Answer Addiction

Tag: MAT

  • They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.

    Beeler worried that a failed drug test — even if it was for a medication to treat his addiction (like buprenorphine) — would land him in prison.

    She was in medical school. He was just out of prison.

    Sarah Ziegenhorn and Andy Beeler’s romance grew out of a shared passion to do more about the country’s drug overdose crisis.

    Ziegenhorn moved back to her home state of Iowa when she was 26. She had been working in Washington, D.C., where she also volunteered at a needle exchange — where drug users can get clean needles. She was ambitious and driven to help those in her community who were overdosing and dying, including people she had grown up with.

    “Many people were just missing because they were dead,” said Ziegenhorn, now 31. “I couldn’t believe more wasn’t being done.”

    She started doing addiction advocacy in Iowa City while in medical school — lobbying local officials and others to support drug users with social services.

    Beeler had the same conviction, born from his personal experience.

    “He had been a drug user for about half of his life — primarily a longtime opiate user,” Ziegenhorn said.

    Beeler spent years in and out of the criminal justice system for a variety of drug-related crimes, such as burglary and possession. In early 2018, he was released from prison. He was on parole and looking for ways to help drug users in his hometown.

    He found his way to advocacy work and, through that work, found Ziegenhorn. Soon they were dating.

    “He was just this really sweet, no-nonsense person who was committed to justice and equity,” she said. “Even though he was suffering in many ways, he had a very calming presence.”

    People close to Beeler describe him as a “blue-collar guy” who liked motorcycles and home carpentry, someone who was gentle and endlessly curious. Those qualities could sometimes hide his struggle with anxiety and depression. Over the next year, Beeler’s other struggle, with opioid addiction, would flicker around the edges of their life together.

    Eventually, it killed him.

    People on parole and under supervision of the corrections system can face barriers to receiving appropriate treatment for opioid addiction. Ziegenhorn said she believes Beeler’s death is linked to the many obstacles to medical care he experienced while on parole.

    About 4.5 million people are on parole or probation in the U.S., and research shows that those under community supervision are much more likely to have a history of substance use disorder than the general population. Yet rules and practices guiding these agencies can preclude parolees and people on probation from getting evidence-based treatment for their addiction.

    A Shared Passion For Reducing Harm

    From their first meeting, Ziegenhorn said, she and Beeler were in sync, partners and passionate about their work in harm reduction — public health strategies designed to reduce risky behaviors that can hurt health.

    After she moved to Iowa, Ziegenhorn founded a small nonprofit called the Iowa Harm Reduction Coalition. The group distributes the opioid-overdose reversal drug naloxone and other free supplies to drug users, with the goal of keeping them safe from illness and overdose. The group also works to reduce the stigma that can dehumanize and isolate drug users. Beeler served as the group’s coordinator of harm reduction services.

    “In Iowa, there was a feeling that this kind of work was really radical,” Ziegenhorn said. “Andy was just so excited to find out someone was doing it.”

    Meanwhile, Ziegenhorn was busy with medical school. Beeler helped her study. She recalled how they used to take her practice tests together.

    “Andy had a really sophisticated knowledge of science and medicine,” she said. “Most of the time he’d been in prison and jails, he’d spent his time reading and learning.”

    Beeler was trying to stay away from opioids, but Ziegenhorn said he still used heroin sometimes. Twice she was there to save his life when he overdosed. During one episode, a bystander called the police, which led to his parole officer finding out.

    “That was really a period of a lot of terror for him,” Ziegenhorn said.

    Beeler was constantly afraid the next slip — another overdose or a failed drug test — would send him back to prison.

    An Injury, A Search For Relief

    A year into their relationship, a series of events suddenly brought Beeler’s history of opioid use into painful focus.

    It began with a fall on the winter ice. Beeler dislocated his shoulder — the same one he’d had surgery on as a teenager.

    “At the emergency room, they put his shoulder back into place for him,” Ziegenhorn said. “The next day it came out again.”

    She said doctors wouldn’t prescribe him prescription opioids for the pain because Beeler had a history of illegal drug use. His shoulder would dislocate often, sometimes more than once a day.

    “He was living with this daily, really severe constant pain — he started using heroin very regularly,” Ziegenhorn said.

    Beeler knew what precautions to take when using opioids: Keep naloxone on hand, test the drugs first and never use alone. Still, his use was escalating quickly.

    A Painful Dilemma 

    The couple discussed the future and their hope of having a baby together, and eventually Ziegenhorn and Beeler agreed: He had to stop using heroin.

    They thought his best chance was to start on a Food and Drug Administration-approved medication for opioid addiction, such as methadone or buprenorphine. Methadone is an opioid, and buprenorphine engages many of the same opioid receptors in the brain; both drugs can curb opioid cravings and stabilize patients. Studies show daily maintenance therapy with such treatment reduces the risks of overdose and improves health outcomes.

    But Beeler was on parole, and his parole officer drug-tested him for opioids and buprenorphine specifically. Beeler worried that if a test came back positive, the officer might see that as a signal that Beeler had been using drugs illegally.

    Ziegenhorn said Beeler felt trapped: “He could go back to prison or continue trying to obtain opioids off the street and slowly detox himself.”

    He worried that a failed drug test — even if it was for a medication to treat his addiction — would land him in prison. Beeler decided against the medication.

    A few days later, Ziegenhorn woke up early for school. Beeler had worked late and fallen asleep in the living room. Ziegenhorn gave him a kiss and headed out the door. Later that day, she texted him. No reply.

    She started to worry and asked a friend to check on him. Not long afterward, Beeler was found dead, slumped in his chair at his desk. He’d overdosed.

    “He was my partner in thought, and in life and in love,” Ziegenhorn said.

    It’s hard for her not to rewind what happened that day and wonder how it could have been different. But mostly she’s angry that he didn’t have better choices.

    “Andy died because he was too afraid to get treatment,” she said.


    Beeler was services coordinator for the Iowa Harm Reduction Coalition, a group that works to help keep drug users safe. A tribute in Iowa City after his death began, “He died of an overdose, but he’ll be remembered for helping others avoid a similar fate.” (COURTESY OF SARAH ZIEGENHORN)

    How Does Parole Handle Relapse? It Depends

    It’s not clear that Beeler would have gone back to prison for admitting he’d relapsed and was taking treatment. His parole officer did not agree to an interview.

    But Ken Kolthoff, who oversees the parole program that supervised Beeler in Iowa’s First Judicial District Department of Correctional Services, said generally he and his colleagues would not punish someone who sought out treatment because of a relapse.

    “We would see that that would be an example of somebody actually taking an active role in their treatment and getting the help they needed,” said Kolthoff.

    The department doesn’t have rules prohibiting any form of medication for opioid addiction, he said, as long as it’s prescribed by a doctor.

    “We have people relapse every single day under our supervision. And are they being sent to prison? No. Are they being sent to jail? No,” Kolthoff said.

    But Dr. Andrea Weber, an addiction psychiatrist with the University of Iowa, said Beeler’s reluctance to start treatment is not unusual.

    “I think a majority of my patients would tell me they wouldn’t necessarily trust going to their [parole officer],” said Weber, assistant director of addiction medicine at the University of Iowa’s Carver College of Medicine. “The punishment is so high. The consequences can be so great.”

    Weber finds probation and parole officers have “inconsistent” attitudes toward her patients who are on medication-assisted treatment.

    “Treatment providers, especially in our area, are still very much ingrained in an abstinence-only, 12-step mentality, which traditionally has meant no medications,” Weber said. “That perception then invades the entire system.”

    Attitudes And Policies Vary Widely

    Experts say it’s difficult to draw any comprehensive picture about the availability of medication for opioid addiction in the parole and probation system. The limited amount of research suggests that medication-assisted treatment is significantly underused.

    “It’s hard to quantify because there are such a large number of individuals under community supervision in different jurisdictions,” said Michael Gordon, a senior research scientist at the Friends Research Institute, based in Baltimore.

    A national survey published in 2013 found that about half of drug courts did not allow methadone or other evidence-based medications used to treat opioid use disorder.

    A more recent study of probation and parole agencies in Illinois reported that about a third had regulations preventing the use of medications for opioid use disorder. Researchers found the most common barrier for those on probation or parole “was lack of experience by medical personnel.”

    Faye Taxman, a criminology professor at George Mason University, said decisions about how to handle a client’s treatment often boil down to the individual officer’s judgment.

    “We have a long way to go,” she said. “Given that these agencies don’t typically have access to medical care for clients, they are often fumbling in terms of trying to think of the best policies and practices.”

    Increasingly, there is a push to make opioid addiction treatment available within prisons and jails. In 2016, the Rhode Island Department of Corrections started allowing all three FDA-approved medications for opioid addiction. That led to a dramatic decrease in fatal opioid overdoses among those who had been recently incarcerated.

    Massachusetts has taken similar steps. Such efforts have only indirectly affected parole and probation.

    “When you are incarcerated in prison or jail, the institution has a constitutional responsibility to provide medical services,” Taxman said. “In community corrections, that same standard does not exist.”

    Taxman said agencies may be reluctant to offer these medications because it’s one more thing to monitor. Those under supervision are often left to figure out on their own what’s allowed.

    “They don’t want to raise too many issues because their freedom and liberties are attached to the response,” she said.

    Richard Hahn, a researcher at New York University’s Marron Institute of Urban Management who consults on crime and drug policy, said some agencies are shifting their approach.

    “There is a lot of pressure on probation and parole agencies not to violate people just on a dirty urine or for an overdose” said Hahn, who is executive director of the institute’s Crime & Justice Program.

    The federal government’s Substance Abuse and Mental Health Services Administration calls medication-assisted treatment the “gold standard” for treating opioid addiction when used alongside “other psychosocial support.”

    Addiction is considered a disability under the Americans with Disabilities Act, said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a nonprofit law firm based in New York City.

    She said disability protections extend to the millions of people on parole or probation. But people under community supervision, Friedman said, often don’t have an attorney who can use this legal argument to advocate for them when they need treatment.

    “Prohibiting people with that disability from taking medication that can keep them alive and well violates the ADA,” she said.

    This story is part of a partnership between NPR and Kaiser Health News.

    View the original article at thefix.com

  • Why Aren't More Doctors Embracing Medication-Assisted Treatment?

    Why Aren't More Doctors Embracing Medication-Assisted Treatment?

    A new op-ed suggests that concerns about “branding” may deter many doctors from offering medication-assisted treatment (MAT) for opioid use disorder.

    A new op-ed on STAT News highlights a troubling concern in regard to medication-assisted treatment (MAT).

    Author David A. Patterson Silver Wolf, PhD, opined that the reason why methadone, buprenorphine and naltrexone aren’t more widely used to treat opioid use disorders (OUDs) may be due to “branding”—specifically, concern on the part of primary care physicians about the stigma associated with OUDs and its effect on their practice.

    But as Silver Wolf noted, the toll taken by the opioid epidemic on individuals and families all but required physicians to undertake the necessary steps to prescribe MAT, despite any qualms they may have.

    In the article, Silver Wolf, an associate professor at Washington University in St. Louis, Missouri and faculty member for training programs funded by the National Institute on Drug Abuse (NIDA), wrote that he came to his opinion after participating in a national panel of addiction experts that produced “Medications for Opioid Use Disorder Save Lives,” a report from the National Academies of Sciences, Engineering and Medicine.

    In the report, he and his fellow experts noted that while the need for medication-assisted treatment is sizable, and drugs like methadone and Suboxone have been approved as safe and effective treatments for OUD by the Food and Drug Administration (FDA), only a small number of physicians have signed up for the necessary training by the Drug Enforcement Administration (DEA) to be able to prescribe it.

    Silver Wolf also cited another STAT opinion piece, which speculated on some of the reasons why more physicians haven’t been lining up to prescribe MAT. One deterrent may be the process for receiving a federal waiver and the specialized training required to administer this treatment.

    But he also suggested that concern over the perception of those with substance use disorders by other patients may also color certain medical professionals’ opinions, who fear that the inclusion of such individuals to a patient base may negatively impact business.

    “Physicians whose practices focus on patients with opioid use disorder don’t have to worry about their ‘brand’ being harmed because it is tied to this treatment and this patient population,” Silver Wolf wrote. “But a typical primary care physician in Manhattan or suburban Atlanta or rural Nevada might worry about the potential trouble that patients with addictions might cause in their waiting rooms.” 

    The answer, according to Silver Wolf, is for more physicians to look past financial concerns and stigma, and take the steps to make medication-assisted treatment a part of their practice—even though, he adds, that many will not.

    But if individuals and families impacted by the addiction crisis—what the National Academies committee has come to view as an “all-hands-on-deck” situation—then Silver Wolf believes that physicians need to do the same.

    View the original article at thefix.com

  • Emergency Rooms Are Failing Overdose Victims, Study Shows

    Emergency Rooms Are Failing Overdose Victims, Study Shows

    Fewer than 10% of people who were treated in West Virginia emergency rooms for non-fatal overdose were connected with medication-assisted treatment.

    When people show up in the emergency room, they expect not only to be treated for the immediate problem, but to be connected with ongoing care. Someone with a broken arm, for example, can expect to have it set and leave with a referral to an orthopedist.

    Yet, this system is failing people with substance use disorder, one of the most deadly medical conditions in the country. 

    According to a new study published in the Journal of General Internal Medicine, fewer than 10% of people who were treated in West Virginia emergency rooms for non-fatal overdose were connected with medication-assisted treatment, and just 15% were connected with counseling. 

    Although the study looked at just one state, the findings are symptomatic of failures in the medical system across the country, Andrew Kolodny, who directs opioid policy research at at Brandeis University’s Heller School for Social Policy and Management, told California Healthline. 

    He said, “There’s a lot of evidence that we’re failing to take advantage of this low-hanging fruit with individuals who have experienced a nonfatal overdose. We should be focusing resources on that population. We should be doing everything we can to get them plugged into treatment.”

    Even the researchers were surprised by the low rates of ongoing treatment for opioid use disorder for patients who were clearly in need of treatment, said lead study author Neel Koyawala, a student at the Johns Hopkins School of Medicine.

    “We expected more… especially given the national news about opioid abuse,” Koyawala said. 

    Dr. Margaret Jarvis, who works as medical director of a residential addiction treatment center, said that despite the prevalence of addiction, emergency room doctors often don’t know how to help people who present with substance use disorder.

    “Our colleagues in emergency rooms are not particularly well-trained to be able to help people in a situation like this,” she said. Marissa Angerer visited the emergency department in Texas many times with substance abuse-related conditions. She was never offered ongoing intervention and was surprised when doctors didn’t understand what she meant when she said she was dopesick. 

    “They were completely unaware of so much, and it completely blew my mind,” she said. 

    When Angerer finally got into recovery, it was because she found a treatment center herself after having fingers and toes amputated because of an opioid-related condition. 

    “There were a lot of times I could have gone down a better path, and I fell through the cracks,” she said.

    View the original article at thefix.com

  • Young People With Opioid Addiction Face Barriers To Treatment

    Young People With Opioid Addiction Face Barriers To Treatment

    Access to medication-assisted treatment is a major issue for young adults with opioid addiction.

    Opioid use among minors has drastically increased since the 1990s—parallel to adult use—yet young people with opioid addiction are largely without access to proper treatment.

    Yale University published a study revealing that nearly 9,000 minors (20 years old and under) in the U.S. died from prescription and illicit opioid poisonings between 1999 and 2016. The related mortality rate increased almost 270% during that same time period, and were mostly unintentional overdoses of kids ages 15 to 19.

    The youth in the study were addicted to and dying from the same opioids as adults, including fentanyl, the deadly drug that is often mixed in with other opioids.

    The National Institute on Drug Abuse writes that research shows that when treating opioid addiction, medication should be the first line of treatment, in tandem with behavioral therapy or counseling. The accepted medications to treat opioid addiction are buprenorphine, naltrexone and methadone.

    Lindsey Vuolo, associate director of health law and policy at the Center on Addiction, assured US News & World Report that these medications work.

    “Overall, approximately 50% of patients who receive medications for opioid addiction are successfully treated, while less than 10% of patients are successfully treated without these medications,” she said. Yet many rehabs do not offer any medication-assisted treatment.

    Adolescents with opioid addiction have an even more difficult road than adults in becoming aware of and accessing medication-assisted treatment.

    Dr. Scott Hadland, a pediatrician, assistant professor at Boston University and researcher at Boston Medical Center’s Grayken Center for Addiction, spoke with US News about the results of his study on opioid treatment and youth.

    Hadland and others looked at close to 5,000 Medicaid-enrolled young people between the ages of 13 and 22 with a diagnosed opioid use disorder in 2014 and 2015. The results were clear: less than a quarter received medication for their treatment within three months of being diagnosed, with most of the youths receiving only behavioral health services. A mere 5% of those under age 18 received timely treatment with medication. 

    Dr. Sharon Levy, director of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and an associate professor of pediatrics at Harvard Medical School, was the lead author of the American Academy of Pediatrics’ 2016 recommendations that called for “increasing resources to improve access to medication-assisted treatment of opioid-addicted adolescents and young adults.”

    The recommendations urged pediatricians to consider offering medication as treatment for young patients with severe opioid use disorders. Levy says that negative perceptions about medicated-assisted recovery (that the person is replacing one addiction with another) are outdated and the benefits of the medications outweigh any associated risks.

    “Policies, attitudes, and messages that serve to prevent patients from accessing a medication that can effectively treat a life-threatening condition may be harmful to adolescent health,” her AAP article states.

    Naltrexone is approved by the Food and Drug Administration for patients age 18 and older, and buprenorphine is approved for patients 16 and older.

    View the original article at thefix.com

  • Are Rehab Centers Equipped With Meds To Treat Opioid Use Disorder?

    Are Rehab Centers Equipped With Meds To Treat Opioid Use Disorder?

    In spite of the availability of opioid addiction medications, many treatment centers have continued to rely only on abstinence programs and talk therapy. 

    A study published in the January issue of Health Affairs found that only 36% of addiction treatment centers in the U.S. carry any of the medications approved for the treatment of opioid addiction. Not only that, but only 6% carry all three: buprenorphine, naltrexone, and methadone.

    As the opioid crisis has exploded in the U.S. and abroad, cities are scrambling to combat spiking overdose deaths and the massive costs associated with the epidemic. In addition to law enforcement and education campaigns, increasing funds have been allocated to the development of medication that can treat opioid addiction.

    For many years, methadone was the only option for those who needed more than abstinence, therapy, and rehabilitation programs to combat their powerful and relentless disease. Buprenorphine and naltrexone arrived on the scene in 1981 and 1984, respectively, and have shown promising results.

    In spite of the availability of these drugs for decades, many addiction treatment centers have continued to rely only on abstinence programs and talk therapy. The study, led by Johns Hopkins School of Public Health Professor Ramin Mojtabai, looked at 10,000 outpatient facilities in the U.S. via surveys collected between 2007 and 2016.

    In 2007, only 20% of the centers offered even one of the medications, so at least some progress is being made in this respect. 

    “Medication treatment (MT) is one of the few evidence-based strategies proposed to combat the current opioid epidemic,” reads the study abstract. “The findings highlight the persistent unmet need for MT nationally and the role of expansion of health insurance in the dissemination of these treatments.”

    Image Source: NIDA

    Lindsey Vuolo, associate director of health law and policy at the Center on Addiction, assured U.S. News & World Report that these medications work.

    “Overall, approximately 50 percent of patients who receive medications for opioid addiction are successfully treated, while less than 10 percent of patients are successfully treated without these medications,” she said. At the same time, only 10 to 20% of people with substance use disorders seek any treatment at all.

    Though Dr. Mojtabai feels that increased attention to the opioid crisis may continue the trend toward more treatment centers offering addiction-combating medications, Vuolo notes that most of the facilities offering these drugs are concentrated in wealthy urban and suburban areas, and is generally more pessimistic.

    “The number of people receiving treatment has not changed significantly, even in light of the unrelenting opioid epidemic,” said Vuolo. “I don’t think research will show significant changes between 2016 and 2019 on a national scale.”

    View the original article at thefix.com

  • Meth Resurgence Highlights The Limits Of Addiction Meds

    Meth Resurgence Highlights The Limits Of Addiction Meds

    As the rates of use for methamphetamine and other street drugs rise, providers are realizing the limitations of medication-assisted treatment. 

    Medication-assisted treatment has been heralded as the most effective way to treat opioid use disorder, and the opioid-overdose reversal drug naloxone has been credited with helping to control the rate of fatal overdoses in the country.

    However, while public health officials praise the importance of the pharmaceutical response to the opioid crisis, they are also calling attention to the lack of medical options for treating other types of addiction. 

    Psychiatrist Margaret Jarvis, a distinguished fellow for the American Society of Addiction Medicine, told ABC News that as the rates of use for methamphetamine and other street drugs rise, providers are realizing the limitations of medication-assisted treatment. 

    “We’re realizing that we don’t have everything we might wish we had to address these different kinds of drugs,” she said.

    Dr. David Persse, who directs emergency medical services in Houston, said that while opioid overdose reversal drugs are an important life-saving tool, actually using them on the scene of an overdose can be complicated, since people often have more than one type of drug in their systems, all of which act differently.

    For example, an opioid overdose is characterized by slowed breathing, whereas during a meth overdose the cardiovascular system speeds up, putting people at risk for heart attack and seizures. 

    Even if there were a similar drug to naloxone that could be used to reverse meth use, emergency medical responders would struggle to know which to use, Persse said. 

    “If we had five or six miracle drugs, it’s still gonna be difficult to know which one that patient needs,” he said. 

    Researchers are working on developing medications to treat the use and abuse of drugs other than opioids.

    Last May, the National Institute on Drug Abuse noted that researchers at the Universities of Kentucky and Arkansas developed a molecule that blocks the effects of meth, in a similar fashion to how medications like Vivitrol block the brain’s opioid receptors. 

    However, without addressing the root causes of addiction, these medications can have unintended consequences. Last year, a recovery counselor in Ohio told NPR that she believes the Vivitrol program in her community was contributing to meth addiction. People who were treated with Vivitrol could no longer get high with opioids, so they turned to other means of self-medication, she said. 

    “The Vivitrol injection does not cover receptors in the brain for methamphetamines, so they can still get high on meth,” she said. “So they are using methamphetamines on top of the Vivitrol injection.”

    View the original article at thefix.com

  • Grant Provides Medication-Assisted Treatment To Inmates Leaving Jail

    Grant Provides Medication-Assisted Treatment To Inmates Leaving Jail

    Inmates in the treatment program also leave jail with counseling appointments in place and other sobriety supports.

    The Wisconsin legislature is giving out $1.3 million in grant money that counties around the state will use to provide medication-assisted treatment for inmates who are leaving jails. 

    The grants, administered through the Wisconsin Department of Health Services, allow people who are ready to be released to receive an injection of Vivitrol, which can block opioid receptors in the brain and make people less likely to abuse opioids. Inmates in the program also leave jail with counseling appointments in place and other sobriety supports, according to Action News. 

    “This is another great opportunity for an individual who wants to make a change to have the resources to be able to do it, and do it at a cost that they can afford,” said Todd Delain, sheriff-elect in Brown County, Wisconsin, which includes Green Bay. “The Vivitrol is one piece of it. The counseling and ongoing monitoring treatment is the other part of it, because if you don’t have both, they’re probably not developing the skills and tools necessary to overcome it long-term.”

    The program aims to help address the vulnerabilities of people who have just been released from a correctional facility, said Paul Krupski, director of opioid initiatives at the Department of Health Services.

    “Specifically to the criminal justice population, they have a very high rate of opioid overdose and opioid overdose deaths upon release in the first 60-90 day period that they are out,” he said.

    Inmates seem eager to take advantage of the program, according to Correct Care Solutions, which provides health care services to jails. 

    Jessica Jones, the company’s regional operations manager, said, “It really needs to be something the patient wants to do. It needs to be a lifestyle change they’re ready to make. The medication is really 50 percent of this. The psych-social component is what they really need to be ready to dedicate themselves to.”

    A pilot program has been taking place at the Brown County Jail, in partnership with Prevea Health. Over the past 18 months, that program has shown success, said Prevea Health President and CEO Dr. Ashok Rai.

    “I remember the first person, when one of our physicians came to me and said, we had our first graduate and that person got a job,” Rai said. “The whole intent here was to try to help people.” 

    Vivitrol, in combination with therapy, can be a powerful tool for people looking to get into recovery, he said. 

    “To get to the heart of addiction is really to get to counseling and what psychological aspect, as part of that disease, led to the addiction,” Rai said. 

    View the original article at thefix.com

  • Promising New Treatments for Opioid-Dependent Babies

    Promising New Treatments for Opioid-Dependent Babies

    Compassionate care for the mothers was crucial to positive outcomes for opioid-dependent babies.

    I gave birth to my daughter in late January of 2014. It was the kind of birth you see in the movies—the contractions started hard and grew closer together within moments. By the time I realized I was in labor, I was already in too much pain to walk. I began needing to push while my husband was on the phone calling for an ambulance. The 911 operator had to walk him through the beginning of my daughter’s delivery. Luckily, paramedics showed up to take over while she was still crowning. The lieutenant who delivered her said it was her first completed childbirth. I will never forget holding my newborn daughter in the elevator while we rode down to the ambulance, or how the entire labor and delivery staff burst into applause when we wheeled into the hospital. But the joy and pride of my wild, badass childbirth was quickly replaced by a deep sense of guilt.

    Within hours, my daughter began showing symptoms of opioid withdrawal—symptoms like rigid limbs, sneezing, and a sharp, screeching cry that burrowed into my belly and filled me with self-loathing. The withdrawal was from methadone, which I was prescribed and taking under a doctor’s supervision. Methadone has been the gold standard of care for pregnant people with opioid dependencies since the 1960s. I did the right thing. Still, watching my newborn daughter go through withdrawal was excruciating. Unfortunately, the treatment she and I received at the hospital—after that initial congratulatory applause—did not make the experience easier.

    My daughter’s level of discomfort was rated using the same system used by the majority of U.S. hospitals. It’s called the Finnegan Neonatal Abstinence Scoring Tool (though its inventor, Dr. Loretta Finnegan, notes with a laugh that her name was tacked onto it later without her knowledge). It consists of a comprehensive list of observable newborn withdrawal symptoms. Hospital staff, usually treating nurses, observe the babies every four hours and tally up the number of listed symptoms they observe. Each symptom is a point, and the overall score for that observation period is used to determine how to move forward with treatment. Usually a score above eight means the infant should begin an opiate wean, or have his dose raised if he has already been started on medication.

    The scoring system is the product of meticulous observations recorded by Finnegan in the early 1970s, when babies were dying from opioid withdrawal simply because nobody knew how to define and treat it. But in 2014, when my daughter was subject to it, and when her scores caused her to be sent to the Neonatal Intensive Care Unit (NICU) to be medicated with titrated doses of morphine for over a month by staff who were less than welcoming to me, I resented the Finnegan Score. Other methadone and buprenorphine-dependent mothers whom I have spoken with have related similar discontent with the system. Usually, the complaints center around variability between the way that different nurses score the babies, or at having their babies sent to the NICU. It turns out, the way some of these hospitals use the scoring system is not in keeping with best practice, according to its creator.

    Loretta Finnegan, who is now the Executive Officer of the College on Problems of Drug Dependence, says that inter-rater reliability is key to correct usage of the tool, and recommends that hospitals which use it conduct re-orientations “a minimum of every six months.” She also doesn’t believe that the modern NICU set-up is appropriate for babies who are experiencing NAS without other complications. In fact, she says that “the NICU is the worst place for these babies,” because of the overstimulation caused by the noise and bright lights. Finnegan puts out a training manual, and gives recommendations for the care of infants include swaddling, non-nutritive sucking, decreased stimulation, and plenty of access to mom. When she was doing her clinical work in Philadelphia, she says they “had [their] moms come in every day,” and that “compassionate care for the mothers” was crucial to positive outcomes for the babies. If I had received treatment more in line with Finnegan’s protocols, I probably would have resented the scoring system—and my daughter’s extended hospital stay—a lot less, and I suspect that other mothers would agree.

    But besides providing better training to staff who are using the current standard NAS protocol, there are a couple of promising new tools for NAS that could help decrease hospital stays for infants, and promote better trust between parents and hospital staff. One of these tools, developed by Matthew Grossman, M.D., an assistant professor of pediatrics at Yale School of Medicine, is called “Eat, Sleep, Console.”

    Renee Rushka gave birth to her daughter in July 2018, while taking methadone prescribed for opioid addiction. Her daughter was treated for NAS at Danbury Hospital in Connecticut. She says that they used the Finnegan NAS Scoring System to assess her baby, but they also performed another form of assessment. Although she says she never heard the term “Eat, Sleep, Console,” and she can’t remember the exact measures, she describes a protocol that sounds very much like the system first developed and researched by Grossman in 2014.

    Grossman’s system essentially measures exactly what the name implies—whether the baby is eating at least one ounce of milk, whether the baby can sleep for an hour straight, and whether she can be consoled within 10 minutes of becoming fussy. The protocol suggests maternal contact and non-pharmacological approaches whenever possible. Pharmacological intervention is indicated based on the infant’s level of functioning and comfort, rather than with the goal of reducing all withdrawal symptoms. According to Grossman’s trial conducted at Yale New Haven Children’s Hospital, only 12% of infants required morphine therapy, as opposed to 61% using the Finnegan system (though the study does not tell us whether they used it the way Finnegan herself recommends), and it significantly reduced the length of stay for many of the babies.

    Rushka reports that her experience with the combined Finnegan and ESC-like approach was extremely positive. She brought her baby home, healthy, after five days, having required zero medication intervention. She also notes that she did not feel judged by the staff, and even recalls receiving compliments and affirmations about her recovery—pointing toward the compassionate, inclusive approach that both Finnegan and Grossman deem crucial to the care of opioid-dependent infants. Finnegan expresses concerns that inter-rater reliability might also be an issue should ESC become more wide-spread, in part because of the design simplicity. But she’s definitely in favor of various treatments being designed for NAS. “In most diseases there are many ways to treat them,” she notes, adding, “I just need to see more proof [that ESC works.]”

    Another promising new tool for treating NAS takes a surprising form. It’s a crib called SNOO, whose designer was not initially thinking about NAS at all—his goal was to reduce Sudden Infant Death Syndrome (SIDS). Pediatrician Harvey Karp says that the crib can not only sense when a baby is in distress, but also what level of distress he’s experiencing—and will rock and emit soothing sounds to help calm the baby, similar to a human caregiver, but all while the real caregiver gets some much-needed rest. Karp says that “NAS babies are more skewed to the irritable side,” then, “the more sciencey way of saying it is that they have poor state control…basically you take a child with terrible state control and give them the rhythmic stimulation they need to get down to a calmer state…it’s so important to our neurology that even adults calm down this way; it’s not an accident we fall asleep in planes, trains, and cars. It’s an echo to this ancient, ancient response to the normal womb sensation.”

    Currently, Mark Waltzman, Chief of Pediatrics at South Shore Hospital in Boston, is conducting a study to test the efficacy of the SNOO in reducing distress in babies with NAS. He’s also using Grossman’s Eat, Sleep, Console tool to assess the babies’ level of discomfort. Waltzman’s study is still enrolling, so there’s no data available yet, but he is hopeful that SNOO will offer a relatively simple, non-pharmacological approach to treating the discomfort associated with NAS.

    It has been almost five years since my elder daughter was treated for NAS. Mothers across the country still report complaints similar to the ones I had then—but there are also moms like Rushka who are finding community and support in the hospitals where their babies are being treated. Regardless of the outcome of Waltzman’s SNOO trial, or further testing for Grossman’s Eat, Sleep, Console tool, the fact that this kind of diverse attention is being paid toward NAS—and alongside it a resurgence of the compassion toward the mothers that Finnegan first championed in the 70s—gives me a sense of much-needed hope. Maybe attitudes about addiction are making a positive shift within the medical community. Maybe, in the future, experiences like mine will be obsolete, and all opioid-dependent mothers and infants will have the compassionate care and affirmative respect enjoyed by Rushka and her daughter.

    View the original article at thefix.com

  • France Approves New Drug To Treat Alcoholism

    France Approves New Drug To Treat Alcoholism

    Some are concerned about the efficacy of the drug as well as its possible side effects.

    French health authorities have approved the use of a muscle relaxant in the treatment of people addicted to alcohol, despite side effects.

    ANSM, the national drug agency, cleared Baclofen for alcoholism treatment after a trial period that began in 2014, reported Medical Xpress. The drug had been used off-label for years before this in several countries.

    Fierce interest in this muscle relaxant as a treatment for alcohol addiction began in 2008 when Olivier Ameisen, a French cardiologist who practiced in the United States, published his book, Le Dernier Verre (the last drink).

    Ameisen outlines cases of his patients with alcohol use disorder who had failed to remain sober through Alcoholics Anonymous or other common treatments. Using a treatment of high doses of Baclofen, Ameisen was able to assist many of his patients in achieving sobriety.

    There are concerns about side effects with this muscle relaxant, and the dosage is limited to 80 milligrams per day, a reduction from the previous from 300 milligrams.

    Other critiques of using Baclofen for alcoholism says that it’s efficacy has not been proven, and others believe that treating addiction to a substance with another substance is a bad idea. The idea that using a substance to assist recovery is harmful has lost traction in America, with many states pushing for wider access to medication-assisted recovery for addiction.

    A French drug oversight agency said last year that Baclofen had shown “clinical benefits in some patients” and despite lack of harder evidence, the country appears more concerned about providing options for those addicted than ensuring solid evidence before opening access for treatment.

    Oftentimes getting through studies and red tape can take years but the frequent use of Baclofen as an off-market treatment for alcoholism may have swayed the government toward acceptance.

    The trial that was done included 132 heavy drinkers. After being treated with Baclofen, 80% either became abstinent or drank moderately. Two other drugs commonly used to treat alcoholics, Naltrexone and Acamprosate, has a success rate of 20 to 25%.

    Medical Press reported that ANSM director Dominique Martin said that the authorization of Baclofen (sold under brand names including Kemstro, Lioresal and Gablofen) was important to meet “a public health need.”

    He went on to say that holding back approval of the drug “did not seem reasonable to us given the needs and the seriousness of alcoholism, and the fact that tens of thousands of people are taking the medicine for this treatment,” he said.

    View the original article at thefix.com

  • Exploring The New Opioids Package: What Does The Legislation Cover?

    Exploring The New Opioids Package: What Does The Legislation Cover?

    The wide-ranging bipartisan legislation addresses overprescribing, overdose prevention, medication-assisted treatment and more.

    New legislation intended to aid in the fight against the opioid epidemic was approved by both the House and Senate in early October, and is currently headed for signature by President Donald Trump.

    The bill, known as the Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (or SUPPORT), is a rare bipartisan effort, authored primarily by Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), and offers $8 billion in wide-ranging programs that intend to boost access to substance treatment, as well as methods of intervention to reduce the influx and availability of opioids.

    Policymakers have expressed their support for the bill, though treatment advocates have voiced reservation about the scope and effectiveness of the legislation. Here’s what is proposed by the SUPPORT Act:

    – Expansion of provisions for Medicaid programs, including expanded access to opioid addiction treatment, including secured flexibility for alternative services not permitted under a state Medicaid plan, improved data sharing between state databases, and increased screening for opioid dependency during doctor’s visits;

    – Increased Medicaid coverage for opioid treatment programs that prescribe medication-assisted treatment (MAT), which is currently not recognized by Medicaid, and an increase in the number of health care specialists that are allowed to prescribe and dispense such treatment;

    – A provision to expand a grant program that allows first responders to administer naloxone for opioid overdoses;

    – Creation of a grant program from the Substance and Mental Health Services Administration to establish comprehensive opioid recovery centers, which will provide dependency and recovery programs for communities;

    – A provision to allow the National Institutes of Health (NIH) to establish “high impact, cutting-edge research” for combating the opioid epidemic and development of non-addictive pain management medication, which will be funded through reauthorization of the Common Fund from the 21st Century Cures Act;

    – Authorization for the Drug Enforcement Agency to reduce manufacturing quotas for controlled substances, including prescription opioids, when the agency suspects diversion; 

    – Authorization for the Department of Health and Human Services to allow doctors to remotely prescribe medication-assistant treatments to assist needy individuals in remote or rural areas;

    – The “STOP Act,” which will assist the U.S. Postal System in preventing the import of fentanyl through international mail by improved digital tracking; 

    – Improved coordination between the Food and Drug Administration and the U.S. Customs and Border Patrol to allow greater means of detecting and halting the import of drugs at borders;

    – Increased penalties for manufacturers and distributors in regard to overprescription of opioid medication.

    Response from health care and dependency officials to the bill was mixed. Some, like Kelly J. Clark, the president of the American Society of Addiction Medicine, called it “an important step in ensuring that individuals with substance use disorder are able to get the help they need.”

    But Keith Humphreys, a drug policy expert at Stanford University who worked with White House staff on the bill, viewed the scope of the bill as limited.

    “This reflects a fundamental disagreement between the parties over whether the government should appropriate the large sums a massive response would require. Lacking that, Congress did the next best thing – which is to find agreement on all the second-tier issues as they could.”

    View the original article at thefix.com