Pain Patients Sue State of Washington

Do doctors suffer from "opiophobia?"

The opium family of painkillers has always been a bane and a boon to the human race, as evidenced by nurses injecting morphine into agonizingly wounded soldiers, and street junkies selling the clothes off their back for another fix.

However, as I wrote in an earlier post, "The Morphine Scandal," the ironies fly thick and fast: In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold. Studies show that 70 per cent of patients present with painful conditions. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference.

Now, a lawyer for a pain relief advocacy group has filed suit against the state of Washington, claiming that overly stringent guidelines on prescription pain medications have had a negative effect on pain management across the country. Attorney Laura D. Cooper, who filed the suit on behalf of a group of Washington residents being treated for pain, said in an Associated Press article by Donna Gordon Blankinship that the state's regulations were comparable to setting a limit on the amount of insulin a doctor could prescribe for diabetic patients. Cooper alleged that the Washington standards have been used as guidelines by insurance companies and workman's compensation boards.

The AP article also quoted Siobhan Reynolds of the Internet-based Pain Relief Network: "The ramifications are enormous. You never see on a death certificate that people died of pain, but people die of pain all the time."

The lawsuit features an excerpt from a University of Wisconsin textbook on pain medicine, Bonica's Management of Pain, 3rd edition:

"Opiophobia is the syndrome of failure to administer adequate opioid analgesics because of the fear of producing addiction or toxicity. The etiology of opiophobia is multifactorial: Peer pressure (provider and patient), regulatory agency pressure (real or perceived), and lack of education on opioids and the fundamentals of pain management all contribute to its persistence.... All of these factors contribute to the underuse of these relatively simple and very effective medications, due to no fault of the patients. "

According to Drug Law Blog, the complaint "asks the court to declare that the state guidelines 'do not constitute enforceable law of any kind and should be stricken and removed from all state publications of every variety,' and seeks other additional relief, including an injunction against enforcement."

As for concerns about addiction, recent evidence for the heritability of opiate addiction looks strong. “Harvard did some really superb studies using a huge cohort of military recruits in the U.S. Army,” according to Mary Jeanne Kreek, a specialist in opiate addiction at Rockefeller University in New York. “Heroin addiction has even a larger heritable component than any of the other addictions, so that up to 54% of heroin addictions seem to be on a genetic basis or a heritable basis.”

Photo Credit: Opioid.org

[Guest Post] Internet Addiction: A Novel Disease?

Or a reflection of the new world order?

[Editors Note: Addiction Inbox has not covered the so-called behavioral or non-traditional addictions--Internet addiction, video game addiction, compulsive shopping and compulsive gambling--because I am not yet convinced that such behaviors show the same chemical and often inheritable propensities associated with alcoholism and other drug addictions. Nonetheless, I am pleased to offer an alternative view, and to welcome guest blogger Elizabeth Dillon, who contributes a thought-provoking post on internet addiction.] --Dirk Hanson

By Elizabeth Dillon

It is impossible to deny the incredible significance of the internet and the effects its development has had on the world. Today the internet touches nearly every aspect of our daily lives; we shop online, we keep in touch through email, banking and credit can be taken care of through one click of a mouse, news from all over the world blinks up at us from the screen every time we log on, and communities of people from all over the planet are connected. Despite its obvious countless advantages, there is a rising concern regarding the overuse of the internet on a personal level. There are more and more people each day who feel a compulsive need to be connected to the internet, a need that some scientists and psychiatrists have begun to consider an addiction. This issue drew major media attention in March of this year when Dr. Jerald Block published an editorial in the American Journal of Psychiatry arguing that “Internet Addiction” should be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a handbook published by the American Psychiatric Association of recognized psychological conditions. Block raised the question of whether this new phenomenon should be classified as a disease or written off as a bad habit.

The traditional view of addiction generally applies to substances like drugs or alcohol and is seen as a result of a combination of genetic and social influences. However, in recent years the definition of addiction has expanded to include different behaviors like gambling and over-eating. The question that remains to be seen is if there are enough similarities between traditional addiction and this so called internet addiction to warrant its acceptance as a disease by the mental health community. For now it is officially titled Internet Addictive Disorder (IAD) or Internet Overuse Syndrome (IOS) and not recognized by the American Psychiatric Association.

Block argues that Internet addiction is characterized by the same four factors as traditional addiction: excessive use, withdrawal, tolerance, and negative repercussions. He contends that users are on the internet for so much time that they are unaware of how many hours have gone by, and neglect other basic human desires, often forgetting to eat or use the bathroom. Users feel angry, depressed, and tense when access to the internet is limited and frequently need better tools and more time of use to experience the original satisfaction. Internet addicts also face such harmful consequences as social isolation and poor achievement.

The statistics regarding the prevalence of internet addiction in the U.S. vary widely. A random telephone survey estimated 0.3-0.7% of Americans are afflicted, while Maressa Hecht Orzack of McLean Hospital in Massachusetts, estimates that nearly 10% of Americans have experienced some sort of internet dependency. Higher rates of addiction are seen mostly in Asian nations like South Korea and China where the popularity of internet cafes is high and the condition is easier to track because of its public nature. In fact, data from 2006 stated that approximately 210,000 South Korean children (2.1%) were afflicted with internet addiction with about 80% requiring treatment that included the use of psychotropic medication. Another interesting aspect of IAD is that most often individuals who suffer from it also are battling another mental illness. In particular, mood, anxiety, impulse control and substance abuse disorders are common in conjunction with internet overuse.

Research has traced other behavioral addictions like gambling and shopping to biological foundations; however the current research on internet addiction merely distinguishes it as a growing issue and draws parallels to other types of addictions. More studies need to be performed on this new phenomenon in order to properly characterize it as an addiction or as simply a destructive behavior.

While the internet may not officially be an addiction, there are still many individuals out there who would benefit from treatment. There are currently no proven forms of effective treatment and no available psychotropic medications for IAD. However, like with other addictive habits, cognitive behavioral therapy may be effective. Cognitive therapy is essentially a method that identifies and helps a person to correct specific errors in what he or she is thinking that produces negative or painful feelings. According to Dr. Allison Conner of Cognitive Therapy Associates, an internet addiction could be treated similarly to other addictions. She asserts that, “so many changes need to occur in the person's lifestyle (mental, emotional, physical, social), and support is crucial. A guide or coach is often essential to help ensure success, but most important is the willingness of the addicted person to get real with themselves and stay committed to the goal of recovery.”

While we may not see Internet Addiction in the DSM-V handbook anytime soon, the issue is controversial and becoming ever more widespread. Ironically enough, you can even look up online resources if you feel you need help.

Elizabeth Dillon is the Director of Communications Management for Cognitive Therapy Associates.

Sources:

Block, Jerald J. (2008). Issues for DSM-V: Internet Addiction. The American Journal of Psychiatry, 165, 306-307.

Goldsborough, Reid, (2008). Internet Addiction Afflicting a Growing Number of Web Surfers. Community College Week, Vol. 20 Issue 11, 0, 22-22.

Shaw, Martha Black, Donald W. (2008). Internet Addiction. CNS Drugs, Vol. 22, Issue 5, 13, 353-365.

Dr. Allison Conner can be contacted through her website:
http://www.cognitive-therapy-associates.com/ or at (212)-258-2577.

Addiction Treatment: Who is the Client?

The Overselling of Drug Rehab.

Professor David Clark, who runs the Wired In recovery website in the U.K., recently posted several passages from William L. White's "Slaying the Dragon: The History of Addiction Treatment and Recovery in America."

According to Professor Clark, "In highlighting [these quotes] on my Blog, I am not questioning the value of treatment. However, I am providing a word of caution to those who are trying to tell 'society' that the government-led treatment system is successful and is a panacea to some of society's problems."

Among the observations from White's book:

Who is the client?

"Addiction treatment swings back and forth between a technology of personal transformation and a technology of coercion. When the latter dominates, counselors become, not helpers, but behavioral police. The fact that today’s treatment institutions often serve more than one master has created the ethical dilemma of “double agentry,” wherein treatment staff profess allegiance to the interests of the individual client, while those very interests may be compromised by the interests of other parties to whom the institution has pledged its loyalty.’

--White, p. 335.

On blaming

"Harold Hughes, the political Godfather of the modern alcoholism treatment system, often noted that alcoholism was the only disorder in which the patient was blamed when treatment failed.... For decades many addicts have been subjected to treatment interventions that had almost no likelihood of success; and when that success has indeed failed to materialize, the source of that failure has been attributed, not to the intervention, but to the addicts’ recalcitrance and lack of motivation. The issue is, not just that such mismatches do not work, but that such mismatches generate their own iatrogenic effects via increased client passivity, helplessness, hopelessness and dependence."

--White, p. 331.

Historical tendency to oversell what treatment can achieve

"The overselling of the ways in which addiction treatment could benefit the home, the workplace, the school, the criminal justice system, and the broader community during the 1970s and 1980s sparked a subsequent backlash. When time - the ultimate leveller – began to expose the fact that these benefits were not forthcoming at the level promised, a rising pessimism fueled the shift toward increased criminalization of addiction."

--White, p. 338

Photo Credit: Cliffside Malibu

Battling Addiction with Exercise

It helps you quit. Can it keep you from starting?

We've all heard the claim: Physical exercise helps addicts who are working their way through withdrawal and recovery. It is one of the most common prescriptions given out by doctors and health professionals, whether you are a recovering alcoholic or a chronic binge eater.

And it makes sense. Exercise has verifiable impacts on not just endorphin levels, but also on levels of circulating serotonin and dopamine. All three neurotransmitter systems are heavily implicated in both maintaining addiction and withdrawing from it. Countless drug addicts have extolled the virtues of vigorous exercise, and there seem to be no compelling reason to doubt them.

But is there reason to think that regular exercise can help prevent addiction from blossoming in the first place?

Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), thinks there is. She told the Cincinnati Enquirer: "It's something we could apply right away. Vaccines, we're not going to get those results in one or two years. It will take probably five, six years to results."

"Exercise has been shown to be beneficial in so many areas of physical and mental health," Volkow said recently at a NIDA-sponsored conference on addiction treatment and research in Cincinnati. "This cross-disciplinary meeting is designed to get scientists thinking creatively about its potential role in substance abuse prevention."

Dr. Bess Marcus of Brown University, who is working on a NIDA-funded study of exercise for smoking cessation, presented the scientific evidence for the addiction/exercise connection. Similarities in the effects on the reward pathways of the brain's limbic system--dopamine activity in particular--may tie the two behaviors together more directly than previously thought. Among the findings:

--Rats in cages with running wheels show less interest in amphetamine infusions than rats without exercise options.

--Baby monkeys who don't roughhouse with their peers have higher levels of impulse control problems and alcohol use when they get older.

--In humans, exercise is known to reduce stress and tension--and anxiety is a well-known side effect of withdrawal, from alcohol and cigarettes to heroin and speed.

--Physical activity may enhance cellular growth in key areas of the brain involved in addiction, thereby aiding the neural rewiring that takes place during detoxification and withdrawal from addictive drugs.

No one knows for sure whether this effect, if it exists, works only in the young, and declines with age, or whether it can be of benefit to anyone as a preventative measure to reduce drug craving. "Statistics indicate that teens who exercise daily are the least likely to report using drugs or alcohol," Volkow said.

However, there are numerous exceptions, one being the classic image of the hard-drinking athlete. "Now the kids who exercise the most actually drink the most," Dr. Lloyd Johnston of the University of Michigan told the Associated Press.

Meth to the West, Cocaine to the East, Pot in the Middle

The geography of drug use.

To paraphrase an old tune by Gerry Rafferty, we got meth to the left of us, cocaine to the right, and here we are, stuck in the middle with pot.

The National Drug Threat Survey of 2007, a product of the National Drug Intelligence Center (NDIC) at the Department of Justice, illustrates the stark nature of regional variation when it comes to illegal drugs of choice in the United States. The map at the right represents the responses of state and local law enforcement agencies to the question: "What drug poses the greatest threat to your area?" Blue indicates cocaine, red indicates methamphetamine, and green stands for marijuana. (Click map for larger image.)

According to the Oregonian in Portland, reporting on similar numbers from the U.S. Substance Abuse and Mental Health Services Administration: "The politics of methamphetamine have been shaped by geography. Lawmakers from the East, Midwest and South focused on cocaine--the most heavily abused drug by far in their home states. By contrast, more than 90 percent of people treated for meth abuse live west of the Mississippi River."

The NDIC's stated mission is "to provide strategic drug-related intelligence, document and computer exploitation support, and training assistance to the drug control, public health, law enforcement, and intelligence communities of the United States...." NDIC obtains its data through direct surveys of federal, state and local law enforcement and intelligence agencies, as well as information from court documents, news sources, and public health agencies.

The NDIC has produced a National Drug Threat Survey annually since 2000, and began deriving state-level estimates in 2003. Federal, state and local government agencies use the statistical estimates as guidelines for promulgating drug legislation and enforcement strategies.

Graphics Credit: National Drug Intelligence Center

Obama and McCain on Addiction Treatment

Candidates differ on medical marijuana.

A drug and alcohol policy group has released a study of positions on drug policy by the presidential candidates, concluding that "neither John McCain or Barack Obama can really be considered a leader in the drug-policy area."

In an article published on the Join Together website, author Bob Curley notes that Obama has admitted to youthful marijuana and cocaine use, and McCain has admitted to youthful alcohol abuse. Both candidates are former cigarette smokers, Obama having quit only recently. Curley write that "both appear to have a broader and more nuanced understanding of addiction issues than their White House predecessor."

The article also quotes William Cope Moyers, vice president of external affairs at Hazelden treatment center, who says he has "never been more hopeful that addiction treatment will begin to get the attention it deserves, because we at least have two candidates who are aware of the issue." Obama's admission of drug use is already on the table as a potential campaign issue, while McCain purportedly had an alcoholic father, and his wife went through treatment for an addiction to painkillers in the 1990s.

Senator McCain has been active in efforts to regulate tobacco advertising, and advocates smoking cessation programs in the workplace. At other times, he has advocated tougher sentencing for drug crimes and capital punishment for international drug traffickers.

For his part, Senator Obama supported the Second Chance Act of 2007, which aimed at reintroducing veteran drug defenders to society. He has called for greater use of drug courts and rehabilitation programs in lieu of lengthy prison sentences. He is opposed to efforts to lower the drinking age to 18.

McCain is against marijuana legalization, and opposes the use of marijuana for medical purposes. He said he "would not support medical marijuana because I don't think that the preponderance of medical opinion in America agrees...."

Obama, according to the Join Together article, while not ready to let people grow their own, told a reporter in March that "my attitude is that if it's an issue of doctors prescribing medical marijuana as a treatment for glaucoma or as a cancer treatment, I think that should be appropriate because there really is no difference between that and a doctor prescribing morphine or anything else."

medical marijuana

Smoking Rates Fall 18% in Indiana

What's their secret?

Addiction is a tough disease, and smoking grabs hold of the addiction-prone with a speed and ferocity that remains impressive even in a world of crack cocaine and ice amphetamine. Zyban may help, and there is the ever-controversial Chantix, as well as a plethora of nicotine replacement products. They are valuable and frequently effective additions to the arsenal of medical approaches to nicotine addiction.

Yet there remains one universally effective--if equally controversial--method of lowering smoking rates in a given population. You can increase the price.

Last year, Indiana boosted state taxes on cigarettes by a whopping 44 cents per pack. The result? Cigarette sales fell in Indiana by almost 18 per cent in the nine months since the new tax was put into effect, according to a June 3 Associated Press report. That percentage represents a decrease in sales of roughly 80 million packs of cigarettes, according to state health experts.

"This is exactly what we predicted, " Dr. Judith Monroe, the state health commissioner, told AP. "We've got to remember that smoking is an addiction... not just a bad habit."

In an editorial, the Indianapolis Star put the matter straightforwardly: "In Indiana and nationally, the research in unequivocal: Taxes reduce smoking, especially among the young. So does serious spending on smoking prevention and cessation. The state used to do the latter, and has paid the price for slacking off."

Indiana currently ranks 6th highest in the nation for smoking prevalence. In 1999, under terms of the state-by-state settlement with the tobacco industry, Indiana used its money entirely for smoking reduction programs. After seeing significant declines in smoking, the state legislature nonetheless diverted the remaining settlement money to other programs in 2003. At which point, according to the Indianapolis Star, "smoking rose again, up to second-highest in the nation," making Indiana "one of the unhealthiest states."

"More than one million Hoosiers use tobacco," Karla Sneegas of Indiana Tobacco Prevention and Cessation told the Associated Press. "But we know from our data that approximately 90 percent of those people want to quit and 30 percent are ready to quit right now."


Photo Credit: SavingAdvice.Com

The Biology of Bulimia

The binge-and-purge addiction.

By 2000, the biological substrate unifying alcoholism, addiction, depression, and certain eating disorders had become irrefutable. Population surveys had shown that nearly half of alcoholic patients had a long history of coexisting depression and/or anxiety disorders. Overall, about a third of patients with depression or panic disorder have had lifelong problems with drug abuse. These are estimates, best clinical guesses, but associating depression and addiction is no longer a speculative venture.

As with more familiar forms of addiction, bulimia was coming to be seen as another serotonin/dopamine-mediated medical condition. As noted, serotonin is involved in both the binge and the purge. Once researchers began performing the necessary double blind, placebo-controlled studies, it became clear that serotonin-boosting drugs dramatically lessened bulimic behavior in general, and associated carbohydrate binging in particular, in a large number of diagnosed bulimics. (Anorexia nervosa, another eating disorder, does not show the same serotonin affinities in action.)

Bulimics often maintain a normal weight, but can suffer serious physical consequence—heart rhythm irregularities, electrolyte imbalances, low blood pressure, and damage to the esophagus. Once the binge-purge cycle has been established, some researchers believe, drug-like changes in serotonin 5HT receptor distributions help reinforce the pattern. It is not surprising to learn that Prozac and other serotonin reuptake inhibitors such as dexfenfluramine were prominent among the drugs being tested against bulimia in the 1990s. By 1995, a paper presented at the National Social Science Association Conference in San Diego stated: “The serotonin hypothesis of bulimia nervosa suggests that bulimia is the behavioral manifestation of functional underactivity of serotonin in the central nervous system.”

In 1997, Prozac became the first drug ever licensed by the Food and Drug Administration (FDA) for the treatment of bulimia nervosa, as this chronic disorder is officially known. The drug’s formal approval was based on three clinical studies showing median reductions in binging of as much as 67 per cent for Prozac, compared with 33 per cent for placebo. Vomiting was reduced by 56 per cent, compared to 5 per cent for female placebo users. (About 10 per cent of diagnosed bulimics are males.) There is often a family history of alcoholism and/or eating disorders. The locus of “serotonergic dysfunction” appears to be the hypothalamus. Low levels of serotonin and dopamine metabolites have been documented in the cerebrospinal fluid of bulimic patients. Evidence exists for the involvement of norepinephrine as well.

Bulimia, like alcoholism and other drug addictions, has its psychosocial side, but twins studies show that there is very probably a genetics of bulimia to be pursued. In one influential study, an identical twin stood a one-in-four chance of developing bulimia, if the other twin was diagnosed with the disorder. A combination of SSRI drugs and some form of structured cognitive therapy is the recommended approach.

--Excerpted from
The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009

Photo Credit: Graham Menzies Foundation