Beacon Health was opened in December 2016 to treat people who have become dependent on opioids, now recognized as a chronic brain disease called opioid use disorder (OUD). At Beacon Health we have a clear understanding of how opioid use disorder causes chaos in a person’s life when they are not committed to evidence-based treatment. The chaos caused by the addictive mode has severe ramifications often leading to emotional disability focusing on compulsive substance use interfering with activities of daily living, many times leading to illegal activity, incarceration with a felony record, overdose and death. Opioid use disorder is a chronic relapsing disease and if untreated has devastating consequences to the afflicted individual, their family, friends and the community at large. This is a very costly disease if left untreated.
We chose the name of Beacon because like a light house guiding a ship at night, we want to be a source of guidance for those lost in the darkness of substance use disorder.
To make the diagnosis of opioid use disorder 11 criteria have been established and are listed below from the DSM-V (https://www.cdc.gov/drugoverdose/)
In order to confirm a diagnosis of OUD, at least two of the following should be observed within a 12-month period:
- Opioids are often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
- A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
- Craving, or a strong desire or urge to use opioids.
- Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or made worse by the effects of opioids.
- Important social, occupational, or recreational activities are given up or reduced because of opioid use.
- Recurrent opioid use in situations in which it is physically hazardous.
- Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or made worse by the substance.
- Exhibits tolerance: Tolerance is defined as either: 1) a need for markedly increased amounts of opioids to achieve intoxication or desired effect, or 2) a markedly diminished effect with continued use of the same amount of an opioid.
- Exhibits withdrawal: Three (or more) of the following, developing within minutes to several days after not using opioids. dysphoric mood; nausea or vomiting; muscle aches; watery eyes, runny nose; pupillary dilation, goose bumps, sweating; diarrhea; yawning; fever; insomnia
Mild disease: 2-3 criteria, Moderate disease: 4-5 criteria, Severe disease: 6 or more criteria
In my practice experience I have evaluated over 2000 clients and greater than 98 percent had moderate to severe disease.
In the past 10 years of treating clients with opioid use disorder not one individual ever told me that their goal in life was to become physically dependent on opioid pain medications or heroin. So then, how did millions of people throughout the world become physically dependent to opioids and developed severe opioid disorder.
My Experience with Opioid Use Disorder
I started my career in addiction medicine in July 2009 when I was asked by the CEO of Dearborn County Hospital to help with their in-patient detox program. At the time I was board certified in family medicine and had no training in addiction medicine, but I wanted to help and agreed to participate. I was the only doctor admitting and managing patients for this detox program. I was doing about 25-30 admissions per month and 99% were for acute opioid withdrawal. The other 1% were for alcohol withdrawal.
I became quite fascinated with this unique patient population. The stories they told me revealed their obsession with opioids obviously hijacking their reward circuitry and I remember thinking these people were no longer in their right mind. I joined the American Society of Addiction Medicine and started going to addiction medicine conferences and studied the neurobiology of the reward circuitry of the brain and gained the knowledge that opioid drug use changes the brain and hijacks the reward circuitry. (https://www.health.harvard.edu/newsletter_article/how-addiction-hijacks-the-brain) Medications like FDA approved buprenorphine or methadone are first line treatments and when used properly reduce mortality rates significantly. Another approved medication, XR-naltrexone (Vivitrol) is also useful for a smaller subset of people with OUD. It is clearly not as lifesaving as the other two medications approved by the FDA for OUD.
By the summer of 2015 I had managed about 1500 detox admissions and had been involved in thousands of encounters with individuals with severe OUD. Most of these encounters included the use of buprenorphine. I also qualified for board certification by the American Board of Addiction Medicine by meeting the board requirements and passing the board exam offered in October 2015. I am now also board certified by the American Board of Preventive Medicine since the American Board of Medical Specialties now recognizes addiction medicine as a subspecialty of preventive medicine as of January 2018.
Access to buprenorphine has been a major problem in our country for many reasons. We need to get over the stigma of treating OUD with buprenorphine.
“Studies show that buprenorphine and methadone, decrease mortality among people with opioid use disorder by half or more. That’s why experts consider the medications the gold standard of care for opioid addiction.. In 1995, France made it so any doctor could prescribe buprenorphine without any special licensing or training. Buprenorphine, a first-line treatment for opioid addiction, is a medication that reduces cravings for opioids without becoming addictive itself. With the change in policy, the majority of buprenorphine prescribers in France became primary-care doctors, rather than addiction specialists or psychiatrists. Suddenly, about 10 times as many addicted patients began receiving medication-assisted treatment, and half the country’s heroin users were being treated. Within four years, overdose deaths had declined by 79 percent.” (France had a big heroin epidemic in the 1980s and ’90s. Here’s how the country fixed it. The US, facing its own opioid crisis, could take similar action. By German Lopez@email@example.com Apr 17, 2018, 11:50am EDT)
The above quote mistakenly states buprenorphine is not addictive, but like all opioids it is addictive.
Buprenorphine is a long acting semi-synthetic opioid first developed in 1970’s by Reckitt & Coleman for pain management and was investigated by researchers at the Addiction Research Center in Lexington, Kentucky and predicted in 1977 that buprenorphine would be very useful for the treatment of opioid use disorder. As an opioid it can be addicting but for individuals with opioid use disorder it helps them to feel normal and avoid euphoria, cravings and withdrawal. The general formula was approved for analgesia in 1989 and was finally approved for OUD in 2002. (J Addict Med, Vol 13, # 2, Mar/Apr 2019)
When I ask my 240 some clients how they feel on buprenorphine the most common response is, “NORMAL.”
“NORMAL” means they no longer are obsessed with thoughts of using or seeking illicit drugs allowing them to participate in the normal activities of daily living.
Buprenorphine is a partial agonist but has a great affinity for the opioid receptors providing a level of blockade from other opioids and has no significant decrease in the respiratory drive making it one of the safest opioids on the market. By itself, overdosing rarely occurs, but is still diverted and used Illicitly mainly to stay out of withdrawal. This drug is life saving for many with OUD.
“In a recent analysis of persons prescribed buprenorphine in France, patients who discontinued treatment were approximately 29 times more likely to die than those who remained on buprenorphine. (Dupouy et al, 2017)”(Buprenorphine Pharmacology Review: Update on Transmucosal and Long-acting Formulations, J Addict Med, Vol 13, #2 Mar/Apr 2019)
This analysis did not mention counseling, NA, rehab, etc. Those add-on treatment modalities to buprenorphine treatment are helpful but by themselves fail to address the chronic changes in the reward circuitry that are leading to overdose deaths. Our first concern should be to save lives with this medication. First line treatment is harm reduction!
According to a 2016 report by the surgeon general, only 10 percent of people in the US with a substance use disorder get specialty treatment — caused by the lack of access to care. And even when treatment is available, other federal data suggests that fewer than half of treatment facilities offer opioid addiction medications.
You do not need to be board certified in addiction medicine to treat this disabling and deadly disease. Learning to prescribe buprenorphine and use basic motivational interviewing techniques can save lives immediately. France proved that lives can be saved by primary care physicians prescribing buprenorphine.
ANYONE CAN DO THIS WITH SOME BASIC TRAINING.
I was working for Dearborn County Hospital from 2009-2016 and had a full family medicine practice and was treating a limited number of patients with buprenorphine as allowed by law (DATA 2000). In the summer of 2016, the law changed and allowed certain providers to increase their limit to 275 and since my contract had ended, I moved to Indianapolis and started a solo practice combining Primary Care and my specialty in Addiction Medicine. We opened on December 29, 2016 and Primary Care was slow to grow, but by April 2018 we were seeing 272 patients with OUD and had to stop accepting new patients with OUD.
The need to expand access to medication to treat OUD is critical to successful reductions in deaths due to the opioid crisis.
We have a 2320 square feet medical office with fully furnished and equipped front administrative office, 3 exam rooms, back consultation room, lab, two bathrooms, comfortable reception area and a break room in a very nice medical office building. We are providing onsite pharmacy and lab services for both point of care testing and GC/MS analysis. The patient’s medication is delivered through our office to the patient at their office visit. The services are provided by Cordant Health Solutions. By January 2021, all controlled substances like buprenorphine/Suboxone will have to be prescribed electronically in the state of Indiana and we have the EHR in place with electronic prescribing and are already doing this. However, the local pharmacies often do not stock enough medication and patients must search several pharmacies to get their script filled. By having onsite pharmacy services, we have eliminated the difficulties of filling prescriptions. Also, the stigma and bias against medication assisted treatment with buprenorphine/Suboxone displayed in many pharmacies is eliminated. Our patients often face the stigma against opioid dependency by pharmacy staff which is very discouraging.
The following blog will explain the many facts about opioids and opioid use disorder. My goal with this blog is to educate the public and health care professionals about the importance of treating this chronic brain disease and saving lives. A full explanation of evidence-based protocols for OUD can be found in TIP 63 supporting the use Buprenorphine by expert panel of addiction specialists.
What are Opioids and how they affect the reward circuitry of the brain?
Opioids refer to the following: The term opioid includes narcotics, Opiates, Semi-Synthetic Opioids and Synthetic Opioids
Opiates are naturally occurring drugs like morphine, codeine and heroin and are extracted from raw opium by heating, adding certain industrial chemicals to separate the morphine and then morphine is heated and treated with more chemicals to produce heroin. There is a drying process between converting morphine to heroin and afterwards. This is done in 55-gallon drums heated over an open fire in rural areas of several third world countries, i.e. Mexico, SE Asia, Afghanistan.
Opiates are naturally occurring drugs that are harvested from the poppy plant named Papaver somniferum and is pictured below in its various stages and produces opium. Thebaine also comes from opium and is used to make prescription pain medications. The effects of opium have been known since the time of the ancient Sumerians about 4-5000 B.C. The poppy plant has many beautiful colored flowers and when the flower falls off the green pod is scored with a razor knife about 2 weeks later. The opium is then scraped off the plant and provides about 80 milligrams per pod totaling 15 to 20 kilograms per acre (33 to 44 pounds). The entire growth cycle lasts about 120 days. The plant grows 2 to 5 feet high when fully matured.
Raw opium you see oozing from the green poppy plant pod is used to make morphine and heroin.
When the opium pod is dried out the commonly used poppy seed can be harvested and is used in the baking industry for poppy seed cake, strudel, rolls etc. If you eat a pastry with poppy seeds you may have a positive urine drug screen for morphine if tested.
The poppy seed is also a substance of abuse and can produce a potent morphine drink also very addictive.
In 1806, the German pharmacist F.W.A. Serturner isolated the principal alkaloid in opium and named it morphium after Morpheus, the Greek god of dreams. Codeine was isolated in 1832 and the invention of the syringe in 1853 by Charles Pravaz and Alexander Wood allowed for the intravenous medical use for severe pain management. Morphine was widely used during the civil war. The use of morphine intravenously resulted in opium addiction which was called “the army disease” or “soldiers disease.”
The abuse and addiction of morphine led to scientific research in the attempt to develop potent non-addictive opium based drugs. The German pharmaceutical company, Bayer, produced a new drug in 1874 converting morphine into Heroin. Initially named Heroisch, meaning strong, or heroic and was thought to be, along with cocaine a safe alternative to morphine. It was widely sold as tinctures (liquid preparations) pills, and throat lozenges. It was not long before it was realized that Heroin was more addictive than morphine.
By the late 19th century there were roughly 300,000 Americans addicted to opiods. “By 1895, morphine and opium powders, like OxyContin and other prescription opioids today, had led to an addiction epidemic that affected roughly 1 in 200 Americans. Before 1900, the typical opiate addict in America was an upper-class or middle-class white woman. Today, doctors are re-learning lessons their predecessors learned more than a lifetime ago.” (David T. Courtwright https://www.smithsonianmag.com/history/inside-story-americas-19th-century-opiate-addiction-180967673/ Mr. Courtwright is the author of “Dark Paradise: A history of Opiate addiction in America.)
For more information about opioids, opiates, heroin and fentanyl, stimulants and other drugs of abuse go to this DEA link: https://www.dea.gov/sites/default/files/sites/getsmartaboutdrugs.com/files/publications/DoA_2017Ed_Updated_6.16.17.pdf#page=40
The other opioids include the semi-synthetic and the synthetic
Semi-synthetic opioids like hydrocodone, oxycodone (Oxycontin, Percocet), hydromorphone (Dilaudid), oxymorphone (Opana), etc. are made by pharmaceutical companies using thebaine, an alkaloid which comes from the raw opium but requires further synthesis in a lab. Using thebaine chemists can make the many pain medications used today for acute and chronic pain management. These compounds have similar affects as morphine and heroin and all attach to the same receptors in the brain and throughout the body.
Synthetic drugs like tramadol, methadone, fentanyl and carfentanil are produced without opium or thebaine from the poppy plant. The synthetic opioids are made from chemical compounds and fentanyl which was first synthesized in 1959 has medicinal purposes for pain management and sedation for surgery and other procedures. According to the DEA it is 50 times stronger than heroin and 100 times more potent than morphine.
Fentanyl is manufactured by reputable pharmaceutical companies in the U.S. for legitimate medical purposes. But because it is so cheap to make it is now being produced in China and is shipped to Mexico and U.S. to increase profits for the cartels. Since it is so potent a small amount goes a long way and is mixed with heroin, methamphetamines, MDMA (ecstasy) and is even pressed into pill form which may look like Xanax and other pain medications. It only takes 2 milligrams to kill someone. This drug is so potent that people who are maxed out on heroin and basically use daily to avoid withdrawal can get high again with fentanyl but they risk overdose death. Hundreds of doses can fit into an envelope and it is easy to hide in other products and cannot be detected by dogs specializing in drug interdiction.
No individual plans on becoming addicted to opioids, so how does this happen?
How does the brain become addicted to opioids?
For some individuals the human brain is very susceptible to the euphoric effects of opiods and other substances and this has been a problem going on for thousands of years. Today there are about 2.5 to 3 million people addicted to opioids. There are 21-23 million Americans addicted to alcohol or other drugs with 14.4 million addicted to alcohol. Alcohol related deaths total about 88,000 per year, making it the third leading preventable cause of death. Tobacco is the leading cause of death and in second place is poor diet and physical inactivity https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics
Hijacking the reward circuitry of the brain
In the Harvard News Letter published July 2011 there is a good explanation of how the reward circuitry and related networks get hijacked by the overwelming addictive characteristics of opioids and other drugs. (https://www.health.harvard.edu/newsletter_article/how-addiction-hijacks-the-brain)
Our brain has kept us alive for hundreds of thousands of years and our survival has a lot to do with our reward circuitry giving us pleasure for the simple acts of drinking water, eating food and having sex. The purpose of pleasure is to reinforce the basic behaviors of survival. When we drink water for thirst or eat when hungry or have sex there is a release of dopamine in the pleasure center (nucleus accumbens) reinforcing these behaviors. Without the experience of pleasure we may have never survived.
Food increases dopamine levels by 50% and sex increases the level by 100% above base line levels as shown in the table.
Drugs of abuse increase levels of dopamine to higher levels and obviously provide greater pleasure than food, water and sex. Nearly 100 % of people I have evaluated for opioid use disorder have told me they have never experienced any better feeling than the euphoric pleasure of their favorite opioid. For those who have pain issues the opioids also decrease their pain. When people have emotional problems such as anxiety, depression, bipolar disorder, ADD, ADHD, loneliness, physical or sexual abuse or have other issues the drugs of abuse make them feel better. The euphoric bliss of opioids helps people to forget problems for a while. It helps with depression and anxiety calming and relaxing one blissfully. The human brain learns this rapidly. Humans love perfect happiness and great joy!
The human brain was never previously exposed to such high bursts of dopamine and intense pleasure on a regular basis for most of our existence on the planet for thousands of years until the modern era. We are now just a phone call away from heroin, methamphetamines and other drugs of abuse. We have gambling, video games and pornography at our finger tips with a couple of taps on our phone or computer. We have alcohol and cigarettes on almost every other corner and tastey fast foods are delivered to our homes. Our reward circuitry has tremnedous opportunities for stimulation. There are many cues and triggers in our environment and the brain is motivated by memories of pleasure whether it is food, drugs, alcohol, nicotine, etc.
The reward circuitry I believe from my evaluation of thousands of patients has a hierarchy placing the highest rewards (behaviors causing the highest dopamine responses) as the most important for survival. In our modern society with such ease of access to drugs of abuse the addicted brain first goes after its favorite dopamine stimulators and worries about water, food and sex later. This is what many of my clients tell me. They would neglect most other things until they got their “fix” and even then would neglect normal responsibilities of daily living. One client told me he was ready to have sex with his girlfriend and then he received a phone call telling him, “I have your Oxycontin.” This client told me he got dressed immediately and left to get the Oxycontin.
Some individuals are prescribed opioids for pain issues and if they have the genetics for addiction can and will become physically dependent if the opioids are taken for several weeks to several months. I have been told many times that prescription opioids used for dental procedures, surgeries, acute pain issues like a fracture and chronic pain make the individuals feel great and continue self medicating after the doctor has stopped prescribing. The feeling of euphoria is very captivating for many people and before they know it they need more and more of the opioid to attempt to get the same feeling. The reward circuitry interacts with other areas of the brain that form memories of the euphoria which in turn stimulates motivation, planning and executing tasks and the brain moves from liking the drug to wanting the drug. There becomes a daily compulsion to plan and obtain the drug.
Over time the reward circuitry becomes less responsive to the same doses of opioids producing less dopamine and tolerance builds to such a degree that there is less pleasure from the drug. This drives the individual to compulsively search for and obtain opioids in larger quantities to try and recreate the same feeling of euphoria. Despite getting less pleasure from the drug the memory of the desired effect and the need to get high persists.
The brain remembers the original feelings of euphoria and the drive to recreate those feelings takes over a person’s life.
The brain also remembers how terrible acute opioid withdrawal is and will seek opioids just to avoid withdrawal.
The initial symptoms of acute opiate withdrawal include muscle aches, runny nose, difficulty sleeping, excessive yawning, anxiety, increased heart rate, sweating, fever, high blood pressure, chills, restless legs and as symptoms worsen a person may develop diarrhea, vomiting, nausea, severe cravings for opiate drugs, stomach pain and depression. Most of my clients have told me they have experienced nothing worse in their life as the symptoms of acute withdrawal. Also, many who make it through acute withdrawal report to me that they have constant cravings and feelings of dysphoria. The symptoms of withdrawal disrupt normal living and most of my clients fear withdrawal more than most other bad experiences or illnesses in their life. I have medically managed over 1500 people in acute opiate withdrawal for inpatient detox and it made me realize how bad this condition can be and transitioning the patient to buprenorphine within 2 to 3 days stops most of the acute symptoms of withdrawal. Many of these clients stated, “thanks for saving my life.”
Because opioid withdrawal is so bad it is a very strong negative reinforcement to keep an individual on opioids. Most of my clients have told me that once their tolerance builds with opioids they often would just medicate to feel normal and to avoid acute opioid withdrawal. To get the euphoric feelings they would have to use large quantities and still never get the original opioid euphoric bliss. One of my current clients told me during one of his office visits that when he had been using 2.5 grams of heroin daily by IV, he claimed he could never get the original high and stated, “That is why they call it chasing the dragon.”
The person with severe opioid use disorder in the modern world probably has permanent changes to the reward circuitry and interrelated networks associated with judgment, motivation, memory, physical activity along with executive function all working together to maintain opioid levels and avoid acute withdrawal symptoms. When a person thinks of withdrawal symptoms or they start the process of withdrawal their memory is ignited on how bad they are going to feel and their judgement advises them it is time to get help from opioids which then motivates the person to start executing a plan to get an opioid asap. Fear is a tremendous motivator to avoid withdrawal.
The genetics for addiction make a big difference
We think genetics plays a major role in addiction and is probably contributory in 40 to 60 % of people who develop a substance use disorder. However, most people who do try illicit drugs do not get addicted. Of the 18 million people prescribed opioids and the 191 million opioid prescriptions available in 2017 there are about 11.5 million people misusing opioids and 2.5-3 million actually got addicted. https://www.drugabuse.gov/related-topics/genetics
In addition to genetics there are other important factors contributing to substance use disorder and include the environment one lives in and a person’s psychological state of mind. This is the biopsychosocial model explaining the many facets of substance use disorders.
People with emotional problems and the genetic predisposition for substance use disorder in our present environment with drugs of abuse readily available for purchase make substance use disorders very likely. Over 90 % of the world’s pain medications (hydrocodone, oxycodone, etc.) are prescribed in the US. There is a continuous flow of heroin, cocaine and fentanyl coming across our boarders daily. Methamphetamine is also manufactured throughout the country in clandestine meth labs and made in Mexico. It is almost impossible to stop the production and flow of drugs.
According to the CDC more than 191 million opioid prescriptions were dispensed to American patients in 2017. This is down from the 255 million prescriptions dispensed in 2012. About 18 million Americans are taking opioid prescriptions to manage their chronic pain. Anyone who takes prescription opioids can become addicted to them. In fact, as many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction. Once addicted, it can be hard to stop.
The Opioid Epidemic
According to the CDC there were 70,237 drug overdose deaths in the U.S. in 2017 and opioids were involved in 47,600. It has become the leading cause of death for people less than 50 years old and the leading cause of accidental death overall. In 2017, the states with the highest rates of death due to drug overdose were West Virginia (57.8 per 100,000), Ohio (46.3 per 100,000), Pennsylvania (44.3 per 100,000), the District of Columbia (44.0 per 100,000), and Kentucky (37.2 per 100,000).
The rate of drug overdose deaths increased significantly in Indiana by 22.5 percent from 2016 (24.0 per 100,000) to 2017 (29.4 per 100,000).May 22, 2019 https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/indiana-opioid-summary
Despite the big decrease in opioid prescriptions going down from 255 million in 2012 to 191 million in 2017 the overdose death rate went from about 22,000 to 47,600. In 2017 there were 17,029 deaths due to overdoses due to prescription opioids and over 30,000 overdose deaths caused by fentanyl and heroin. The decrease in opioid prescriptions has happened at the same time the overdose death rate has increased from heroin and fentanyl. https://www.cdc.gov/drugoverdose/opioids/prescribed.html
Finally, according to the CDC we have seen a decrease in the provisional drug overdose deaths peaking to 72,224 in December of 2017 to 67,165 in June 2019. Somewhere between 180 to 190 people are dying daily from a drug overdose. Deaths due to prescription opiods are decreasing but deaths caused by fentanyl, methamphetamines and coaine are increasing.
Summary of the Morbidity and Mortality Weekly Report Weekly / Vol. 68 / No. 34 August 30, 2019 created by the CDC:
Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine — 25 States, July– December 2017 to January–June 2018 (https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6834a2-H.pdf)
“What is already known about this topic? Provisional opioid-involved overdose deaths suggest slight declines from 2017 to 2018, contrasting with sharp increases during 2014–2017 driven by fentanyl overdose deaths.
What is added by this report? From July–December 2017 to January–June 2018 in 25 states, opioid deaths decreased 5% overall and decreased for prescription opioids and illicit synthetic opioids excluding illicitly manufactured fentanyl (IMF). However, IMF deaths increased 11%. Benzodiazepines, cocaine, or methamphetamine were present in 63% of opioid deaths.
What are the implications for public health practice? Continued increases in IMF deaths highlight the need to broaden outreach to persons at high risk for IMF overdoses and improve linkage to risk-reduction services and evidence-based treatment. Prevention and treatment efforts should attend to broad polysubstance use/misuse.
TREATMENT FOR OPIOID USE DISORDER Please go to https://store.samhsa.gov/system/files/sma18-5063pt3.pdf
Below are the metabolic pathways for opioid metabolism