Vol. 139 January 1, 2016 HEROIN: Cape Cod, USA

Hub thumbnail 2015

A HBO documentary shown on December 28, 2015

 As a pediatrician and a parent I found this moving documentary of eight white, middle class heroin addict kids from stable families on Cape Cod to be very disconcerting. It was brutally honest with several scenes of addicts preparing and injecting heroin. The repetitive, “almost-expected”, relapses after detox, and the seemingly casual acceptance of inevitable drug deaths of other addicts set a tone of hopelessness. The onset of addiction in half of these addicts followed standard treatment with opioids for post-accident or post-surgical pain. 30-day detox programs, despite their noble intent, were depicted as mostly fruitless in the long run, like spitting in the ocean. (None of the eight addicts appeared to be enrolled in a heroin-replacement program – Suboxone or methadone) The recognition by the addicts that their craving drove them into behavior they themselves detested confirmed that insight is not enough.

 One addict said that “one dose of heroin was all that was needed to get you addicted”, but NIH statistics suggest that 23% of first heroin users become addicts. Even so, those one-in-four odds are worse than the odds of Russian roulette with a six-shot revolver! One could consider appropriate opioid treatment for post-surgery pain as a “screening test” to find those one-in-four addicts!

For the past decade physicians have been told that the patient should direct pain control. “How bad is your pain on a scale of 1 to 10?” Hospitals and doctors were, and are still, graded on their ability to reduce patient-reported pain quickly. Many of us physicians remember the pain control conferences that basically told us “you are not giving enough”. Perhaps that mind set contributed to the current easy access to opioids.

The Massachusetts Medical Society just promulgated lengthy opioid therapy guidelines consisting of 11 statements for acute care and 16 statements for chronic treatment (over 60 days). The guidelines are sprinkled with words like “function and pain”, “quality of life”, “short-term trial”, “minimum dosage”, “partial-fill prescriptions”, “low-dose sequential prescription”, and “useful consultation with a specialist or a second opinion”. Treatment of cancer. hospice, palliative care, and hospital inpatients is exempt from the guidelines.

The simple patient pain scale of 1 to 10 has been trumped by 11-16 sentences. If you think that is an overstatement then consider these words in the new guidelines,  “The guidelines will provide valuable guidance to physicians [mostly primary care] in their practices and as evidence of best practices and to the Board [of Registration in Medicine] in its responses to patient complaints, accusations of substandard care, or accusation of inappropriate prescribing.” [emphasis added].

The multiple pathways to addiction, its frequent appearance in several members of a family, and on functional MRIs similar active areas of the brain common to all types of addicts suggest a genetic basis of addiction. If that is true, than the cure for heroin addiction in the long run will depend on identification of the responsible genes and the development of drugs that will block or modify those specific genes.

In the short run, maybe we can do more in the U.S. to reduce the harms of addiction; overdose deaths, infectious diseases, and criminal behavior. One mother in the parents’ group eloquently summed up the need to “destigmatize” heroin addiction. ( “No one sent me casseroles when my son died of an overdose.”) To “destigmatize” addiction we will need to “decriminalize” it and treat it as a medical condition. Other countries (Switzerland 1994, Portugal 2000, Vancouver B.C. 2003, Netherlands 2009, Germany 2009, and U.K. 2009) have done that with both “heroin-replacement” and “heroin-assisted” treatment programs. Those programs have resulted in a reduction of overdose deaths and AIDS/Hep C infections WITHOUT increasing drug use.

According to the Boston Globe the “supervised injection site” in Vancouver (called “Insite”) has been shown by 30 peer-reviewed studies to have “saved thousands of lives, saved millions of dollars in both health care and public safety costs, reduced transmission of AIDS and hepatitis C, and promoted entrance into treatment without increasing drug use or drug-related crime”. (1) The Cato Institute studied the results of the successful Portugal program in 2009 and confirmed the same positive results. Critics remarked that such a model would not work in the U.S. because of our size, heterogeneity, and politics.

Isn’t that a shame?

References:
1. Boston Globe, December 27, 2015, K5, “Massachusetts needs safe injection sites”

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