Showing posts with label Musto. Show all posts
Showing posts with label Musto. Show all posts

Saturday, March 18, 2017

Exploitation Of Opiate Addicts - Same Song Different Century



Most people don't know or care about the past history of addictive drugs in America.  The best examples of this are the people who want to legalize all drugs and don't realize that there was a long history before regulation and that there were legal over-the-counter forms of opium and cocaine.  Contrary to the Utopian way that it is portrayed today, regulation of addictive drugs occurred because of problems and not the other way around.  The only way that you can think that the legal aspects of drug control created the problems rather than the drugs themselves is if you completely ignore what really happened.  The quote by Osler is particularly poignant with regard to that history.  The quote is from his classic text The Principles and Practices of Medicine and a chapter he wrote in that text on opiate addiction.  The year was 1894.  It occurs in the context of a marked increase in opium use.  The isolation of morphine from opium in 1804 and the commercial production of morphine in 1826 as well as the invention of the hypodermic needle in 1855 were thought to be contributors to the opiate epidemic of the late 19th century.  Although morphine had been injected into areas close to nerves previously, the hypodermic needle allowed unprecedented ability to inject morphine very close to affected nerves.  Within a short while morphine injections to treat various forms of neuropathic pain were common.  The statement about women being higher risk may reflect the estimated risk that women were twice as likely to become addicted to opiates from precriptions by their doctors.

The new method of treating nerve pain with injected morphine was thought to be a major advance in the treatment  of chronic pain.  Despite frequent injections it took some time for physicians to recognize the fact that people were getting addicted to morphine.  Musto in one of his excellent texts titles a chapter:  "The Belated Recognition of Addiction to Hypodermically-Administered Morphine" (1)  Although that title may seem laughable today the historical mistakes have been repeated again.  Just a few examples include "tamper proof" addictive medications that turn out to not be tamper proof, tramadol as a "non-addictive" option to opioids. and the idea that benzodiazepines are safe and non-addicting.  All have all been disproved on a historical basis.  The historical approach to addictive drugs has been a naive one - even before the era of intense marketing to physicians, massive lobbying efforts and direct to consumer advertising.

There seem to be very few people who are knowledgeable about the regulatory landscape for narcotics in the United States over the past 150 years.  It is an interesting parallel to the origins of the current opioid epidemic and it rests on the principle that increasing access to addictive compounds will result in more members of society with addiction.  It also has implications for the disease concept of addiction well before there was any established neuroscience.  The argument in those days was whether opiate addiction permanently altered the physiology of the nervous system to the point where the need for ongoing drug was inevitable.  There has been plenty of evidence to support that and the evidence has been there for a long time.  As early as 1875, a German physician Eduard Levinstein collected follow up data on patients he had weaned off opiates and found a relapse rate of 75% (ref 1 p 74).  In 1914, physicians at the Tombs prison in lower Manhattan estimated that it would take two months to get opiate addicts off drugs and unless they were isolated from drugs for another year the prospects for cure were low (ref 1 p 107).  That sums up my experience with opioids even today.  The main difference is that people are now on maintenance opioids for at least that long and get the message that they need to take these drugs for the rest of their life.

In the early 20th century, some American physicians looking to "cure" opiate addicts were fairly pessimistic about the prospects.  By 1920 there was one estimate that there were a million opiate addicts in the United States.  The population at the time was about 107 million people.  Two options were considered at the time - indefinite maintenance on opioids and the elimination of all non-medical use.  There was a relatively small number of physicians referred to as dope doctors whose practices consisted of maintaining large numbers of people in addiction by ongoing opiate prescriptions.  As regulations proceeded from the belief that federal control over narcotics and prescription practices of doctors was unconstitutional in 1900 to the enactment of the Harrison Act on March 1, 1915 outlawing the non-medical prescription of opiates - there were a small number of physicians engaged in the practice of maintaining addiction.  That practice was declared illegal by the Harrison Act until it was modified years later to allow methadone maintenance.  The evolution of medical practice over that time was interesting.  In less than a generation, opiates and cocaine went from being over-the-counter medications to being highly regulated.  Medical and pharmacy practice was impacted and there were political battles along the way.  Post Harrison Act there are still physicians engaged in the now illegitimate practice that are described in the popular culture in the 1950s and 1960s.  Legitimate and illegitimate prescribing of controlled substances is always a fine line.  In the 21st century, the main problem is the number of patients who are trying to game the system and get opioids and stimulants.

It is still illegal to prescribe addictive medications to an addict.  The only exceptions are methadone and buprenorphine.  Methadone prescriptions for addiction treatment can only occur in licensed methadone clinics.  Buprenorphine can occur in outpatient medical practice but a special license it required and the total number of patients treated is regulated.  But what about the patient who claims that they can take an addictive medication in a controlled manner?  It may not be the primary addiction, but there are many patients with alcohol use disorders and opioid use disorders who believe that they have Attention Deficit~Hyperactivity Disorder (ADHD) and claim that they can take stimulant medications.  There are many people with stimulant use disorders who claim that they can take prescription stimulants in a controlled manner and insist on it.  How many doctors continue to prescribe these medications to patients who they know are addicted?  My speculation is that there are currently millions if not tens of millions of people being maintained in addiction by physicians who think that they are being helpful as their primary motivation.

I started this post with the intent to comment on a the specific practice of buprenorphine maintenance.  I commented recently on the problems with buprenorphine maintenance and why it is a far from ideal solution to the centuries old problem of opioid addiction.  Since that post I have become aware of a new problem.  In many areas there are very few buprenorphine prescribers and many opioid addicts.  There are many excellent physicians who are addictionologists and addiction psychiatrists out there trying to make a difference.  Running a buprenorphine clinic is a fairly intensive exercise that typically involves counseling and frequent toxicology screens.  Many of these patients have significant medical and psychiatric comorbidity.  That said, there are apparently some buprenorphine prescribers that are motivated to make a significant profit from this practice by charging patients $500 to $1,000 for brief monthly visits with additional charges for the toxicology and counseling.  These charges are all in cash and in my opinion are problematic.

The problem with these charges is that they directly impact the relationship with the physician.  A straight economic argument is often made.  That argument goes something like this: "What would this person be spending if they were still using heroin?"  That number is highly variable based on individual physiology and geographic location but a rough cost estimate would be $1200 - $5,000/month.  On straight cost basis an expensive buprenorphine clinic comes in at the low end of the estimated monthly cost of daily heroin use.  But that misses the point.  When people are in recovery, many of them are working at low paying jobs with minimal or no insurance.  They need a cost effective solution to opioid treatment and that includes buprenorphine maintenance.  If they see a physician and need to pay $500-1,000 cash essentially for a prescription it will lead to immediate thoughts about why they are bothering to stay sober.  It will lead to resentment toward the physician or at the minimum a loss of physician credibility.  It leads to a question about physician motivation.  People with addictions are no different than anyone else seeing a physician.  They have to realize at some point that the physician is interested in them and helping them rather than just making a profit.  There are clearly some physicians out there who don't get that point.  The outcry has been palpable with a backlash on buprenorphine prescribing that is visible on several social media groups.  The toal membership of these groups is over 10,000 people.  Many of these people are clearly interested in tapering off buprenorphine at some point rather than life-long maintenance.

The dynamic of taking advantage of people with addictions in the US goes back to the early 20th century.  The landscape  has changed based on what is considered to be a legitimate prescription to people with addictions. In the 21st century we are currently operating under the premise that we may have a treatment for opioid addiction, but there are many limitations.  Physicians would do better heeding Osler's warning at the top of this post. modifying his quote about hypodermic syringes to include the equivalent today - high potency opioids.  In the case of people with know addictions, treatment needs to be ethical and patient focused.  We have seen a rapid move to "evidence based" treatment for opioid addiction based on medications and little else.  That is really not a solution to the problem of known addiction or the ongoing drug epidemics in the US.

Prevention is the best current approach to addiction.
    



George Dawson, MD, DFAPA


References:

1:  Musto DF.  The American Disease: Origins of Narcotic Control.  3rd ed.  Oxford University Press.  New York, 1999.

2:  Musto DF.  Drugs In America: A Documentary History.  New York University Press.  New York, 2002.










Wednesday, January 22, 2014

Snorting Smarties

"Throughout the history of the United States, popular attitudes and legal responses regarding the consumption of mood-altering substances have oscillated from tolerance to disapproval and back again in cycles roughly the length of a lifetime."   David F. Musto, MD; Drugs in America, 2002 (p 3)


I heard about this story on my way in to work this morning.  Middle school kids crushing a particular brand of candy and snorting it.  I prefer the term insufflation but that is probably a bit too stodgy for a talk radio venue. I will let any readers who are interested in it Google it and look for relevant links and significant complications.  Before we go any farther I will say that I am unequivocally against snorting anything.   I am commenting on it here as an observation of two cultural phenomena - children's behavior mimicking adults and possibly predisposing them to the adult behavior and the cultural phenomenon of permissive versus prohibitive use of intoxicants.

I had an immediate association to a Psycritic blogpost that I responded to last night on whether marijuana legalization puts children and adolescents at risk.  Having lived through the era of an 18 year old drinking age, I would say that it definitely does.  The idea that you will now "tax and control" a newly legal intoxicant is a myth that only a politician or marijuana advocate would believe.  My high school class of predominantly 17 year olds was one of the first locked up in an all night graduation party in order to prevent drinking and driving deaths.  I don't imagine that anyone will be any more successful in keeping marijuana out of the hands of underage marijuana smokers than they were in keeping alcohol out of the hands of underage drinkers.

I found this behavior interesting because I observed a similar pattern of behavior among some of my classmates as early as the sixth grade.  People were smoking various materials that were not meant to be smoked.  They were ingesting materials that they believed would make them high, even when it was pharmacologically impossible.  Even before that I remember candy cigarettes.  They were in packs that resembled the real thing.  My father was a two pack a day smoker of high tar and high nicotine cigarettes and I had asthma so smoking even at a dress rehearsal level never interested me.  Candy cigarettes were frequently bought for children when I was growing up and everyone seemed to enjoy watching kids pretend to smoke.

It raises a larger question about addictive behaviors and whether modelling and rehearsing them can lead to practicing with the real thing.  A related question would be whether a society that is permissive about a particular drug would be more likely to support behaviors that mimic using the actual drug.  In the addiction field it is common to encounter these behaviors using both addictive and non-addictive compounds.  For example, many people in the first stages of stimulant, sedative,  or opioid addiction will start by crushing prescription tablets and smoking, snorting, or injecting them.  Using a prescription in this manner is typically not a good sign in terms of controlled use of a potentially addictive medication because all of these methods of use are designed to deliver high levels of drug to the brain in a shorter period of time.  That will often produce a temporary high after tolerance occurs to the oral form of the medication.  In some settings, non-addicting medications like antihistamines, antidepressants, and others will be smoked, injected, or snorted.  This can occur in correctional settings or situations where people may be trying to block out their conscious state and choose to produce a delirium consistent with that goal.  It can get to the point where medications in general are banned from a certain setting because there is a black market for them right in the prison even though they have no value out side of the prison setting.

Getting back to the mimicking of addictive behavior and whether it may predispose you to using the compound at risk it was investigated for smoking.  The authors of the study take a look at incomplete and indirect evidence and conclude that there is some evidence that candy cigarettes were possibly used as a marketing device by cigarette manufacturers.  In one survey 5.3% of adult smokers attributed their smoking to a past use of candy cigarettes.  I want to be clear that I am using the current trend of snorting candy as an example of mimicking addictive behavior with a substance that is meant to be eaten as candy.

I don't consider myself a crusader for one law versus another.  I have beaten my head against the wall on numerous political issues in the past and know that there are many hidden forces in this country that you can bet have much more leverage than I do either as a private citizen or a member of a medical professional organization.  There is one thing that you can count on in America and that is money will carry the day.  Politicians believing that there will be new tax revenue from the sales of an intoxicant is very reinforcing for them.  Their friends in the business world creating a monopoly product that people will line up to buy is another.  Don't forget that in 1884 Heroin was the brand name of an over-the-counter patent medication that was originally marketed by a pharmaceutical company.  At about the same time a competitor was selling 15 different brands of cocaine for smoking, injecting, and sniffing.  All of them were available over the counter without a prescription.  The restriction on that practice did not occur until the Harrison Act in 1914.

The coming rush to see who sells marijuana in this country will be an interesting one.  The outcome should be as predictable as the previous oscillations toward tolerance in this country.


George Dawson, MD, DFAPA


Klein JD, Forehand B, Oliveri J, Patterson CJ, Kupersmidt JB, Strecher V.  Candy cigarettes: do they encourage children's smoking? Pediatrics. 1992 Jan;89(1):27-31. PubMed PMID: 1728016.

Klein JD, Clair SS.  Do candy cigarettes encourage young people to smoke?  BMJ.2000 Aug 5;321(7257):362-5. Review. PubMed PMID: 10926600; PubMed Central PMCID: PMC1118335.