HHS Advises Coprescribing Naloxone and Opioids

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“We have begun to see some encouraging signs in our response to the opioid crisis, but we know that more work is required to fully reverse the decades-long epidemic. Co-prescribing naloxone when a patient is considered to be at high risk of an overdose, is an essential element of our national effort to reduce overdose deaths and should be practiced widely,” Giroir said.

The opioid overdose reversal drug naloxone (multiple brands) should be prescribed to all patients at risk for opioid complications, including overdose, according to new guidance released today by the US Department of Health and Human Services (HHS).”Given the scope of the opioid crisis, it’s critically important that healthcare providers and patients discuss the risks of opioids and how naloxone should be used in the event of an overdose,” Adm. Brett P. Giroir, MD, HHS assistant secretary for health and senior advisor for opioid policy, said in a news release.

To reduce the risk for overdose deaths, the new guidance recommends that clinicians “strongly” consider prescribing or coprescribing naloxone to the following individuals:

Patients prescribed opioids who:

  • Are receiving opioids at a dosage of 50 morphine milligram equivalents per day or greater
  • Have respiratory conditions such as chronic obstructive pulmonary disease or obstructive sleep apnea (regardless of opioid dose)
  • Have been prescribed benzodiazepines (regardless of opioid dose); have a nonopioid substance use disorder, report excessive alcohol use, or have a mental health disorder (regardless of opioid dose)

The guidance defines individuals at high risk of experiencing or responding to an opioid overdose as those:

  • Using heroin or illicit synthetic opioids or misusing prescription opioids
  • Using other illicit drugs such as stimulants, including methamphetamineand cocaine, which could potentially be contaminated with illicit synthetic opioids like fentanyl
  • Receiving treatment for opioid use disorder, including medication-assisted treatment with methadonebuprenorphine, or naltrexone
  • With a history of opioid misuse who were recently released from incarceration or other controlled settings where tolerance to opioids has been lost

The guidance also advises clinicians to educate patients and those who are likely to respond to an overdose, including family members and friends, on when and how to use naloxone in its variety of forms.

“Promoting the targeted availability and distribution of overdose-reversing drugs is one of the five pillars of HHS’s comprehensive, science-based strategy for the opioid epidemic,” HHS Secretary Alex Azar said in the release.

“This new guidance reflects our commitment to ensuring those who need overdose-reversing drugs have them and provides practical steps that clinicians, patients, and the public can take to reduce the risk of an overdose,” Azar said.

In April 2017, HHS put forth its 5-Point Strategy to Combat the Opioids Crisis. Those efforts include better addiction prevention, treatment, and recovery services; better data; better pain management; better targeting of overdose reversing drugs; and better research.

In April 2018, US Surgeon General Jerome M. Adams, MD, issued an advisoryencouraging more individuals, including family, friends, and those who are personally at risk for an opioid overdose, to carry naloxone.

No Safe Limit’: Even One Drink a Day Increases Risks

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Alcohol consumption is responsible for 2.8 million deaths per year across the globe, with cancer the leading cause of alcohol-related death among people aged 50 years and older, warn researchers, who also emphasize that there is no safe level of alcohol consumption.

The findings come from the latest version of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), which analyzed data on 28 million people from 195 countries to estimate the prevalence of alcohol consumption, the amounts consumed, and the associated harms.

The report was published online in the Lancet on August 23.

The analysis found that among individuals aged 15 to 49 years, alcohol accounted for around 4% of deaths in women and 12% in men. Tuberculosis and road injuries were the leading causes of death related to alcohol.

For those aged 50 years and older, alcohol was linked to 27% of deaths in women and 19% of deaths in men, with cancer the leading cause of alcohol-related death.

Overall, consuming just one drink a day increased the risk of developing alcohol-related health problems by 0.5% vs abstaining; drinking five drinks a day led to 37% increase in risk.

Lead author Max G. Griswold, MA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, said in a release that although previous studies have suggested that alcohol is protective against some conditions, “we found that the combined health risks associated with alcohol increase with any amount of alcohol.

“In particular, the strong association between alcohol consumption and the risk of cancer, injuries, and infectious diseases offset the protective effects for ischemic heart disease in women in our study,” he said.

“Although the health risks associated with alcohol starts off being small with one drink a day, they then rise rapidly as people drink more,” he added.

The new findings echo those from in the 2014 World Cancer Report, which found a dose/response relationship between alcohol consumption and certain cancers.

Griswold calls for public health policies to focus on “reducing alcohol consumption to the lowest level” and to revise the “widely held view of the benefits of alcohol.”

Coauthor Emmanuela Gakidou, PhD, also from Institute for Health Metrics and Evaluation, went further, declaring: “Alcohol poses dire ramifications for future population health in the absence of policy action today.

“Our results indicate that alcohol use and its harmful effects on health could become a growing challenge as countries become more developed, and enacting or maintaining strong alcohol control policies will be vital,” she said.

She suggested that countries look at measures such as excise taxes and controlling the availability and advertising of alcohol.

“Any of these policy actions would contribute to reductions in population-level consumption, a vital step toward decreasing the health loss associated with alcohol use.”

In an accompanying comment, Robyn Burton, PhD, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, and Nick Sheron, MD, Division of Infection, Inflammation and Immunity, University of Southampton, United Kingdom, say that the results are “clear and unambiguous.”

The Twelve Stages to an Alcoholic Life

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This was submitted to us from a fellow traveler in  recovery. We think it makes some valid points and hereby pass it on.

AA teaches that there are no levels or stages of alcoholism. Alcoholism is alcoholism and drunk is drunk. I don’t agree with that analogy. It is my experience there has been definite advancements within my alcoholics drinking life. This is how I see it:

STAGE ONE – It’s just a few beers and a football game.

You wouldn’t recognize an alcoholic in this stage. One might see a person just having a good time. He is still able to get to work on time, do a good job and meet daily responsibilities. But when the weekend comes, there’s always a reason to drink – SuperBowl, New Year’s Eve, Barbeque, Graduation, Birthday parties… there’s always something going on involving alcohol. It doesn’t appear to be so bad because he’s a family man and he is always there for his wife and kids.

STAGE TWO – It’s five o’clock somewhere.

Drinking has progressed now to happy hours after work. He gets home from work later and may already be drunk by the time he gets home. Drinking will now take him away from home more often than not. He prefers to drink with people who share his drunkenness. He still may find time for the wife and kids, but they are no longer his top priority. He may lie about the amount on his paycheck to hide money outside the regular budget. And the budgeting responsibility falls more on the shoulders of the non-alcoholic.

STAGE THREE – Working gets in the way of my drinking.

By this time, he may have lost a job or two because he has neglected his duties as an employee. Lunch hours will be drinking hours and usually last longer than a normal hour. Leaving work early and not getting home until well into the night is more common. No need to wait for him to join you and the family for dinner, because when he does show up he goes straight to bed to pass out. He will not be able to account for most of his paycheck because he will lose it, give it away or drink it away. His real friends will stop spending time with him because he is not fun anymore. The only friends he has now are the ones he met at the bar last night.

STAGE FOUR – I think I have food poisoning.

Employment is a faint memory. His day starts with a cup of vodka and a coffee chaser. By noon, he must take a nap because if he doesn’t he will fall down and pass out wherever he is at the moment. His eating diminishes and he complains that his stomach is always upset. His skin begins to turn a jaundiced shade of yellow. Nosebleeds are commonplace and he will pick at every sore on his body until they bleed. He no longer contributes to the household responsibilities and the non-alcoholic becomes a single parent. Since he’s incapable of driving to the bars, the few friends he had are now no longer around. He is left with only his family and their constant pleading for him to get help.

STAGE FIVE – I want to see a doctor.

He knows there’s something wrong and thinks maybe a doctor can fix it. But, he doesn’t want to stop drinking so the doctor must be able to work some magic that will allow him to drink and get well at the same time. He still does not understand that the drinking is what is making him ill. He is probably sleeping during the day and awake at night. His memory is all but gone and may confuse people, places and times. He may not know for sure where he is or how he got there. Inappropriate behavior may start occurring, i.e, using crude language around very small children and/or not putting on pants while there are visitors. No one wants to visit. Miraculously family members are tolerant but disgusted by his behavior.

STAGE SIX – Why bother to detox?

The only way to save his life is by detoxification. The liver is no longer functioning at an optimal level and toxins are not being removed from his blood stream. A result is a high level of ammonia accumulating in his frontal lobe of the brain. His kidneys may be shutting down and he may be bleeding internally. His skin and eyes are a sickly yellow and may even become florescent. He is as demanding as a three year old in an ice cream parlor. Irrational reasoning and convoluted thinking become his daily entertainment. At this stage, he is close to death’s door.

STAGE SEVEN – You’re not going to make it.

At this point there are two choices – detox or not to detox. Detoxing has its own risks and doesn’t mean the alcoholic will recover from his self-abuse. Not detoxing is a certain death sentence. Neither choice holds much hope. But, they are the only options on the table.

STAGE EIGHT – In memoriam

The non-alcoholic is now grasping at vague memories of happier times so that she will have something – anything – good to say at his funeral. There are conflicting emotions – if he dies, it will be a relief. It will be over.  If he survives, the entire process could be repeated. Or he could recover, rehab, and stop drinking – become a happy productive member of society.

STAGE NINE – What!! You’re still alive!!

He makes it through. It will still be a long road to recovery, but he will be just fine. He decides to go to rehab because he realizes now that he has been walking down the wrong path. The family is ecstatically happy and they vow to aid in his rehabilitation. They offer to do whatever it takes – to understand everything they didn’t understand before. They want to support in his recovery.

STAGE TEN – I must be selfish because I’m in recovery.

A regiment of 12-step meetings begins and nothing else matters. He’s never available because he must go to a meeting. Tunnel vision develops and 12-step groups become his only focus. He’s just as unavailable as he was during drunkenness. But how can his supporters do anything but support his quest for enlightenment?

STAGE ELEVEN – I’m stronger than alcohol.

And because I’m stronger than alcohol, I can have a beer or a glass of wine with dinner. He believes he is invincible and the drinking starts again. Small doses at first, then he is suddenly back to STAGE FOUR or any of the other following stages. The first time the repeat happens a feeling of disbelief that he could do this again is shocking to the family.

STAGE TWELVE – Haven’t we met before?

The cycle continues from whatever stage he returns to after resumption of drinking. It can resume at any stage. The more times he goes through detox or rehabs the more likely that he will resume to a stage closer to Stage Eight. It’s a never ending circle. The trick for the non-alcoholic is to try not to be in the center of the circle while it’s forming.

Only One in Ten Who need Treatment Get it.

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Some snapshots from the nation’s fight against drug abuse: President Donald Trump at every opportunity calls for the building of the wall, which he says will stop drugs (along with immigrants) from entering the country; he has also endorsed tougher criminal sanctions for traffickers, including the death penalty for major ones. Twenty-four states are suing Purdue Pharma (the maker of OxyContin) and other manufacturers of painkillers for their deceptive marketing practices. Federal prosecutors in Brooklyn are preparing to try Joaquin “El Chapo” Guzman, the Mexican cartel leader, on charges of drug trafficking, money laundering and horrific acts of violence. New York Mayor Bill de Blasio recently announced plans to open four supervised drug-injection sites in the city; San Francisco, Seattle and Philadelphia have similar intentions.

None of this, however, is likely to make much of a dent in an epidemic that last year claimed 72,000 lives due to overdoses, for they fail to address the truly urgent need in the fight against substance abuse: repairing and expanding a treatment network that is severely underfunded, badly splintered and completely overwhelmed. At a time of widespread anguish and hand-wringing about addiction, neither the president, nor Congress, nor governors, nor journalists are paying enough attention to the one thing that could truly make a difference: more and better treatment.

According to a 2016 report by the Surgeon General, only 1 in 10 people who needs drug and alcohol treatment gets it. Of course, not everyone who needs treatment wants it, but enough do to create shockingly long waiting lists across the country. In West Virginia, the state with the highest rate of overdose deaths, there are a mere 171 beds for detox (which weans users off drugs over a period of days) and 151 for longer-term residential treatment, forcing carpool moms and dads to drive up to five hours to find an opening. (The number of beds is expected to more than double thanks to new state and federal funding, but that’s still a fraction of what’s needed.) In New Hampshire, another hard-hit state, waits of four to six weeks are common for a publicly funded residential bed, while in Maine the primary detox facilities are the state’s 15 county jails. The small subset of users who have private insurance can generally gain quick access to facilities that cost up to $10,000 a week and (in the upper tier) feature saunas, yoga, rock climbing and aromatherapy. The vast majority who rely on Medicaid or are uninsured, however, face long waits for admission to facilities that often lack even basic medical, psychiatric and therapeutic services.

For those in the grip of drugs, the openness to treatment is often fleeting, and if a slot is not immediately available, they’re back on the street, snorting, shooting up, overdosing, landing in emergency rooms or worse. In New Hampshire, a heroin user was found dead in his apartment along with a list of rehab facilities on the table next to his bed, which he had called in vain. In Springfield, Massachusetts, beds are in such short supply that those seeking help sometimes have to get arrested so that a judge can mandate them to a facility. In Huntington, West Virginia, the parents of a 21-year-old woman spent 41 days trying to get her into a facility, without success; on the 42nd day, she overdosed and died.

Dr. James Berry, the director of the addictions program at the West Virginia University School of Medicine in Morgantown, says hospital emergency rooms throughout the state “are flooded every day with scores of people who are desperate for treatment.” The courts are similarly overwhelmed. “I get calls from various courts asking for help in getting people into treatment because it’s not available in local communities.” The three hardest words for a user to say are “I need help,” he observes. If they can’t get it when the window is open, the opportunity quickly fades. “Every community should be able to provide immediate access.”

But does treatment work? By now, there is a shelf-full of studies showing that it significantly reduces the harms associated with drug and alcohol abuse. According to the Surgeon General’s report, every dollar spent on treatment saves about $4 in health care costs and $7 in criminal costs. The savings mount when one adds in family anguish, days lost at work, child abuse and neglect, newborns going through withdrawal and homelessness. Needless to say, relapse often occurs; in fact, it is chronic. Yet even if people refrain from using drugs for a limited period, the benefit-to-cost ratio is high. And over time, many do return to a productive life.

In the case of opioids, the treatment options include two medications, methadone and buprenorphine, that both have a well-documented record of helping stabilize users. Yet these treatments remain in pitifully short supply, particularly in rural areas that have been especially hard hit by the epidemic. Since methadone and buprenorphine (marketed under the name Suboxone) are both opioid-based, they are frequently dismissed as just another form of addiction, but this is misguided, for both reduce the craving for drugs and the symptoms of withdrawal and so help the drug-dependent function normally.

That making such treatment more accessible could help stanch the current epidemic is clear from the nation’s experience with an earlier one—the heroin wave of the late 1960s and early 1970s. In 1971, President Richard Nixon, intent on combating the crime associated with drugs—set up a special drug-abuse prevention office in the White House and authorized its director, Dr. Jerome Jaffe, to make methadone (and other forms of treatment) widely available. Clinics were quickly established across the country, and within 18 months almost everyone seeking treatment could find it. Both heroin use and the crime related to it sharply declined.

Unfortunately, during his 1972 reelection campaign, Nixon—wanting to look tough on crime and drugs—began shifting federal attention away from treatment to law enforcement and incarceration. In May 1973, New York adopted the Rockefeller Drug Laws, mandating long prison sentences even for minor offenses. Other states rushed to copy them, and the war on drugs was on. Prisons filled with low-level offenders, many of whom would have been more effectively dealt with through treatment. During the Reagan years, the national treatment network set up under Nixon crumbled. When the crack and cocaine epidemic hit in the mid-to-late 1980s, the treatment centers that remained were completely overwhelmed; waiting lists grew and crime rates and the associated costs soared.

Amid today’s exploding opioid use, we are paying the price for this long neglect of the nation’s treatment infrastructure. The Trump administration in its 2019 budget has proposed an additional $900 million for Health and Human Services to help address the epidemic—a mere droplet of what’s needed. To make treatment available on demand would require spending tens of billions of dollars annually for years to come. That might seem like a lot, but it’s modest compared with the estimated $450 billion that substance abuse costs the nation every year.

Some of the needed sums could be diverted from programs that seek to keep drugs out of the country, for they are generally futile. Despite all the efforts to seal the nation’s borders against drugs, they continue to pour in; heroin and cocaine are easily concealed and transported, and hypertoxic fentanyl can be purchased online with cryptocurrencies. The war on drugs in Mexico, meanwhile, is not only ineffective but counterproductive; the drive to dismantle the Mexican cartels has served mainly to destabilize the market, setting off bloody wars among traffickers, with countless civilian casualties. Our anti-drug efforts should be directed at reducing the demand for drugs rather than cutting off the supply—an approach that is not only more humane but also more cost-effective.

In addressing demand, it’s essential to offer a full array of services. The effectiveness of methadone and buprenorphine can be enhanced when accompanied by counseling. To treat the most serious cases, residential facilities (both long- and short-term) need to be vastly expanded. Supplementary services are needed to help those in recovery find jobs, housing and mental-health support. Outreach workers are needed to locate users and connect them with services. Central intakes need to be established in cities and towns to help connect people with services and track their progress through the system. More doctors and nurses should be trained to diagnose drug disorders and prescribe medications like buprenorphine. Treatment should be made more available in the nation’s prisons and jails, and schools should have counselors trained to watch for adolescents struggling with drugs and alcohol. Needle-exchange programs should be expanded and more closely connected with treatment facilities. And the treatment industry as a whole should be subject to stricter regulation and oversight. (Many centers are unlicensed and amateurishly run.)

All of this would require a vast expansion in staffing. Establishing treatment on demand could thus become a substantial provider of jobs, especially in regions where factories have shut down. Rehab centers could even be opened in shuttered industrial facilities.

Finally, news organizations need to rethink their approach to the drug issue. They too often focus on sideshows—the drug war in Mexico, police raids in big cities, the culpability of Big Pharma. (The number of opioid prescriptions nationwide actually peaked in 2012, and in 2016 they reached their lowest level in a decade, yet the epidemic continues.) Journalists should instead seek to expose the glaring gaps in the nation’s treatment system and dramatize the plight of those who want help but can’t get it—the real scandal in the fight against drugs.

Drug Overdoses Killed 72,000 Americans Last Year: CDC Reports

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Drug overdoses rose 10 percent last year, killing an estimated 72,000 Americans, according to a new report by the Centers for Disease Control and Prevention (CDC).

More Americans are using opioids, and the drugs are becoming more deadly as fentanyl is increasingly mixed into heroin, cocaine and methamphetamine, The New York Times reports.

The CDC reported that overdose deaths involving synthetic opioids such as fentanyl increased sharply, while deaths from heroin, prescription opioid painkillers and methadone decreased.

Overdose deaths increased by more than 17 percent in Ohio, Indiana and West Virginia, while New Jersey saw an increase of 27 percent.

Meth Use is Rising Among People Who Use Opioids

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Over one-third of people using opioids in 2017 reported also using methamphetamine – more than double the rate in 2011, according to a new study.

The study included 13,251 participants in 47 states who entered a substance abuse treatment program for opioid use disorder. The researchers found past month concurrent opioid and methamphetamine use doubled from 16.7 percent in 2011 to 34.2 percent in 2017.

Concurrent meth and opioid use increased among both men and women, among whites and in those under age 45, the researchers found. Past-month meth use significantly increased among those using prescription opioids alone, heroin alone and both prescription opioids and heroin.

“We were surprised to see such an increase in meth use among people using opioids,” said lead researcher Theodore Cicero, Ph.D, John P. Feighner Professor of Psychiatry at Washington University in St. Louis, who described the findings at the recent annual meeting of the College on Problems of Drug Dependence. “We knew that since there was a clamp-down on opioid abuse, people were switching to other drugs, but our main concern was heroin. We were surprised to not only see a rise in heroin use, but a sharp increase in the use of methamphetamine.”

Specifically, Dr. Cicero said, amphetamines, such as meth, produce the opposite effect of opioids. “They wake you up, while opioids are downers,” he said. “Apparently, more people use both drugs so one counteracts the effect of the other – they can balance each other out.” He emphasized that each drug alone carries dangers, and mixing them is especially hazardous.

When meth use was at its peak, Congress passed the Combat Methamphetamine Act in 2005, which required stores to put the cold medicine pseudoephedrine – a key meth ingredient – behind the counter, and limited sales. Meth sales plunged as a result. Then Mexican drug cartels started bringing meth into the country, according to the Drug Enforcement Administration. In the past five years, the amount of meth seized has tripled, U.S. Customs and Border Protection reports.

The new study illustrates that public health policies can have unintended effects, Dr. Cicero says. “As we address the opioid epidemic, we’re creating a different problem,” he said. “We have to realize that people often take drugs trying to escape from depression, anxiety and the circumstances of their lives. We have to address the demand side of the equation – why do people need to escape from life, not just try to limit the supply.”