Single Question That Determines If Drugs or Alcohol May Be A Problem In One’s Life

addictionResearchers at Boston University have found that one key question may gauge the severity of unhealthy drug and alcohol use as well or better than many of the lengthy questionnaires used by addiction specialist and primary care physicians for screening.  As a primary care physician and an addiction specialist, I have found that long questionnaires are a barrier and most are not used at all.  The single question not only identified those with alcohol dependence 88% of the time and those with drug dependence 97% of the time, but it also identified the severity of the problem.  So what is this key question?

For alcohol use, the participants were asked how many times in the past year they had consumed five or more drinks in a day (for men), and four or more (for women). For other substance use, they were asked, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

This tool was used in a primary care physician setting, and thus should be implemented into the routine care of all adolescents and adults as a screening tool to identify those who we can offer services for drug or alcohol dependence or addiction.

If you or a loved one has a potential problem or challenge controlling their alcohol or drug use, I highly recommend you encourage them to find help.  Often the family may be ready for change long before the drug or alcohol dependent person is willing to admit they have a problem.  If you are a parent, then you need to set very clear boundaries.  Those with drug or alcohol dependence should not be supported with access to a car, nor should they be given money that they can then use to purchase more of the drugs or alcohol.  Regardless of age, sometimes an intervention is needed.  This might be accomplished by a family and friends meeting where all those who love and support the individual gather and share their concerns.  This process may require a professional, and should always include options for treatment or change.

Treating addiction saves lives.  It is not always a linear process from identifying the illness to being drug and alcohol free.  It’s more of a journey, with relapses more common than not.  The earlier in the disease process the addict or alcoholic (or dependent person) gets help and learns about the disease, the better their chances are for recovery.  This disease is chronic and progressive, and the bitter end is often institutions, prisons, or death.

For the family members of the dependent person:  love them enough not to enable them.  Be willing to take a tough stand.  It often means being willing to kick them out of the home (with treatment options if you can afford them). That being said, each case is unique.  Get professional help.  Some individuals are so far gone or so incapable intellectually and emotionally to survive on their own, that to kick them out would be a death sentence.  If you suspect that may be the case, then definitely get professional help so the decision of what to do is not yours alone.

You can read the study from Boston University here…

Dr. Paul

 

Neonatal Abstinence Syndrome- Treatment of Newborn Addicted to Opiates

happy babyNewborns of moms who are on opiates go through acute withdrawal at the time of delivery since they have been continuously exposed to opiate drugs (pain pills, heroin, methadone, etc.) then at birth are suddenly without these opiates.  The symptoms of withdrawal in an infant can be mild irritability to seizures. Tremors, increased tone (we would comment “the baby seems strong”), and poor feeding are common.

The studies are now showing less neonatal symptoms for women on Buprenorphine compared to those on methadone. You can read more about this here…

This has been my experience in my addiction clinic where we have had 4 pregnancies now on Buprenorphine. Each delivered babies who had absolutely no withdrawal symptoms. Three of the four were weaned to 1-3 mg by the time of delivery and one was on 12 mg at the time of delivery.  It should be noted that weaning the dose while pregnant has been discouraged due to fear of relapse and the risk that would put on the fetus.  I have found for motivated moms, as long as they know they have an addictionologist willing to support them should a weaning process get difficult, and they will have access to more Buprenorphine should they need it, we have had 100% success with a very slow and gradual taper of the dose.

You can read here for  a great overview with tools for managing the neonate in withdrawal.

 

Dr. Paul

 

 

 

 

 

What is the Link Between Marijuana Use and Anxiety (Does it Help or Hurt?)

anxiety2More and more you read or hear that marijuana is safe and that it “helps my anxiety”.  I run an opiate addiction clinic, where most are there to get off heroin, and most also smoke marijuana, saying it helps their anxiety.  The study “Immediate Antecedents of Marijuana Use: An Analysis from Ecological Momentary Assessment,” (which you can read here… ) looked at marijuana craving, peer use, and anxiety over multiple assessment times daily for two weeks.

Here are some of the findings:

  • Marijuana use days were associated with higher craving for marijuana.
  • There was higher anxiety prior to using marijuana and it did not decrease significantly following use.
  • Craving can increase anxiety.
  • Anxiety was related to marijuana withdrawal.
  • Those using marijuana for anxiety may get short term relief but anxiety returns.
  • 1/3 reported greater anxiety during marijuana use.
  • 1/3 reported greater anxiety during non-use of marijuana.

 

For the 1/3 who perceived less anxiety with marijuana, it seems likely they are physically dependent or addicted and the vicious cycle of withdrawal anxiety becoming better with use only to withdraw again is driving the THC use. Clearly not all individuals get an anti-anxiety benefit, and for many, it will cause anxiety or worse psychological symptoms.

 

To answer the question, does it help or hurt anxiety: for 1/3 of users it helps, but only temporarily, and then worsens the cycle of anxiety.

 

 

Dr. Paul

 

 

 

 

Chronic Pain- What Can We Do To Help?

pain4If you suffer from chronic pain or know someone who does, then you understand that there is a fear that others will not believe that the pain is real.  We need to validate the pain… that we believe that the pain is real. There is nothing more isolating to a person than to be suffering and have your suffering dismissed!

Are you or your person of concern sometimes drinking wine or beer or alcohol?  If no, why not? I’m not saying you should be drinking, just trying to get a true picture of what is going on. So often we self medicate with alcohol or other drugs when we are in pain.

How many times in the past year have you/they had over 4 drinks at one time? Have you/they used drugs or pain medicine not prescribed to you?  To what extent is depression, anxiety, or PTSD involved?  Do you/they have social support? Is what you are doing working?  Are you functional?  Are you having side effects and symptoms when you can’t take your pain medications?

Remember, if you or your loved one is taking opiates and is sleeping a lot or sleepy, you may be over medicated and the risk of suppressing your breathing to the point you stop breathing is a concern.  It may be time to lower the dose or see your doctor to change the medication.  Sometimes, those on chronic opiates develop dependence or addiction to opiates and can become hyperalgesic, where opiates are actually increasing the pain sensation.

We are seeing increased prescriptions resulting in increased deaths from opiates. The JAMA article 2011 by Bohnert et. al. “Association between Opioid Prescribing Patterns and Opioid overdose-related deaths”, showed a 124% increase in unintentional opioid overdose deaths in the US from 1999 to 2007. 71% of those who abuse opiates get them from family and friends.

I encourage you to get help from either an addictionologist or pain physician who will work with you to not only manage pain, but, where appropriate, help you get off the opiates that may now be a large part of the problem.

Remember, there is great benefit in adding exercise, psychotherapy, or mindfulness training and often medications can be shifted to safer and more effective combinations or even reduced completely in many cases.

Here is a resource for patients to look a bit more closely at the meds they are taking…

 

 

Dr. Paul

 

 

Cannabis: Studies Show Impaired Thinking and Creativity, Impaired Motivation and School Success, and MRI Proven Brain Damage

marijuanaIn the article recently published in the journal Psychopharmacology, October 2014 “Cannabis and creativity: highly potent cannabis impairs divergent thinking in regular cannabis users” (which you can read here… )  it was shown that regular users who were taking high dose cannabis did significantly worse on thinking tasks when compared to those taking low dose and placebo.  In other words, your mind works better and is more creative, when you do NOT use cannabis or use just low doses.  Too often you hear artists and musicians, writers, and performers tell you that they do their best work under the influence of this or that substance.  The truth is that the opposite is true.  Those who become dependent on a substance, be it marijuana or alcohol, etc. will need to rationalize the need to continue using that substance.  We do not have a cannabis deficiency or alcohol deficiency that is treatable with using these substances.

In the Lancet Psychology journal, September 2014, is the article “Young adult sequelae of adolescent cannabis use: an integrative analysis” showed significant adverse effects for those who became daily users before age 17 including:

  • Decreased graduation from high-school
  • Fewer degrees in higher education
  • Increased cannabis dependence
  • Increased use of other illicit drugs
  • Increased suicide attempts (you can read more about this here… )

I guess those who want to see these effects increase, should continue the push to legalize this horrible drug. I get it that we need to stop filling our prisons with young people who are found in possession of marijuana, but that could be accomplished by changing the laws.  I cringe when I hear the frequent statements about how safe marijuana is.  These individuals either themselves have not yet been harmed by this drug or they just don’t see all the damage it does.

The American Academy of Sleep Medicine has published this year a study showing that well rested students do better academically and in another study they showed that marijuana use was associated with poor sleep.  They report that any history of cannabis use was associated with increased difficulties falling asleep, staying asleep and waking up refreshed.  Those who started marijuana before age 15 were more than twice as likely to struggle with all three of these sleep-related disorders.

You see, as with most addictions, what initially helps you get to sleep or feel better, ultimately becomes your nemesis and imprisons you in a vicious cycle of needing the substance that is actually giving you short term benefits while making you worse over time.

In the Journal of Neurosciences, April 2014 “Cannabis Use is Quantitatively Associated with Nucleus Accumbens Abnormalities in Young Adult Recreational Users,” they showed that as little as once a week marijuana use resulted in structural changes in the size and shape of the area of the brain involved in emotion and motivation. (you can read more here… )

We are talking about MRI visible changes to the brain.  Can you even imagine the changes at the chemical level?  When I hear ignorant comments about how harmless marijuana is, I don’t even know where to start. I guess those who want to keep their head in the sand will only hear what the sand has to say, which is just the echo of their own thoughts!

 

Dr. Paul

 

 

Half of Those Prescribed Opiates for a Month Still Taking Them 3 Years Later

opiate2If you are taking opiates for pain, how long can you take them before you become dependent or addicted to them?  Those who have undergone major surgery, or had a serious bone-breaking accident, have likely known the benefit that opiates can provide for pain relief. As an Addictionologist who treats primarily opiate addicts who are mostly in their 20’s, I have seen all too often the story of a dental procedure or relatively minor surgery that resulted in a prescription for opiate pain killers that then led to an opiate addiction and, ultimately, heroin when the availability of pills disappeared.

The express scripts study, “A nation in pain,” (which you can find here… ) looked at more than 36 million opioid prescriptions issued to 6.8 million Americans from 2009-2013.  Here were some of the findings:

  • Half (50%) of the group taking opiates for an average of 3 years or longer were on short-acting opioids (much more likely to cause an addiction).
  • Younger adults (20-44) filled more prescriptions.
  • 60% used these opiate with other medications (1/3 were benzodiazepines, which are known to be a fatal combination with opioids).

 

Those who have become addicted or dependent on opioids probably need help getting off of them.  If you wish to try this at home, start by having someone else hold your medications, then reduce the dose by 10-20% every 1-4 weeks until you get off of them.  Most addicts will need the support of addiction counselors, a treatment program, or an addiction specialist.

If you have had surgery or an injury that resulted in a prescription for opioids, ask your doctor what is the usual length of time you would need to use opiates. If you feel that you are now continuing to have pain past that expected time frame, get re-evaluated by your doctor or surgeon. Perhaps something is wrong and perhaps you are starting to become dependent on the opiates.  Withdrawal symptoms can  first can feel like the pain of your surgery or injury, making you think you need more opiates, when, in fact, you need to wean off.

If you have had trouble getting off of opiates in the past and need a legitimate prescription, have someone else hold it and dispense to you only as prescribed.

We physicians and nurses were trained the past two decades that pain was a vital sign, and to not pay attention to that pain was a form of neglect.  We undoubtedly have ignored the huge down side to the use of opiates for pain that has become chronic.

 

Dr. Paul

 

Is Cannabis (Marijuana, THC) Use Harming Brain Function?

marijuanaWith legalization in many states, including Oregon, more and more adolescents believe that regular use of marijuana is harmless and more now are using it daily.

In the study “Persistent cannabis users show neuropsychological decline from childhood to midlife,” (which you can read here… ) neuropsychological declines were significant and worse for those who started cannabis use as adolescents.

This study was prospective, following over 1000 individuals born in 1972/1973 to the age of 38 with interviews at ages 18, 21, 26, 32, and 38. Neuropsychological testing was done at age 13 before any marijuana use and again at age 38.

Here are some of the findings:

  • If you never used THC your IQ was unchanged to slightly improved = 100.
  • If you used THC regularly your IQ dropped, and if it was persistent use, IQ dropped 6 points.
  • There were significantly more memory and attention problems in persistent users.
  • There was greater IQ decline in those who started THC use as teenagers.
  • Greatest decline was in users of over 20 years, especially if they started THC use as adolescents.
  • This study ruled out pre-existing neuropsychological issues and education differences.
  • The impairment was global across 5 different domains of function and testing.
  • Others in the users life verified the impairment.
  • The impairment was still there even a year after the THC user stopped use.

 

Puberty (ages 13-18) is a critical time of brain development, with neuronal maturation, myelination, synaptic pruning, and dendritic plasticity making this a time of vulnerability to toxic insults.

Other studies have shown structural brain differences with cannabis use.

This study conclusively puts to rest the notion that cannabis is harmless.  You are dumbing down, and causing permanent brain damage, especially if you started your use as a teenager.

 

 

Dr. Paul

 

 

 

 

What Factors Are Most Helpful to Reduce Substance Use by Teenagers?

substance abuseIf you have a teenager who is drifting into substance use or perhaps they are clearly abusing drugs or alcohol, which treatment approach should you consider?  What works and how does it work?

The article “Mechanisms of change in adolescent substance use treatment: How does treatment work?,” published in June of 2014 in the journal Substance Abuse, gives a good review of the literature. They found that positive social support, motivation to stop using drugs and alcohol, and positive parenting behaviors helped the most. You can read this article here…

There is often a discussion of whether cognitive behavioral therapy or motivational interviewing approaches work best. Since I work with this age group, trying to help those physically dependent or addicted to opiates (usually heroin), I am very aware of the high failure rate of treatment. My experience definitely supports the findings of this review.  Those parents or loved ones who remain engaged, supportive, while not being enabling, seem to have higher rates of success for their teenagers or young adults. Those substance users who plug into a 12-step or similar ongoing support program seem to remain motivated to stop the substance use.

When the endpoint is successfully stopping your substance use (be it alcohol, marijuana, opiates, methamphetamine, cocaine, or others) the study found that all roads that lead to reduced substance use travel through:

  • Supportive therapeutic or other relationships.
  • Increased motivation to reduce substance use.
  • Improved coping skills.
  • Increased self-efficacy to reduce use.
  • Improved affect regulation.

 

Cognitive behavioral therapy (CBT) was shown to work through coping skills training and increased self-efficacy to abstain or reduce use. Motivational Interviewing (MI) works through eliciting more client “change talk”, working best when the therapist was non-confrontational.

Parents, we can learn from this review article.  We should remain non-confrontational, supportive but not enable our teenager or young adult. This article did not address al-anon, an organization for the parents, family, or loved-ones of the substance user. As a parent who has found himself with young adults living in his home, eating the food and basically failing to find a job or even look for a job due to substance use, I have had to show these able-bodied, normal intelligence, young men, the door on more than one occasion.  Sometimes the hardest thing to do is to stop making it possible for them to use.  When faced with homelessness, each time my substance using young adults have found an apartment (sometimes we help make that happen) and gotten a job (some may need help with that). Al-anon is a place where you can get the support to stop enabling them and establish loving firm boundaries, if you are struggling with that.

 

Dr. Paul

 

 

 

 

Addiction Medicine- Birth of a New Specialty – Addictionology

Stages-of-Addiction-RecoveryIs addiction an issue in our society? Addiction to something is usually defined as repetitive use or behavior that you no longer control and that causes harm to yourself or others.  The most common being alcoholism or drug addiction. With these conditions, many of us have the image of the drunk under the bridge or on the street, and the heroin junkie with a needle in their arm in a back alley. Most alcoholics and addicts are functional.  They could be working at a major company, a business owner, a college student or indeed very often as the disease progresses, they start to loose things; jobs, homes, relationships, etc.

The article “Addiction Medicine the birth of a new discipline” September 2014 (you can read it here… ) outlines the fact that this is now a recognized specialty with board-certification requirements for the doctors who choose to become experts in the field of addiction medicine. Even though I’m board-certified in Pediatrics and Integrative Holistic Medicine, I chose to become board-certified in addiction medicine.  I have been helping opiate addicts under the age of 30 get off the opiates for the past several years at my clinic Fair Start, in Portland Oregon.

Substance use causes significant suffering for the individuals and their families and accounts for over $500 billion in economic costs in the US. In the 2012 NSDUH (National Survey on Drug Use and Health) surveying Americans over age 12:

  • 32% binge drink
  • 7% report heavy drinking the past month
  • 9% used illicit drugs the past month
  • Heroin use increased 79% since 2007
  • Opioid overdoses now exceed deaths from MVA’s (car crashes).

You can read this data here…

What can you do if you have a problem?  Ask for help, get to a 12-step meeting then keep going back, and if needed, set up inpatient treatment for yourself.

What can you do if you are the family of one suffering from substance use or addiction?  Stop enabling them.  No more money given, excuses made, etc.

Offer them treatment and then if necessary set up an intervention where a professional helps you get them either into treatment or out of your home.  Be ready to go to any lengths for your loved one.  It means risking everything in one sense, but too often the lack of willingness on the family’s part is what kills them anyway.

The diseases of addiction or substance use are progressive and fatal if untreated.  Think of it as slow suicide.  You can no longer stand by and throw your arms up saying you are helpless.  Do your part by not enabling, but also realize you cannot help them until they hurt bad enough or have enough motivation to get help. If you keep the environment nice and safe (roof over their heads and food in their tummy) why would they need to change?

I have had to show my adult children who were deep in their disease the door many times.  It is one of the hardest things a parent can do.  You must be willing to help them in any way possible when they are ready – but not in ways that allow them to continue in their drinking or using.  The same goes for spouses or anyone else in your life who may be using your kindness to get access to drugs or alcohol. The kind thing to do is to care enough to stop enabling them.  For those who struggle with that, there is a program for you: Al-Anon. You can learn more about Al-Anon here…

 

Dr. Paul

 

Start Your Buprenorphine Treatment for Opiate Addiction at Home or Observed?

opiate addictionBefore making the decision of where or how to get help for your opiate use, abuse, or addiction, one must first acknowledge that they have a problem with their use of opiates.  Like most addictions, (be it alcohol, marijuana, cocaine, or meth) until the person struggling with this overuse or addiction or dependence can get help one of two things must happen:

  1. They must acknowledge they have a problem and ask for help or at least be willing to get help.
  2.  Loved ones can do an intervention where the ultimatum is placed, lovingly, that they have reached the end of the road – no more financial support unless they go to treatment.

This article in Journal of Addiction Medicine Sept/Oct 2014, “Unobserved Home Induction onto Buprenorphine,” looks at the studies to date on this topic. You can read the article here… They looked at 10 studies and 9 provider surveys and while the studies were weak and seemed to have bias, they found no significant differences. International guidelines in the US, United Kingdom, France, and Australia emphasize clinician or pharmacist observed induction with only Denmark endorsing unobserved induction.

As a board certified addiction specialist, and the physician for hundreds of Buprenorphine opiate addicts over the past 5 years  (less than 100 at a time), I can clarify this issue. Most of the opiate addicts today are using heroin daily and cannot go 24 hours without using or they suffer severe withdrawal symptoms.  They are in bondage to the drug that once was their savior!  They will do almost anything to avoid going into that withdrawal, hence the tremendous pressure to get money and opiates no matter what.  This becomes the primary goal period.  Few can juggle this for long unless they have plenty of money.

The second group that is addicted or dependent on opiates are the pain patients or those who have been on pain opiates for more than a month or two. They are in the same situation; the withdrawal symptoms are so severe that it feels like the pain is getting worse.  Indeed, because your body adapts to the opiate use (tolerance) the patient or person needs more and more to get the same effect. What 99% of these “pain” suffering individuals learn (eventually) is that once we start weaning down the dose of opiates, they actually end up with less pain.  Opiates are a wonderful drug class for acute pain and generally a bad idea for chronic pain. If you have terminal cancer or some other devastating injury, obviously take all the opiates and other pain meds you can to get relief- I am not advocating suffering.

So the question raised in this article is this: can we give our opiate addict the Buprenorphine prescription and have them fill it, then at home wait until they are in enough withdrawal to start taking the Buprenorphine, or should we have them arrive in our office in withdrawal, give them the first dose and then have them fill their prescription?

I will tell you that with most of my patients, the first choice will fail and here is why.  If I am at home getting high on heroin or pills, (for which I usually must struggle to find the money to obtain) and I’m given let’s say 60 Buprenorphine 8 mg tabs (value $900 – $1800), what are the odds that I will allow myself to get to that dreaded feeling of severe withdrawal before taking one? My heroin or pill dealer would gladly take my Buprenorphine in exchange for all the heroin or pills I would need for the coming month.

Once you have induced the opiate patient (we do a scoring of withdrawal symptoms that is near impossible to fake) the fact that the person has started Buprenorphine, now makes success much more likely.  Buprenorphine is a partial agonist (meaning it gives a partial opiate effect) and a partial but very strong opiate blocker (meaning that once you are taking 16 mg a day it is very unlikely you will experience the “high” from using opiates).

In addition to insisting on an observed (in office, in our case) induction, it is advisable that someone other than the patient hold the Buprenorphine for the first month or longer if needed.  This removes the temptation of selling the Buprenorphine (or Suboxone, Zubsolv).  If outpatient treatment fails, or your opiate user has severe mental health or other addictions besides opiates, it may be best to have them observed inpatient at an addiction treatment center where you spend several days or weeks.

If you are prescribing Buprenorphine without following urine drug screens, you are also potentially just contributing to the problem of diversion, where these patients are selling their Buprenorphine and you may be just as bad as the drug dealers on the street. I know as a physician we are taught to believe our patients and we are trying to help, but seriously, think of the addict and be realistic. Not all patients are diverting and indeed we save lives with treatment, which is why we do this.

I obviously am not a fan of home induction, simply because it is risky and I am certain there will be many more cases of diversion. Home induction is not the current standard of care, although I fear we are headed that way, and as a result we shall see more and more Buprenorphine on the black market.

For an appointment with Dr Paul Thomas (opiate users age 30 and under) contact Fair Start here…

 

Dr. Paul