as a disease, what all these games of medical musical chairs most reliably did was create ‘new and improved’ addicts.
Anatomy of Addiction by Howard Merkel – page 76
Unless we learn from history, we can going to repeat the same mistakes.
Mr Menzies, we agree on one thing 100%: “The bulk of the treatment should occur in the patient’s ‘home’ environment, while being exposed to a myriad of cues and triggers associated with past drug use.” Thanks for clarifying the confusion over the name.
I will work through the other comments over the next day, and I welcome the robust debate. Excuse the delays, I have been traveling.
I am so glad Shaun we got introduced by Marc through his website. I look forward to continuing our debate. Both of us are well-read and well-versed on this subject, especially the history and politics of drug addiction. I hope sometime in the future we can meet in person.
Likewise. I always appreciate being pushed on issues and appreciate good debate.
Hi Donnie. I think your criticism is way too harsh. Dr. Menzies defends himself, without being provocative. But here’s my view:
Why would you assume that his clinics are a direct lineage from an investment initiative that places profit above all else? That’s clearly not the case. And by the way, a clinic consortium that balances for-profit with not-for-profit is not evil. It’s often practical.
But some of you guys are missing the main point: Dr. Menzies is, yes, very optimistic about naltrexone, but his clinics offer a range of treatment options, including standard OST (including methadone and buprenorphine), and he emphasizes the importance of keeping those choices open.
The one argument that I think maintains perspective is to challenge his claim that diversion is caused by excessive use of OST. Okay, then keep your criticisms focused, and don’t ignore the aspects of the post that are intelligent, caring, and conscientious!
Donnie,
I agree with Percy on most of his points without any financial interest at all- I’ve never worked for ACA or any of it’s affiliate clinics. As a counselor, I listen to my clients every single day and have found the discussion on this blog to be quite enlightening even when I disagree with someone, I appreciate that they’re part of the conversation.
However, my one suggestion would be to note the stark differences in Canada with regards to treatment for heroin addictions and that of the US due to differences in legislative attitudes toward addiction, health care access (as we re not socialized in all states). Given that, I would be curious as to what your feedback would be with that suggestion.
Best,
Rebecca
“Why not treat addictions as we have treated chronic pain in the past? Will this solve the problem? Not by any stretch of the imagination. It will only exacerbate the existing problem as the pool of opioids will greatly increase.”
This is not the case in Switzerland, which drastically changed its drug policies in response to its own opiate epidemic in the late 1980s. They essentially treat addictions as we have treated chronic pain—mostly with longer-term opioid maintenance, whether methadone, buprenorphine or even prescribed heroin for those for whom all other methods of treatment have failed, along with other social supports. The results have been overwhelmingly positive. So much so, that prescribing heroin to addicts is no longer controversial there anymore. Among the heroin treated population, not a single person has died from an OD, rates of drug-seeking crimes have plummeted, along with rates of illicit drug use and drug-related diseases like HIV and hep C. Perhaps most importantly, there was actually a slight drop in the rates her new users. These results have been repeated in the growing number of countries conducting clinical trials with heroin-assisted treatment.
This strongly suggests that set and setting are extremely important factors here, at least as important as supply. Yes, supply matters and should be appropriately and sensibly controlled, but we need to intelligently discuss what that should control should look like.
It certainly shouldn’t look like the ridiculous prohibitionist policies we’ve been living with so far, which are far from the ultimate form of control they are perceived to be, but rather represent the complete abdication of control over both the quantity and quality of the drug supply to criminals.
One other quick note: OST is not just based on the questionable presumption that opiate use causes permanent changes to the opiate receptors (though that may well be the case for some people). It recognizes and capitalizes on the protective effect of tolerance, something unique to opiate dependence that is not true for any other substance. Once tolerance is established, maintaining that dose does not cause impairment, staves off cravings and withdrawal symptoms and most importantly, protects against overdose. When that tolerance is abruptly lowered or otherwise altered significantly (typically following periods of short-term abstinence such as stints in rehab or jail or by consuming fentanyl-laced heroin or consuming other depressants like alcohol or benzos), the risk of OD dramatically increases.
When tolerance is established and a therapeutic dose is maintained with a clean supply, opioids are among the safest drugs to consume long term. When that tolerance is altered significantly, they are among the most fatal.
I’m not an expert in opioid addiction. There are neuroscientists and MDs on this board who can speak to the neurochemistry of this. I do find that I am sympathetic to the argument that treating opioid addiction with opioid substitutes seems like a band-aid rather than a solution, though it obviously has “worked” for some people in some environments. Perhaps this is an “and” situation – opioid substitution can help some addicts in some situations AND making opioids and their substitutes widely available brings its own set of problems. Regardless, I appreciate hearing multiple perspectives on this blog, and hope that we continue to be a welcoming community for all who are motivated to care about, and for, people struggling with addiction. Even when we disagree. Thanks to Marc for making the forum available, and to Percy for getting into the kitchen.
I have being sober for almost five years now, sometimes I fell falling back into the old habits but I always remember what the people from http://www.northpointrecovery.com would tell me when I spent sometime with them, they said that love was the key to staying in a clear path so please always remember that we will always be strong as long as we something strong enough to hold on like love, it can even be love for yourself, you do not necessarily need another person but that does help.
Do we want to move towards a policy that could have unintended harmful effects, such as legitimate pain patients not getting the medicine they need? (which is happening in many places with limits and restrictions placed on physician prescribing due to the “heroin” crisis ( often benzos, fentanyl and other crap– not heroin). In the Boston area where I visit many detoxes, people are dying, but it’s often not from the heroin or prescription meds.
Do we want to go in a direction that could have the unintended effect of another failed version of the “war on drugs”?
Treatment durations for inpatient detox, residential, IOP, PHP, TSS and other step down services are woefully short, hard to find, and often in the hands of people that don’t adequately understand addiction and have little training. Insurers won’t pay because of low success rates, which takes money from hospitals, treatment beds dwindle, and on and on. We are just starting to get more effective preventive education. The social supports that accompany effective, enduring success are scattershot.
People will get access to drugs if they want them. Limiting their availability is a short term fix, a band-aid.
I personally had a very bad reaction to methadone, which I was taking for pain (opioids are occasionally switched in chronic-acute pain syndromes; sometimes there is a mild lessening of cross tolerance). Methadone was a nasty drug for me. My IQ felt like it went down 30 points the day I started it. I got more depressed, even though the pain was managed, to the point where I tried to kill myself.
Addiction is a complex, multidimensional problem of which access is only a part–the fuel in some cases– but not the engine.
People are always good for spouting off their opinion. But here’s an idea: remember in your comments that people are dying. If you think that methadone and suboxobe and nalaxone are terrible or a bad idea, think of a way to help people stay off high dose opiates that is 93% effective and I’m all ears. And one that is affordable and legal. If ALL opiate addicts could do it without the medication then we wouldn’t be having this discussion. Anecdotal evidence isn’t enough and opinion on what people should and shouldn’t do doesn’t matter when our hospital er’s are full of parents who just found out that they’ve lost their children. – Rebecca, licensed substance use disorders counselor
Also, if the person above is looking at supply and demand, sure there’s heroine available in the US- 70% of heroin users currently started with pain pills. We need to reduce demand and the supply will go- but not the other way around. In the US counseling is always required with OST, so the idea of using it without any other support is not possible.
I totally agree. But requiring counseling with OST doesn’t always guarantee there will be adequate funding and staffing to implement it.
That may be a difference of country perhaps? I’ve been at 3 clinics as a counselor and seen otherwise on all occasions. We certainly could talk offline, but in ten years of practice Ive only seen it as a client compliance problem and not a staff/funding issue. There are not any guarantees, however I would beg to differ on an overall hesitation on the requirement.
Sorry, Rebecca. I’m afraid I was unclear. This is again “anecdotal” evidence but opiates kept me alive and functional in many ways when I was deathly ill. My anecdotal point about methadone was not that it is a bad drug, but that it was a bad drug for me. If it made me depressed to the point of suicide, odds are somebody else has gone through the same thing. With methadone– not anything else.
My criterion for success for any OST is that it gives people the ability to function productively free from the dangers of illicit acquisition and use. But there are cases where it adds yet another drug of abuse to people’s already desperate lives. I’m sure as a an experienced SUDs counselor you’ve seen this. Like you, I prefer to err on the side of OST providing an opportunity for people to get their lives back. I have no opinion on what people should or shouldn’t do other than being supported in discovering what works for them. At the moment, most treatment approaches (in the US) are focused on expediency, short stays, minimal step-down and follow-up. All I’m saying is that in light of what a complicated societal problem this is, just looking at access is not enough.
Sorry again for my lack of clarity. It’s hard to talk about this in sound bites.
Matt,
It was not your post that I was replying directly to but rather the comments that started at the beginning of the comments list, including Lew, Richard and Shaun.
I sit on the same side of the fence as you do with regard to OST use, though in my state it’s referred to as MAT (medication assisted treatment). It is hard to justify harm reduction, short term assistance and the relapse prevention clause in America that is made for pregnant women and those just released from incarceration to seek MAT as a relapse prevention, (based on protection from opiate use during pregnancy, and return to criminal institutions of which our country can’t afford) among black and white opinions.
The sad reality now is that we have a demand problem- not a supply problem. It’s driven by disease-and the stats we have are based on treatment center admissions, people dying, and doctors losing their schedule II prescription licenses. I believe there is a place for opiate medication for chronic pain, along with doctors being mandated to run DOPL reports- the list that they can pull to show all controlled substances filled within the past several years. It will show evidence of doctor shopping and numbers of how many opiates are dispensed (indicating patient addiction/ irresponsible practice by medical prescribers)- only a handful of states in the US have this as a legal requirement, which is horrifying to me.
The price of heroin on the streets has increased two fold in my city, which has one of the highest overdose rates in the country short of the Kentucky/West Virginia area. We are able to measure demand by increased costs on the supply side- no large wall at the border will solve the issue nor will any medication assisted treatment without counseling towards lifestyle change and monitoring for progress. This is why I get bristled when we talk about this as a “drug alone will not fix this” concern; the federal government knows this as do we counselors- which is why it is a mandated part of treatment.
There are irresponsible MAT (OST) clinics out there as well, just as there are doctors, but let’s not rule this option simply because we believe that it’s not a good idea for whatever reason. There are long term side effects with high-dosing clients on methadone- though they are largely dose dependent and controlled by doctors who client’s see more than their primary care provider (once per month for many clinics, once per year for some, depending on stability).
If anyone is concerned about this issue, please do the homework- because like I said before people are dying at the rate of one every 24 minutes from medication overdose in the US. OST is not for everyone- its for the most desperate who have 12 consecutive months of use with several attempts to quit with no success. It is a small subpopulation of addicts- the ones most likely to die.
I work at the community clinic in Salt Lake City, Utah. We are 7 blocks east of the homeless shelter, one block west of the welfare office, at ground zero for recovery. Anyone is invited to visit, though for clients we are booking out one to two weeks for intake because more and more people are realizing that there is a place they can go to try and get well, reclaim their lives, and change their world.
…and it’s too bad that statistic isn’t taken more seriously as demonstrating the demand for treatment and driving better funding ! I think everyone on this blog knows that there is a window of opportunity where people with substance issues are most motivated to go into treatment, and if there aren’t any beds available, that window can close relatively quickly. Bless you, Rebecca, for your persistence and dedication and everyone else on this forum committed to this work, and a better understanding of this intractable human problem.
Very thoughtful and nuanced overview. Thank you, Rebecca!
Rebecca, I think you misunderstood my comment. I am all for the supply of OST. I also think that counseling should NOT be a prerequisite for accessing OST – please see the next post for my position.
Let’s keep it civil. We’re all spouting our opinions here. I also know someone who became very depressed while on maintenance methadone. He went to coke, then crack, to relieve the grey monotony of methadone sedation. Now he’s dead.
Anecdotal evidence is powerful in tuning one’s perspectives, but of course anecdotes must be seasoned by a consideration of individual differences.
I agree with “Increasing access to opioids as part of treatment may help some people, but it is only going to worsen the big picture.” Great article, thank you for sharing.
Thanks for sharing your thoughts – they certainly make sense. There is not a one size fits all solution for people seeking recovery from opioid addiction. For many though, buprenorphine treatment as part of a comprehensive treatment plan can help them to break the cycle of addiction.
Dr. Vincent Dole, who did the early work on methadone was shocked at the punitive nature of methadone administration. Patients are required to go to the methadone clinic each morning to ingest the drug. How many medications in this country are administered this way? Zero. He remarked: “The stupidity of thinking that just giving methadone will solve a complicated social problem seems to be beyond comprehension”. Now we think that prescribing buprenoprhine will solve the heroin problem! We are facing an unprecedented crisis with heroin supply. This supply in getting more and more people to try heroin, which then triggers demand. We are inadvertently expanding the supply (access) with using OST as the only treatment option.The restrictions on buprenorphine were placed to limit diversion, but it has not worked. I would recommend reading a very insightful article by Rick Barnett titled: Maintenance Medication Madness. Here is the link
.http://vtdigger.org/2016/04/26/rick-barnett-maintenance-medication-madness/
Until we shrink the supply of legal and illegal opioids, the problem is going to get worse. Our present strategy of clean needles, distribution of naloxone should be expanded, but cannot just stop here. The present silos have to be broken down.
It is astonishing to me that you can write about this issue without addressing the elephant in the room: mortality. Methadone and buprenorphine are the *only* treatments proven to reduce the mortality rate by 50% or more— and this is when they are used indefinitely for maintenance, not short term.
A study of everyone in opioid treatment in the UK found that these two drugs were the only things that cut mortality, in this study it was by 50%, but other studies have found higher rates. Abstinence treatments didn’t save people, maintenance did. There is no such evidence for naltrexone or Vivitrol— and no one is following up patients who don’t come back for more, who are at at least as high risk for OD death as people coming out of prison, which is dozens to over 100 times greater than at other times in treatment.
It is a violation of informed consent to not tell patients these facts from the data. If they still want antagonists when informed, that’s fine— but failure to inform should be seen as malpractice.
As should claims that people on methadone or buprenorphine somehow live in a shadow world of recovery that isn’t “real” and that because these drugs run through their veins, they are somehow “high” all the time and unable to grow emotionally or some other such nonsense. There’s no data to support this: you cannot tell them from other people in recovery once they are on a stable, steady and appropriate dose and are not misusing other drugs on top. Unlike alcohol tolerance to impairment, opioid tolerance to impairment is complete when the dose is stable— so these ideas that methadone or bupe are inferior are based on a misunderstanding of pharmacology.
It’s like saying that because I take Prozac, I’m not “really” in recovery from depression. You don’t know what it’s like to live in my nervous system and what my baselines are and whether I need to go up or down from them— and the same is true with opioids. Some people may benefit from antagonists and others from agonists, but the data on agonists is overwhelming on mortality and till we know that Vivitrol doesn’t increase death rates the way oral naltrexone does in opioids, we need to stop pushing it without providing patients and their families with the information about what we do and don’t know about mortality.
Hi Maia, Great to have your input, and you certainly make a clear and convincing argument. Please see Shaun’s second post — next — in which he also rebuts some of Dr. Menzies’ points — with data. I’m going to mostly stay quiet and be awed by others’ expertise.
Exactly Maia.
I begin by a direct quote from an article Maia wrote in Time titled: Are Doctors Really to be Blamed for Overdose Epidemic?. This article seemed to hold physicians blameless for increasing the access to powerful opioids.
“Indeed, it is impossible for a doctor to “make someone” into an addict. Even if the doctor tied the person down and injected him or her daily with heroin or other strong opioids, only physical dependence could be created. That means the person would suffer withdrawal symptoms when the doctor stopped, but whether such victims genuinely became addicted would be determined by their own actions after that point. drugs”. Here is the link to the entire article:
http://healthland.time.com/2011/11/02/are-doctors-really-to-blame-for-the-overdose-epidemic/
There is no doubt the present problem started when the access to opioids was expanded under the guise of treating ‘chronic’ pain. Way too many of the wrong patients went to ‘pill mills’ and the doctors were only too eager to oblige.
This is keeping in line with a number of writers in blaming patients for getting addicted. Johann Hari who wrote the: Chasing the Scream also insists that heroin is not addicting and therefore should be legalized! They cite Portugal, Switzerland and Vancouver as shining examples.
Mortality is going to be reduced if patients stay on all three medications – methadone, buprenorphone and naltrexone. The fly in the ointment is that patients are notoriously non-compliant. The success of methadone – one of the most dangerous drugs, pharmacologically speaking is entirely based on tightly controlling the access – methadone clinics. We know what happened when methadone was prescribed to treat ‘chronic’ pain, Methadone kills more people in this country than any other opioid. Yet virtually none of the deaths can be traced to methadone clinics. If these two drugs are life-savers, then why the restrictions? Why not give them the same status as naloxone (Narcan)? Would we see reduction in overdose deaths if patients had easy access to methadone, buprenorphine, clean needles and Narcan? I am afraid we would have a disaster. The only people toasting with tequila would the the Mexican narco warloards!
At my clinics in St Louis we use oral naltrexone very safely and effectively. The patients have to come to the clinic three days a week and ingest the medication while being watched by a staff member. We have not seen a single overdose case in patients who kept their appointments. We warn them that naltrexone pharmacologically reduces tolerance – no different than going to a residential program or prison. The introduction of Vivitrol has solved the compliance issue to a great extent.
What is so wrong in offering a naltrexone as a treatment option that might benefits 15-20% of patients to be abstinent from opioids? If they change their mind they can always switch to buprenorphine or go to the methadone clinic. Treatment outcomes are best achieved by giving patient choices.
I would invite you and others to visits our clinics and see for yourself how treatment options help people overcome addictions. We treat in excess of 400 heroin patients a month – a staggering number.
I strongly contend that expanding OST as the only treatment option increases the access to the licit and illicit pool of opioids and is a strong incentive to bring more heroin into the country. We joke that there is more buprenorphine on the street than in pharmacies!
Percy: Maia, Shaun and others make the mortality argument very persuasively. But strangely, you seem to agree that uncontrolled access to methadone (and other opioids) is a bad idea. What you seem to agree on is availability, control, and choice. I wonder why this keeps disappearing under the firestorm.
You say “If these two drugs [methadone and bupe] are life-savers, then why the restrictions?” I think that’s a strange rhetorical twist. You know why the restrictions, and it’s one thing that you all agree on.
Low threshold access and good control (from Maia’s next retort): hooray for the Netherlands!
The million dollar question is how to create low threshold access and good control to OST but prevent leakage into non-medical use. The US is not Netherlands. We consume 90% of the worlds prescription opioids; we are the largest consumers of methadone and buprenorphine and we have the highest mortality rates from opioid drugs. Couple of suggestions from what happened to hydrocodone. Hydrocodone was the most prescribed and abused prescription opioid. The schedule for this drug was changed from III to II in 2013 and the prescriptions for this drug dropped by 19% in 2015. Methadone clinics should be incentivized to offer all three medications and particularly buprenorphine; nurse practitioners and physician assistants who generally spend more time with patients should be allowed to prescribe buprenorphine formulations and pharmacists should play a greater role in the administration, monitoring and education of OST, In other words create a disease management program for addictive disorders similar to other chronic disorders like diabetes, asthma and hypertension. Several schools of pharmacy are offering specialized programs for the treatment of addictive disorders. We need to bring them all together to increase access to treatment and decrease diversion.
I am not saying that your clinics don’t provide NTX and XR-NTX safely – I have no data around this, but you avoid saying what happens when people miss their appointments. My issue is with the promotion of NTX as an equivalent of OST (MMT & Bupe). Should it be available? Yes, for the well motivated and well informed, as per WHO and NICE guidelines. Should it be the first line treatment, absolutely not, and particularly not for prisoners and indigent populations (see my post and article on the Influence).
The reason that methadone is so dangerous in pain treatment is not because it is more controlled for OST programmes, but because of the patient population and the way it is prescribed for pain patients. Firstly, they are mainly opioid naive patients and secondly it is prescribed as a 3x per day regimen to maximise analgesic properties. Considering the half-life, this is a really bad idea. In OST programmes dosing is once daily unless the individual is a fast metaboliser, and then it may be twice daily. Fact is that most GPs are clueless when it comes to prescribing methadone! Even the FDA cocked up the package insert and the recommended dosing schedule could have killed an opioid naive patient. Methadone is NOT a good idea for pain management.
You say that patients are notoriously non-compliant and lump MMT, BUPE and NTX in the same catergory. Well, that is just misleading. Cochrane and other reviews show that OST has retention rates significantly better than placebo, NTX not so.
Further, you ignore the super-sensitization of opioid receptors in antagonist therapies, which make risk of overdose greater than for agonist and partial agonist therapies where some degree of tolerance is maintained.
Let me add to this: In Tanzania I visited programmes where Px were receiving up to 360mg per day Methadone and fully functioning – no “nodding”. they have very high quality heroin and most are HIV and TB co-infected, hence the high doses. One would expect high mortality, but no, very low mortality, and now they are giving take-home doses because they are beginning to get optimal coverage. In no ways could I imagine NTX being able to hold and keep this population safe.
This is a sad case of upping the dose of methadone. Was a cardiac work up done for possible torsade? I wonder what is happening to this patient’s testosterone level? What is the future of this patient? Stay on such a high-dose methadone for the rest of his/her life? The patient is not going to experience any long-term effects?
Imagine this patient doing well on a 360 mg daily dose is given a week’s supply – 2520 mg! What should prevent him/her from sharing some of the methadone with a friend or neighbor or selling part of it or taking it all? The success of methadone is entirely due to the tight controls on dosage and daily visits. Change this and you have the same disaster of using methadone in physicians office for chronic pain.
On the other hand, if the patient was given a week or months supply of naltrexone or any non-addicting drug,in all likelihood they would not take it. Direct Observed Therapy is the most effective way to get the patient ingest the med. This is no different than patient on anti-TB meds. Patients come to the clinic three days a week to ingest the naltrexone. What is wrong if 20-30% of patients benefit from this approach?
Yes, every patient has an ECG on initiation, and they are then monitored. The data tells us that high dose methadone works. In this setting there are many Px on this type of dose, and they are really functional and happy and the role-out has had an amazing effect on heroin users and their re-integration into society in Tanzania.
I would argue that the success of methadone is not the DOTS, See my later comment.
You are missing the point. I am not suggesting naltrexone be the first line treatment. It was not developed for this purpose and is never used in this manner. It is a very unique medication that cannot be compared to any other medication. It is best described as a post-exposure prophylactic or ‘insurance’ against relapse when patients stop methadone or buprenorphine. They are very vulnerable to relapse if they not protected. A patient after being on methadone or buprenorphine for two years comes to us and says he wants to get off the drug and be opioid free, what should be the response? Naltrexone is an option to protect the patient from relapsing. What is so wrong with this approach?
If patients are on naltrexone we warn them that this medication makes them opioid naive and if they decide to go back to using heroin, they should start gradually.
The bottom line is the treatment of opioid addiction is most often done with OST and after a period of stabilization the patients are given the option of weaning off the opioids and going on a non-opioid as an insurance from relapsing. I cannot make this any clearer. Naltrexone is rarely offered as a first-line treatment.
With OST there is over-compliance – they either take bigger doses, particularly with methadone and sell/trade the buprenorphine. They don’t show up for the naltrexone if they have used or decided to use.
Ok, so I would certainly support choice, and what you have stated above makes sense to a large degree. This is, however, not what we are seeing in the criminal justice system – we are seeing parolees being placed on NTX with little choice and courts ordering it.
Here is an link to an article published in the Journal of Psychiatric Practice on expand or not to expand buprenorphine prescribing.
http://journals.lww.com/practicalpsychiatry/Fulltext/2016/05000/Buprenorphine_Prescribing___To_Expand_or_Not_to.4.aspx
First, I didn’t say pharma was blameless— but nice attempt to divert the conversation away from the fact that the data is overwhelmingly on the side of opioid agonist maintenance and that what you are suggesting is NOT linked with reductions in mortality.
Nor did I ever say anywhere that I am opposed to patients having options: indeed, I said they should have options with informed consent.
Again, you have no data by which to suggest that increasing maintenance access increases addiction problems. None. It’s been studied for 50 years around the world and this has never happened. You add maintenance and death rates, crime and disease go down, you cut it and those things go up. It is lack of low threshold access that causes diversion because people don’t prefer maintenance drugs and the ones who take them illicitly are overwhelming patients outside of treatment who don’t want to jump through hoops or who simply cannot access maintenance. And you can do low threshold access with good control— as has been done in the Netherlands for decades.
This remains a conversation about “we think using drugs is immoral and we don’t care if you die to prove our point” and it’s sickening.
Let me reiterate the premise of my original argument: Increasing access to licit and illicit opioids contributes to the spread of addiction and is a significant contributing factor to relapse. The goal of maintenance treatment with any medication is to prevent patients from illegally obtaining opioids. Patients don’t comply with methadone, buprenorphine and naltrexone because they like to use other opioids that give them a bigger ‘high’. This is problem in treating any condition that impacts the biological instincts of survival. Look at the challenge in treating obesity! The opioid has tricked the patient into believing that he/she needs the opioids for survival and the longer the patient goes without it, the stronger the desire to use, especially when there is easy access to the opioids.
It would be nice if patients stick to the maintenance treatment – they don’t. The lure to use legally or illegally obtained opioids is way too strong. Diverting the opioid, especially buprenorphine is ready cash. If methadone and buprenorphine are reducing mortality rates, then why these draconian restrictions? We know the answers well. Lifting the restrictions will only compound the problem. You have to be in a drug-induced coma to believe that buprenorphine is not being diverted for non-medical use. Here is an link on an article whether to expand or not expand buprenorphine access.
http://journals.lww.com/practicalpsychiatry/Fulltext/2016/05000/Buprenorphine_Prescribing___To_Expand_or_Not_to.4.aspx
I am opposed to legalization on the grounds that legalization affects poor people disproportionately. Sadly, for these folks ‘treatment’ is three hots and cot! I have seen first hand the devastation of opioid addiction and yes, alcoholism in countries like India and South Africa and read extensively of the problem in other countries. In every instance it caused by increased access. I am in strong favor of drug decriminalization. I consider it far more immoral not to offer people treatment choices. Let’s face the uncomfortable fact that maintenance treatment is incredibly profitable and calling it the ‘gold’ standard and the only effective treatment is a transparent fig leaf!
My staff sometimes ask me why can’t we be like the others and make a lot more money – have the doctor see the patients once a month for a few minutes and get them out of the door with a script for buprenorphine for whatever dose they want! Why do we need nurses, counselors, therapists, internists and psychiatrists at the clinic? My answer is: Because the addiction is only the tip of the iceberg and they need all these services to put ‘humpty dumpty’ back together.
In South Africa there is currently no access to OST in the public sector.
Maia wrote a column in today’s NYT titled: Focus on Preventing Addiction Instead of Prescribing Medication. Here is the link:
http://www.nytimes.com/roomfordebate/2016/05/05/should-opioid-training-for-doctors-be-mandatory/focus-on-preventing-addiction-instead-of-prescribing-medication
She ignores access to drugs as a major contributing factor. She is right in stating that 75% of the people who misuse prescription pain relievers are getting them from friends, family members and dealers. And how are the friends,family members and dealers getting them? Most likely from diverted opioids prescribed by physicians. Two hundred and seven million prescriptions for opioids were written in 2013 and some of these pills were diverted into non-medical use. Teens are incredibly curious and they will experiment with just about anything. Easy access to drugs is a major contributing factor to habits and addictions. This is the reason we don’t have cigarette dispensing machines, beer being served etc. in schools. Most schools have removed soda vending machines. Early data from Colorado shows that kids are smoking more marijuana and consuming less alcohol because the access to marijuana has increased because they were curious to try it and some of them liked it more than alcohol. Mental illness or childhood trauma is not the only cause of addiction, although this is a major cause. Easy access when combined with peer pressure, curiosity, cultural and familial factors contribute to the spread of addiction. Better understanding of addiction is going to do little towards prevention and treatment, when drugs are ubiquitous.
Maia advocates indefinite maintenance treatment with either methadone or buprenorphine because it cuts the risk by 50-70%. She laments that these two drugs are far more strictly regulated than opioid prescribing. I am eager to know how the access for these two life-saving drugs can be increased?
I answer all these questions in my post and here: http://theinfluence.org/pushing-naltrexone-as-the-answer-to-our-heroin-problems-is-unscientific-and-unethical/
Percy and Maia,
I’d like to propose a third opinion, which is this: access=funding.
In Utah, one of the 19 states that declined medicaid expansion (along with Missouri, as I believe one of you is there) meaning that we are in an absolute crisis with treatment access in Salt Lake City.
Folks may wax and wane with the idea of medication assisted treatment, but I think whether it’s preferable or not, it’s fills a gap: most treatment centers are $1500 per month for outpatient care (up to an ASAM LOC 2.5) and residential runs $3200 per month. So unless you’ve got great insurance or a bunch of money, then treatment a higher level of care with immediate access is not an option.
Rather, you can wait on the list for government funding, which on my last contact to admissions departments, was 6 months for most and 8 months for another. I think we can agree that opiate addicts are less likely to have a bunch of money or be on salary somewhere and when the moment of motivation is high will seek the most affordable way to get well: medication assisted treatment (MAT).
Admissions departments have disclosed that people die while waiting for treatment. Which is an incredibly sad state of affairs- both on a micro level and a macro level.
My clinic has the local contracts with the VA, drug court, medicaid, and TANF grants. We are able to offer discounted or free medication assisted treatment for those who can qualify for it. However, this applies only to methadone. Grants and funding sources do not currently cover suboxone free of cost or naloxone. It has been a long time since I have seen any buprenorphine around, it is highly divertible and generally all perscribers in the state are aware of this; they opt for the suboxone strips which run about $500 per month for a 30 day supply.
Though here comes the health care system: some insurance agencies, notably United Health Care, will only cover buprenorhine. A doctor can go through the lengthy pre-auth process to advocate for the suboxone strips, however this requires documented medical need for the strips over the pills- when what we are really advocating for is a societal need based on diversion risk.
For those reasons, our clients (400 or so) are largely on methadone. The only 100% funding for suboxone comes from the department of veteran’s affairs.
Maia, I would advocate for maintaining control over these substances as is- while I agree with Percy, I would also share that the structure of daily attendance at a clinic with mandated counseling is the best shot that our clinic has at providing the most structure possible for our clients. The majority of them need a higher level of care, though will never gain access to it. That being said, we do our best to institute higher structure to try and fill a little bit of that gap.
Percy, it is my understanding currently that methadone is responsible, country wide, for 30% of all opiate deaths. I don’t believe we can make any arguments for offering all 3 drugs- or clinics being encouraged to- until we create better access to care and funding for everyone seeking services, be it naloxone, suboxone, or methadone, residential care, or whatever else may be appropriate.
This is the health care system dictating the way that a chronic and deadly condition is being handled- those who can’t afford much are on methadone. The more privileged are on suboxone. The most privileged access the vivitrol shot. Naloxone, simply stated, is prescribed for people after tapers who are moving into aftercare in our outpatient suboxone clinic… Methadone clients will likely never see the benefits of it due to financial hardship. At the risk of sounding dramatic, we are being told- through dollars and cents- how to best save people’s lives.
Maia, I agree that it’s frustrating that the amount of control put on methadone and suboxone clinics is much more than that of opiates. Rather than step down the controls at the level of the clinic, we need to step up the levels of control with regard to opiate prescriptions. For Utah, there is only one place that our pill supply comes from: doctors- we have a higher overdose rate than the majority of the nation and while individuals have to show their ID for a short supply of sleeping pills, no one is scanning ID’s for drugs that kill one person every 24 minutes in the US.
I’ve appreciated reading your respective opinions.
Rebecca Jo Breiman, LSUDC (Substance Use Disorders Counselor)
Informative commentary – I am thankful for the facts – Does someone know where my assistant might get ahold of a sample a form form to edit ?
This is a great blog post. I have been struggling with personal addiction issues for 10 years and have found reaching out online to seek the advice of others has helped me through the good and bad time. I have always had relationship issues because of my addiction and have started to follow the advice of Dr. Robi Ludwig. I saw her on a tv show once and I really appreciated her take on current psychological issues. I have been following her twitter for updates and advice https://twitter.com/drrobiludwig?lang=en
Blocking any receptors in the brain, to me, is not a long term option.This strongly suggests that set and setting are extremely important factors here, at least as important as supply.This remains a conversation about “we think using drugs is immoral and we don’t care if you die to prove our point” and it’s sickening.
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