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Wednesday, July 7,2010

Drugs of choice

The good news: Heroin abusers no longer dominate local rehab clinics. The bad news: They are being overtaken by prescription drug abusers. Methadone is the cheap new culprit.

by Andy Balaskovitz

A true opiate addict claims to "feel normal" the first time he does opiates. David Blankenship, program director for Victory Clinical Services, which operates an addiction recovery center on South Cedar Street in Lansing, calls these people “lifers.”


Some of the most popular opiates, both pharmaceutical and illicit, include oxycodone, methadone and heroin. Methadone is used to wean addicts off the other two drugs due to its longer-lasting effects on the body. However, records show that illicit methadone use has jumped significantly in the past few years.


According to a report by the state Department of Community Health, 267 people in Michigan admitted to using methadone illicitly in 2005. In 2009, that number jumped to 661 people. Officials are quick to mention that not all cases of abuse go reported and not all cases of addiction are treated.


How can it be that a drug used to cure addiction can lead to illicit use, further addiction and sometimes death? Local medical professionals point to the ease of obtaining opiate prescriptions for pain and also those drugs’ potency.


Blankenship’s center is one of the few in Michigan to offer adjunct therapy, which is a combination of medication to fight off physical withdrawals in opiate addicts and mental health therapy. He says all of his patients are opiate addicts. But what is troubling to him is that eight years ago, 70 percent to 90 percent of his patients were intravenous drug abusers, typically heroin. Today, about 40 percent of his patients are heroin users and about 60 percent are addicted to pharmaceuticals.


“Over time, pharmaceutical companies have gotten much better at making drugs,” said Blankenship, who was formerly the drug and alcohol liaison with the U.S. Navy in Guantanamo Bay. “Now they (prescription opiates) are at least as pure as street heroin and more consistent.”


Due to a nationwide “epidemic” of abuse, state Medicaid laws made it tougher — and more expensive — for physicians to prescribe oxycodone (such as OxyContin) to manage pain. Blankenship said methadone is a cheap and easy replacement for oxycodone. “Problem is, I think they got carried away with it,” he said.


At Victory’s Kalamazoo, Jackson and Saginaw clinics , Blankenship said he has noticed physicians prescribing methadone for pain — not its original purpose.


“It’s for addiction,” he said, adding that it is legal to prescribe it for pain but doctors who do so “are not following best practices.”


Oxycodone and methadone are both opiates but have very different effects on the body. Oxycodone is time-released and gradually dissipates over 24 hours. It is abused by snorting it or injecting it intravenously, he said. Methadone, on the other hand, has a longer half-life, giving it a lagging effect in the body that can last for days. “People abusing (methadone) don’t realize this and keep taking more, thinking it isn’t kicking in.


That’s where there is usually trouble,” he said.


Patricia Wheeler, executive director of the National Council on Alcoholism- Lansing Regional Area office, also has seen a rise in illicit methadone use among patients. Adding to physicians’ willingness to prescribe and the heightened potency of those drugs, Wheeler says funding for rehabilitation — or the lack thereof — contributes to further abuse.


“The dollars going into substance abuse treatment and prevention continues to dwindle,” she said. “We are not educating people as well as we’d like to.”


Wheeler said there is a misperception about the dangers of initially being prescribed drugs like oxycodone and methadone. “Our clients report that methadone is as addictive as heroin,” she said.


When taken with other drugs, it sets the stage for complicated physical and mental reactions in a person, unlike any we have seen before. “There are more drugs and prescriptions but less familiarity with their dangers,” she said. “We are all trying to do a lot more with more complicated patients and less money.”


Wheeler said with less money coming in for rehabilitation services, society pays more at the other end by dealing with criminal activity like drug dealing and drunk driving. And in the end, people are abusing something they know nothing about rather than being predisposed to addiction.


“This is not a behavior issue. It is a medical issue,” she said.


The National Council for Alcoholism in Lansing offers two residential outpatient programs at the Glass and Holden houses. A majority of its clients are from Ingham County, but are not given methadone to manage their addiction, as is done at Victory.


Of the 135 drug-related deaths in Ingham County in the past five years, 68 are specifically opiate-related. Twenty-three of those made specific mention of methadone, Dean Sienko, chief medical examiner for Ingham County, said in an e-mail. Due to the complexity of the database, he said his assistant was unable to compare those numbers with the previous five years.


Blankenship said he never expected the nature of his job to change so drastically over the past 10 years. He believes physicians today play a role that facilitates illicit prescription drug use. “I never saw it coming — not to this extent.”



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The two previous comments are wonderfully written and appreciated. This article creates an opportunity for dialogue to address the world of drug and alcohol abuse and addiction. I would like to comment on a few points in the article. It implies from the sub-title that methadone is the only culprit in today’s epidemic of prescription drug use. In my experience, it is the collective use of all opiate-based prescription drugs that can be abused when prescribed to individuals with addictive behaviors by physicians that are not as familiar with the treatment of addiction. Methadone, however, has been approved for the use as a prescription drug to combat the physical addiction to opiates, such as heroin. It blocks the receptors in the brain that would cause an addict to want more. When methadone is used in combination with substance abuse counseling, we see positive changes in these individuals. Andy also mentioned that I call these patients “lifers”. The statement lifers was in context that some of the patients in methadone treatment may need to maintain in treatment indefinitely; this is true for some individuals in treatment but not necessarily true for every person in treatment. Many are able to successfully detox from methadone. Another clarification I would like to make is that I was the drug and alcohol liaison with the US Navy. I was, in fact, the liaison for only my division on the US Naval base in Guantanamo Bay Cuba. With regard to the comment on prescription opiates being at least as pure as street heroin and more consistent, this is misleading. These are comments our patients inform us at intake, the key point is the consistency of the pharmaceutical drugs as compared to heroin. As with all prescription drugs, the formulas are consistent and provide the same amount of medicine within each dose, making it much safer to ingest since you are guaranteed to receive the correct formula. The comment that methadone’s original purpose was not intended for pain is misleading. The point I was trying to make was methadone should be prescribed as a last resort for pain management. Methadone is most effective as a pain medication with individuals with severe long term pain issues or terminally ill patients. Some primary care physicians have prescribed methadone to patients that are physiologically addicted to opiates but also have addicted behaviors. This practice can lead to patients abusing the medication or perhaps even selling the medication. This is not a best practice use of methadone. In the article I was quoted as saying that I believe physicians today play a role that facilitates illicit prescription drug use. I do not mean to say that every primary care physician that prescribes methadone is in error. I do mean that I have seen a shift in the number of physicians who are willing to prescribe methadone to patients with addictive behaviors. Without the proper supervision, education and follow-up this practice can lead to increases in abuse, selling on the streets and morbidity from the improper use of the prescribed medication, In the end, there are many individuals in our society who are physiologically addicted to opiates and methadone provides way to help these individuals with the physiological addiction. Under supervised settings, in combination with substance abuse counseling, the treatment of opiate addiction with methadone is very successful, allowing people to recover and lead better lives as a result. Once again, I’d like to thank you for opening the dialogue regarding opiate addiction and the use of methadone prescribed for pain. David Blankenship
 
Methadone was NOT originally created to treat addiction--it was created to treat PAIN in WWII Germany, when supplies of morphine were low. It was not used for addiction treatment until the 50s and 60's, first at Lexington Narcotic Hospital, then in New York City by Dr's Vincent Dole and Marie Nyswander. Prescribing methadone for pain is in no way going against Best Practice guidelines--that is absurd. It IS true that methadone prescribed for pain must be carefully titrated and the patient educated to avoid overdosage and to store the drug safely. The vast majority of doiversion of methadone and subsequent deaths come NOT from the clinic system, but rather from pain management and those who steal from pain patients. SAMHSA did 2 studies on this in 2003 and 2007, both with similar results. Lastly, saying that methadone is "as addictive as heroin" twists the actual meaning of "addictive". Though methadone does cause a physical dependency, because of it's slow crossing of the blood brain barrier, there is no "rush" and the high that it provides to non-tolerant persons is weak compared to short acting drugs like heroin, vicodin, etc. (in tolerant patients there is no high at all). Addictiveness is not measured by the length of time that it takes to taper off a drug, or by how sick the withdrawals make you, either. Addictiveness is measured by the reinforcing properties of the drug--by how much it makes you want to do it again. ANd by that standard, methadone ranks low on the scale. Think about it--when people leave methadone treatment and relapse, they don't relapse on methadone. They relapse on heroin or whatever short acting opiate they prefer. If methadone were "more addictive", people would be relapsing on that.
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Well said as always Zenith. I would like to add something though. In this article it says that " A true opiate addict claims to "feel normal" the first time he does opiates. " The first time someone abuses opiates, they don't get that "normal" feeling. They get a buzz, a high that makes them feel happy, content, euphoric and friendly. It isn't until later when the damage has been done to the opiate receptors that an opiate addict takes opiates to "feel normal" and usually they are also no longer able to feel that same "sweet" high. The damaged opiate receptors have gotten so use to large amounts of opiates just to function that when they don't get it, the person feels extreme symptoms of depression, anxiety, moodiness, cravings and other symptoms. Symptoms that can continue LONG after actual physical withdrawal symptoms are over. Thus the person takes the opiates just to "feel normal" or to reach the theraputic level of opiates to reach the level of what thier brain receptors have gotten to know as the new "normal". Granted there are some opiate addicts who start out abusing opiates to self medicate for pre existing cases of mental illnesses such as depression or bipolar disorder, but the drive to take the opiates to "feel normal" usually doesn't set in until well into opiate addiction.
 
 
 
 

     
     

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