Doctor Calls For Caution In Reducing Opioids

Today, much of the medical community is focused on reducing opioid prescriptions after decades of overprescribing, but one doctor is an outspoken critic of weaning patients who are doing well on long-term or high-dose opioid prescriptions. Dr. Stefan Kertesz, a primary care physician who focuses on addiction medicine and works with the homeless population, told STAT News that he is challenging the idea that even people who are doing well on opioids need to have their medications reduced or replaced. “I think I’m particularly provoked by situations where harm is done in the name of helping,” said Kertesz, who is also a professor at the University of Alabama at Birmingham School of Medicine. “What really gets me is when responsible parties say we will protect you, and then they call upon us to harm people.”In particular, Kertesz takes issue with the CDC’s 2016 opioids prescription guidelines. The guidelines were interpreted very strictly, and have led to many pain patients—even those who have not abused their medications—seeing their care regimen change. For some patients who have been doing well on opioids long-term, it makes sense to “leave well enough alone,” Kertesz said. He believes that the general recommendation to be careful when prescribing opioids is sound advice. However, when the recommendations are taken as a mandate, problems can arise, he said in a written response to the guideline. “This is a guideline like no other… its guidance will affect the immediate well-being of millions of Americans with chronic pain,” Kertesz wrote.In another written response he said, “Most of us wish to see an evolution toward fewer opioid starts and fewer patients at high doses,” but doctors need to be able to leave some patients on opioids as clinically necessary without feeling like they are putting their careers at risk. Kertesz encouraged the CDC to clarify that the guidelines were recommendations only, not policy proclamations. “It is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation,” he wrote in one letter that he co-authored. “Patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”Now, Kertesz is hoping to secure funding to study suicides caused by reduction in pain medications. “You have three things that are potentially simultaneously associated with harm: Pain itself. Opioid dependence, the dependence itself. And the event, however we wish to interpret it clinically—as resurgent pain or untreated opioid dependence—in patients who are having opioids taken away,” he explained. Despite his dedication to speaking out against uniform opioid reductions, Kertesz sometimes still feels nervous about standing against the mainstream medical community.  “Every single bit of it involves ambivalence and driving myself crazy,” he said. “Like, am I making a mistake? Am I going to blow up my career?”

Recovering Every Day

The people who are most successful in maintaining their sobriety — those who have been sober for 10 years, 25 years or more — often talk about themselves not as “cured” from their addiction, but as living a life in recovery.That’s a key difference, according to Monica Armas, program director at Asana Recovery, which offers detox, residential treatment and an outpatient program in Costa Mesa, California. While people who are cured have done their treatment and moved on, people who are living in recovery have made treatment and sobriety a part of their daily lives.“It is important to integrate recovery into everyday life because it can provide strength and hope,” Armas said. “It is Important to be actively participating in a routine that is conducive to how you want to live your life.”It’s so crucial to long-term recovery that integrating recovery into daily life is an instrumental part of “The Asana Way.” That begins early on in the recovery process, by involving clients in day-to-day decisions, like what recreational activities will be offered. Then, it continues throughout treatment as The Asana Way is integrated into therapeutic approaches.At Asana, Armas and other providers help people who are newly sober define what values are the most important to them. This might be family, faith, career, or exploration. These values are what drive people to do the hard work of recovery, and they are also the values that will define the person’s new sober life. Whatever those priorities are, Armas encourages clients to start “living with your values in mind.”“Once we are able to identify what we value, then we’re able to start putting our values first and are able to see personal growth in all areas of life,” she said.Oftentimes, this involves redefining the values that clients have held in the past. Before, their values might have been dictated by their substance use problem, but in recovery they are able to focus on what really matters most to them when the desire for the next high is taken away.This is why setting boundaries is an important part of early recovery. Boundaries help people announce to the world what values they’ll be focusing on, and how those have changed.“Establishing a new sober way of life involves setting boundaries with family, friends and work,” Armas said.When it comes to setting healthy boundaries, Armas encourages clients to walk the middle ground between emotional and logical choices.“By walking the middle path a person is able to live a more balanced life and make decisions that are purposeful to them,” she said. “Walking to the middle path can be challenging in the beginning but, it’s amazing how it can transform life and how we perceive situations.”Using this approach, clients can fulfill their emotional needs and desires, while also letting logic protect them from emotional pulls that might have negative consequences.Armas encourages clients to use that combination of emotional and logical decision-making to gain new perspective, both when they are newly sober and as they live their life in long-term recovery.“One of my favorite quotes is by Dr. Wayne Dyer and he says, ‘When you change the way you look at things, the things you look at change,’” Armas said. “I would say if you need a boost in recovery take a step back and see how you are perceiving your recovery and life.”Along the journey of recovery, fellowship is an important tool to help gain that perspective on how far you have come, and how your history of addiction might still put you at risk.“It is important to have fellowship in recovery because it provides a sense of belonging to a group,” Armas said. “At the end of the day we all want to feel accepted, and finding a recovery group that provides that sense of belonging is powerful. Also, it is an open place for others to share a similar struggle and it can help provide insight into addictive behaviors.”Asana Recovery offers residential and outpatient treatment in Costa Mesa, California. Learn more by calling 949-438-4504.

Overdose Death Rates Skyrocket Among Middle-Aged Women

A recent news story from KNXV-TV adds a human perspective to recent statistics from the Centers for Disease Control and Prevention (CDC) about a demographic on the rise for national drug overdose deaths.The Phoenix, Arizona-based ABC affiliate profiled several area women who developed dependencies on drugs or alcohol between the ages of 40 and 64.Addiction treatment centers in the Phoenix Metropolitan Area reported an increase in admission for women in that age group, which coincides with the CDC's report that overdose death rates among women aged 30 to 64 years rose by 260% between 1999 and 2017.To determine this statistic, the CDC reported in January 2019 that it had examined overdose death rates for this age group during the aforementioned time period, and categorized these fatalities according to drug subcategories, including antidepressants, cocaine, heroin, prescription opioids and synthetic opioids (except methadone).From this data, they determined that the unadjusted drug overdose death rate increased from 6.7 deaths per 100,000 population (or 4,314 total drug overdose deaths) in 1999 to 24.3 (or 18,110 deaths) in 2017. The rate of overdose deaths involving any opioid increased 492% during this time period, while nearly all subcategories of drugs saw increases in deaths, save for cocaine, which decreased significantly between 2006 and 2009. The highest death rate increases involved synthetic opioids (1,643%), heroin (915%) and benzodiazepines (830%).Those figures reflect the experiences of the women profiled in the KNXV piece. Pamela Aguilu became dependent on prescription opioids after undergoing spinal surgeries. "I would say that I got addicted right away," she said. "I was taking massive amounts of oxycodone."Aguilu expressed gratitude that she had not become one of the overdose statistics cited by the CDC. But she certainly came close. After confronting a police officer who had been sent by her landlord, Aguilu said, "The last thing I remember is the ER physician saying we need the Narcan now, and then I was out. I was out for two days."KNXV also cited Cheryl Hawley, a clinical director at the Valley Hope alcohol and drug treatment center, who said that women between 30 and 64 often put their roles as mother, wife and homemaker ahead of their own health, and then refuse to share their struggles with their families.Aguilu agrees. "You hit middle age, and you think you've got it all figured out," she said. "We live in a society where we take pills for everything."

HIV Prevention Pill Offered to Opioid Users in Philadelphia

An increase in the number of IV drug users infected with HIV in Philadelphia has spurred the city's health department to train medical providers in the use of pre-exposure prophylaxis (PrEP), a pill that can prevent HIV infection.An op-ed piece in the Philadelphia Inquirer suggested that making PrEP and medication-assisted treatment (MAT) available to this demographic could not only provide much-needed assistance to an at-risk population, but as the story's author noted, would also place Philadelphia at the forefront of helping to prevent the spread of HIV among that demographic. The Inquirer noted that while the overall number of new HIV cases has been on the decline since the mid-2000s, with current statistics showing that 19,199 Philadelphia residents live with HIV, the number of individuals who acquired HIV through IV drugs rose from 45 cases in 2017 to 61 in 2018.The newspaper also cited a study by the National HIV Behavioral Surveillance System, which linked the rise in new infections to a high number of sex workers in Philadelphia. According to the study's findings, 51% of women with new infections and 30% of male subjects had traded sex for money, drugs or other goods.Coverage of the rise in cases by the Philadelphia Tribune found that city health agencies have increased education efforts regarding the use of PrEP among HIV patients. These include the Philadelphia Department of Public Health, which trained doctors in areas with high rates of HIV about talking to their patients about the medication.  The non-profit syringe exchange program Prevention Point worked directly with IV drug users to let them know about how to get PrEP. The Tribune piece noted that the emergency departments of Temple University Hospital and Episcopal Hospital offered screenings for HIV and STDs. The city's Federally Qualified Health Centers and many primary care physicians offer PrEP as well. If the patient is found to be HIV-positive, doctors at these hospitals, centers and practices work with the individual to begin immediate treatment with PrEP. The medication is fully covered by most health plans, and when taken under the supervision of a medical provider, has reportedly few to no side effects.Despite this, the Inquirer op-ed noted that many local providers and treatment centers may not be aware of the availability of MAT with PrEP for HIV. The story advocated consistent referral of the medication to not only stem the tide of new cases, but to establish Philadelphia at the forefront of such treatment."These type of local emerging best practices offer a way bridging national policy, clinical guidelines, local contexts and patient choice," wrote the op-ed's author, Kevin Moore, who serves as director of care coordination at ARS Treatment Centers.

CBD May Help Curb Heroin Cravings

Cannabidiol, a compound of marijuana commonly known as CBD, is effective at reducing anxiety and cravings in people who are dependent on heroin, according to a new study that could potentially open up new means of treating opioid use disorder. As part of the study, researchers gave heroin users doses of CBD in the form of Epidiolex, an FDA-approved cannabis-based medication. They received doses for three days, with follow-up doses over a two-week period.The study participants were long-time heroin users with an average history of 13 years of heroin use, who had not successfully stayed clean for more than a month, according to CNN. Researchers found that people who received CBD had 2 to 3 times fewer cravings for heroin than people on a placebo, and also had less stress hormones. Lead researcher Yasmin Hurd, director of the Addiction Institute of Mount Sinai in New York, said that reducing cravings can help people stay sober. "The intense craving is what drives the drug use," she said. "If we can have the medications that can dampen that [craving], that can greatly reduce the chance of relapse and overdose risk."Hurd was careful to point out that the study participants were using a regulated medication, not traditional marijuana. "We are developing a medicine,” she said. “We are not developing... recreational cannabis.”Psychiatrist Julie Holland, former assistant professor of psychiatry at the New York University School of Medicine, said that the study—though small—is very important. "This is an extremely significant paper. We need to utilize every possible treatment in helping people with chronic pain to find other ways to manage their symptoms and in people with opiate addiction to find relief,” she said. "CBD not only manages the anxiety and cue/craving cycle, it also diminishes the original pain and inflammation that leads to opiate use in the first place.”Hurd said that the study indicated that CBD could be a better alternative to current medication-assisted treatment options like methadone or buprenorphine. Those medications are opioids that can be abused, so their use is tightly regulated. CBD could offer a less restrictive form of medication-assisted treatment. "It's not addictive. No one is diverting it. It doesn't get you high, but it can reduce craving and anxiety," Hurd said. “This can really help save lives."Although some states allow medical marijuana as a treatment for opioid use disorder, there has been controversy over whether cannabis is helpful for people with opioid addiction.In March, National Institute on Drug Abuse (NIDA) Director Nora Volkow said that there is no evidence that cannabis can help treat opioid addiction. 

Why Aren't Doctors Prescribing Suboxone To More Black Patients?

The racial disparity in the prescribing of opioid treatment drugs like Suboxone is highlighted in a new study out of the University of Michigan.The study, published in JAMA, looked at two national surveys of prescriptions as reported by physicians between the years 2012 and 2015.While the total number of buprenorphine-related medical visits drastically increased to 13.4 million during this time span, researchers noted that the number of buprenorphine prescriptions did not increase among African-Americans, or any other minorities.Buprenorphine, most commonly known by the brand name Suboxone, is a medication that dramatically reduces opioid cravings and blocks the effects of opioids. "White Americans have 35 times as many buprenorphine-related visits than black Americans," Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and the study's corresponding author, told NPR.Although white Americans have been the face of the opioid epidemic, during the time period studied, the number of overdose deaths among black Americans was rising faster than their white counterparts.In addition, there is a shortage of clinicians and clinics prescribing buprenorphine, Dr. Andrew Kolodny, co-director of Opioid Policy Research at Brandeis University, told NPR.Currently, physicians must take on eight hours of training to become certified to prescribe buprenorphine. And even if they do receive authorization to prescribe it, they are then faced with a cap that only allows them to prescribe it to 30 patients in the first year and up to 100 patients afterwards. A bill in New York that would end the extra training required for physicians and nurses to dispense Suboxone, and the caps, has gained tremendous support. The special training for both doctors and nurses has meant that there are not enough providers who offer the lifesaving drug.According to STAT News, only 5% of doctors have completed the training required to prescribe buprenorphine.In France, where additional restrictions on prescribing opioid addiction treatment drugs were removed in 1995, there was an 80% decrease in opioid overdoses in the subsequent years.Michael Botticelli, director of the Grayken Center for Addiction at Boston Medical Center and the former director of the Office of National Drug Control Policy, has questions about specific points of interest in the disparity between white and black patients receiving Suboxone.Botticelli questions if Medicaid reimbursement rates are too low to attract doctors to work with low-income patients, or if there is a scarcity of inner-city doctors prescribing buprenorphine, or if African-Americans are not seeking the treatment for an unknown reason. White patients typically paid cash (40%) or used private insurance (35%) to fund their buprenorphine treatment. A mere 25% used Medicaid and Medicare to pay for their visits.

For Teens in Recovery, Parents Are Crucial Resource

As a parent, watching your child hurting or struggling is one of the most painful experiences you can have. It’s even worse when their destruction is self-inflicted through drugs or alcohol. Parents of teenagers struggling with substance use disorder are often hurt, embarrassed, and worried, but they are also a critical part of helping their child succeed in recovery.“Your support is one of the most vital pieces of your teen’s recovery,” said Jaymes Murphy, business development assistant at Clearfork Academy, a residential, Christ-centered treatment center for boys ages 13-17 in Fort Worth, Texas.Murphy often sees parents who want to help their sons get sober, but who don’t know where to start, or are misguided in how they are trying to help. Here are his tips for helping teenagers succeed in recovery:Be Prepared to Do Your Own Work.Parents often send their children to Clearfork Academy when they feel fed up or hopeless. While they are excited for their sons to get treatment tailored to teens, they soon realize that as parents they also need to do some recovery work as well. Part of that involves letting go of blame and anger toward their son for the damage that his substance use has inflicted on the family.“We often tell parents to recognize that their child is still good under all that junk,” Murphy said. “Even if they have gotten to the point of losing hope and frustration, their little monster still has a heart and still desires the things they once did.”Partaking in individual and family therapies can help parents sort through their feelings and move forward in a more positive mindset.Know When to Step Back.While parental involvement is a cornerstone of treatment at Clearfork Academy, it’s also important that parents foster independence in their sons.“The goal — or even more strongly the responsibility — of parents is to raise a child that no longer needs them,” Murphy said. “It is easy to accept this statement on a cognitive level, however, dealing with that emotionally is deeply dismaying because we want our kids to need us.”Yet, giving teens the “Helicopter parent” treatment will lead to more strife and arguments. Instead, the staff at Clearfork Academy encourage parents to give their sons autonomy and allow them to deal with the repercussions if they make poor choices.“If we cannot let them face consequences for some of their actions, how will they deal with things that become overwhelmingly more difficult?” he said.Let Them Know They Are Loved.Many times teens in recovery recognize how their substance use has hurt them and their families. This can erode their self-confidence and self-esteem even more than addiction already did.“Addiction rips apart a lot of things externally, but the internal stuff is just as bad. It shreds apart self-esteem, self-confidence, self-respect, and many other character attributes, making the teen almost completely unreliable to themselves,” Murphy said.Parents can help to rebuild that self-belief by engaging with the teens and showing that they believe long-term recovery is possible.“Encouragement and simply showing a small amount of interest in their hopes, dreams, and goals rebuilds their confidence that was torn apart by the tangled web they have weaved,” Murphy said. “Love and an emotional relationship in the midst of the addiction will always go far to ensure the teen knows that there is someone that cares for them and is fighting on their side.”Oftentimes, Murphy said, teens are beating themselves up for their actions more than they show. In these cases, their fear and sadness might be expressed as anger. Defusing that rather than engaging can help facilitate healing.“They are confused and not in control of the situation which is a formula for chaos,” Murphy said. “But if we can maintain a relationship that does not point fingers or say, ‘look what you’ve done’ we can reduce the chaos.”Prepare for their return home from treatment.The transition home from treatment is a pivotal time for teenagers in recovery. While they’ve stayed sober in the confines of residential treatment, they now need to test their sobriety in the real world. Parents can help ease this transition by being proactive, including:Remove any drugs or paraphernalia from their space.Pay particularly close attention to the teen’s bedroom, car, or other space where they spend lots of time. Check outlets and light switch panels, inside light covers, AC supply and return vents, inside toilet tanks, soles of the shoes, etc.Make a sobriety plan.Before a teen leaves treatment, work with their treatment team to make a sobriety plan. That way you know what you’ll do when inevitable hurdles come up. Remember that using substances isn’t the only sign that a teen is struggling, Murphy said.“As time passes and confidence rebuilds, they may feel inclined to take shortcuts and even ignore the plan that has been put in place,” he said. “This way of thinking is a definitive path to relapse and if a mental relapse occurs, a physical one is not far behind it.”Recognizing that teen recovery is a process of progress, not perfection, can help the whole family heal from the effects of substance abuse.Clearfork Academy offers residential treatment for boys ages 13-18 in Fort Worth, Texas. Connect with them on Facebook, Twitter or Instagram.