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The Opiate Epidemic: Current Trends and Best Practices

by Dr. Nancy Duff-Boehm, Ph.D.

Ohio is overwhelmed with the problem of opiate addiction with the highest number of deaths in the country, and the problem is still growing by 30% each year. This was the take-home message of the CPA program on March 17, 2018, which featured three professionals that work in the field of addictions: Gregory X Boehm, M.D., Sybil Marsh, M.D. and Nancy Duff-Boehm, Ph.D. In 2016 more drug users died of drug overdoses in the US than soldiers died in the Viet Nam, Afghanistan and Iraq wars put together. We in general practice are in the best position to catch a developing problem at the start or to direct a full-blown problem into treatment. However, detecting the problem can be tricky, and forging a path to treatment for an addict who is content with how things are can be a daunting task.

Luckily, the American Society of Addiction Medicine (ASAM) and the National Institute of Drug Addiction (NIDA) have done the research and developed protocols for an evidence-based referral process. The procedure is called SBIRT (Screening, Brief Intervention and Referral to Treatment), and training in it is available on-line at the NIDA website. NIDA urges all primary care doctors to learn it and use it in their daily practices. We psychologists should, too.

Usually, in our practices, the problem will come to our attention through stressed-out family members. We can do a lot to help. We must help the loved one refrain from protecting the addict from his or her consequences, such as paying bail to get them out of jail faster or hiring a lawyer to plead to a lesser or non-drug-related charge, or even providing a dose of opiate to help the addict avoid withdrawal without seeking medical attention. We can help the family member detach with love and continue to be available when treatment does finally click in. We can direct the family to Al-anon, where they will find 24-hour support of others who have been in their shoes. We can help them support their loved one in the recovery process by paying attention to their own needs.

Why Ohio? The book Dreamland by Sam Quinones provides a fascinating account of how the confluence of events led to central Ohio’s being one of two ground zeros for distribution from a small town in Mexico. Pharmaceutical companies falsely advertised that opiates were not addictive in the presence of real pain; doctors bought the idea and started prescribing increasingly massive amounts of narcotics to chronic pain patients, making dependency wide-spread. The DEA saw what was happening and started arresting doctors and closing pain clinics that had proliferated. Doctors started cutting people off their meds with no alternatives.

In the meantime, the California market that kept many Mexican heroin producers flush became saturated. One family sent out tentacles to Crawford County, Ohio and Charlotte, North Carolina. They created a business plan that involved perfect service, including under-20-minute delivery to your door. The deliverers carried only 4-5 doses, tied into balloons, so the whole stash could be swallowed if the driver was stopped by the police. This black tar heroin cost $4 a dose, in contrast to the $80 cost of one pill of oxycontin. They drove the speed limit in gray Camrys, dressed in clean, unassuming clothes, with no tattoos or piercings.  If a driver was caught, he went to jail and was deported, providing an opportunity to the endless supply of young men waiting for the job back home. This procedure built a lot of homes for many families in a very poor town in Mexico. By the way, the heroin is flown in; no wall would keep them out.

New rules and education for doctors have drastically cut the number of excess prescriptions that are written now. However, as Dr. Boehm pointed out, the horse has already left the barn; the resulting epidemic is ours to manage and contain. The economic pressures that keep it alive are enormous.

Psychosocial treatment and medication assistance are the combination that works best for the treatment of opiate addiction. Psychosocial treatments are long-term and intensive, and they involve a variety of evidence-based practices such as group therapy, cognitive-behavioral methods, relaxation training, assertion training, anger management, relationship counseling, and family group meetings. Case management is also a crucial component, as many addicts have lost their families and homes, lack access to transportation, have extensive court-related obligations, and are involved with Children’s Protective Services, among other life-complications that require managing resources in the community. Facilitation of 12-step community support is crucial in helping the addict develop long term recovery and a way to avoid relapse.

One indication of the effectiveness of a comprehensive psychosocial and medication assistance approach is the case of Portugal. In 2001, Portugal had the highest rates of heroin addiction, deaths due to narcotics overdose and new cases of Hepatitis C in all of Europe. That year the legislature decided to switch the approach from the law-enforcement they had been using to requiring treatment. They decriminalized individual use, but for those caught with illicit drugs, required meetings with a social worker, a lawyer and a counselor, and engagement in whatever treatment was recommended by this committee. Treatment included mandatory 12-step involvement. Monitoring was close. Within five years, Portugal went from the highest to the lowest rates in Europe of all three criteria studied: heroin addiction, deaths due to overdoses and new cases of Hepatitis C.

The goal of medication-assisted treatment is the restoration of highest possible functioning. There are three basic medications used to assist treatment of addiction. Methadone has been around for the longest, and it is a full agonist. One dose lasts a whole day. It must be dispensed at a Methadone Clinic, for the first several months on a daily basis. Buprenorphine is a partial agonist, so that it does not cause tolerance or intoxication. Induction is done on an outpatient basis, and involves daily dosing for the first two weeks, involving a trip to the local pharmacy every day. After that, the patient earns the gradual increase in number of daily doses he or she is provided with each prescription, up to a month at a time. Vivatrol is a monthly injection of a medicine that prevents a person from becoming high on opiates or alcohol. It does not prevent other drugs such as cocaine or stimulants from having their regular effects.

The final point of this program is a simple one: Treatment works. Testimonials of patients in solid recovery, while they do not amount to evidence that a treatment works for everyone, do demonstrate the profound changes in character as well as behavior that can come as a result of making full use of these treatment opportunities. In contrast to the self-absorbed, apathetic and hopeless condition in which they began treatment, these patients, two years after initiating therapy, are cultivating strong family relationships and leading productive work lives while managing the stresses and disappointments of ordinary life.

Dr. Duff-Boehm, Ph.D. and her husband, psychiatrist and addictions physician Dr. Gregory Boehm, M.D., share a practice which runs Intensive Outpatient Programs using medication-assisted treatment in North Olmsted and Beachwood, Ohio. You can visit their website,  www.boehmpsychservices.com, or contact them by email at boehmpsychsvc@gmail.com

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