By Laura Perches-Roberts, MD, and Bertram W. Roberts, MD, DrPH, MHA
In America, here are an estimated 18 million alcoholics and five million illicit drug abusers who need treatment, but these numbers seem to be increasing. The total economic burden is $450 billion including incarceration, crime, treatment of the problems and complications.
However, there are only 11,000 providers (counselors, doctors, therapists) to treat 1,000,000 heroin and multidrug users daily. About 1.6 million drug and alcohol users enter programs each year, 83 percent as outpatients in a counseling setting. According to the DEA at a recent USA Opiate Treatment Program meeting in San Antonio, the extent of illicit prescription drug abuse is unknown and there is no plan on how to stop the increase. Hydrocodone ranks in the top 10 causes of ER visits and deaths in the US.
The risk for youth to become drug abusers is high and increases from primary schools (5 percent) to middle school (10 percent) to high schools (20 percent) depending on area and socioeconomic conditions.
In some communities such as San Antonio, many young people start their addiction in their early teen years due to the availability of prescribed addictive drugs in their home taken by their parents. “Pharm parties” introduce them to more drugs and they use uppers, downers and alcohol regularly without their parents’ knowledge or consent. Available on the street and in schools are all the illicit and prescribed agents, so it becomes a matter of acquisition. “Cheese” heroin which is colored and mixed with ephedrine is now popular for distribution in primary schools to get kids started early and fast.
Because HIV and Hepatitis C are complications of IV drug use (and not pills or snorted heroin) teen users think they can handle these drugs and still do sports, schoolwork and be productive — and they often can for a while until they fail, drop out, become pregnant or are arrested. The fact that they are less than 18 years of age complicates their therapy since they cannot be treated in standard substance abuse clinics and must seek other outpatient facilities which limit client number and may be costly.
Just like in adults, the use of methamphetamine, marijuana, cocaine and other designer drugs make management extremely difficult since they are often cheap and available everywhere.
Fortunately, medical treatment for opiate abuse and dependence for those 18 years or over has proven very successful with the recent development of buprenorphine agents (Suboxone), and these drugs have the potential for opening a new era for long-term management by primary care doctors in their offices.
Crime and Drugs
More than four million addicts are in “jurisdiction of the criminal justice system” (under observation by the court) and two million addicts are incarcerated in the US every year! More than one-half of criminal offenses committed in the U.S. are drug related.
Studies find positive urine drug screens in 2/3 (66 percent) of arrestees. If untreated, 9 of 10 (90 percent) return to drugs and crime. Average jail “time” for drugs is 75.6 months, compared to 63 months for violent felonies. A lot of college tuitions could be paid with the costs of incarceration of drug users!
EVALUATION OF PATIENTS FOR SUBSTANCE ABUSE:
A CASE HISTORY (an example of the problem facing the practitioner):
Carole, 42 years of age, a divorced RN with two children, admits to taking 10-15 opiate analgesic tablets (Oxycontin) each week for migraine headaches from GYN and recurring back and pelvic pain she says is due to endometriosis.
As her primary doctor, she is requesting from you a refill since she could not sleep last night and had to take an aprazolam tablet that she had been prescribed several years before. She declines to discuss her current personal relationships because of “legal issues.”
She has a history of drug use since early in high school, but denies ever having shot up heroin in the past. She currently denies using cocaine, amphetamines or crystal meth, but says she has asthma for which she takes over the counter medication and she thinks that this contains “ephedrine.” She denies alcohol use except as a “social drinker.” She is employed as an office manager at a private physician’s office. There is no personal history of HTN.
PE: BP-170/115, P-95 regular, Wt: 120 lbs, Ht: 5’6”, T-98.6, R-24
HEENT- negative except for slightly dilated pupils bilaterally. Thyroid is not enlarged, no jugular venous distention or thyroid enlargement, with clear lungs sounds and RR heart without rubs or gallops. Abdomen is soft and bowel sounds are active. Liver and spleen are not enlarged but pain is present in the Right Lower Quadrant. She has no tract evident on her upper or lower extremities.
Lab including CBC, U/A and Chem 20 are negative except slightly elevated liver enzymes. Pt says she has never used IV drugs, and she says she has been tested recently for Hepatitis A, B, C and HIV about one year ago and these were all negative.
True or False
1. Doing a urine drug screen will not help since she admits to taking an opiate medication.
False: A drug screen will identify recent opiates and can distinguish which type, and most identify methadone which is now also a common street drug. More testing can distinguish ephedrine from amphetamine, check for occult cocaine abuse as well as marijuana and benzodiazepines. If there is question of this being someone else’s urine, then an “observed urine” should be obtained and the urine temperature recorded. If there is a question of validity, it should be repeated randomly with a similar controlled situation. The bottom line is that the urine drug screen should be consistent with the story and details are critical. If equivocal results appear, then further chemical tests can be done, and include other tissues.
2. If the urine drug screen is done and shows amphetamines, benzodiazepines and opiates (no cocaine or marijuana) and she has the medication bottles to prove the sources, the prescription for oxycontin can be written.
False: It would be premature since there should be documentation of the endometriosis by GYN, the details of her opiate pill use by her pharmacy, other MDs, and a review of her licensure status by the Board of Nursing.
In addition, consideration of the underlying causes of her abnormal liver enzymes (gall bladder disease, ethanol, fatty liver, Tylenol toxicity) should be planned and discussed. The fact that she has dilated pupils makes opiate withdrawal a strong consideration. Cocaine and amphetamines are negative on the urine drug screen, so detailed questioning about the withdrawal symptoms from opiates is indicated before a prescription is written. Common ones are “goose flesh”, yawning, diarrhea, irritability, decreased appetite, difficulty sleeping and most often, dilated pupils.
Finally, the fact that this patient will not confide details about “legal” or any historical issues should make the physician very hesitant to comply with any patient’s request for opiates. There is a very low mortality from opiate withdrawal, although patients feel like they will die.
The increasing purity of imported heroin has made it easier to use by non-injection routes such as ‘snorting’
and smoking. Heroin addicts in San Antonio use from $50 to $300 per day (average about $100/day) so that their entire life becomes “looking for the money to support their habit.”
Bexar County has an estimated 10,000 heroin addicts, with only about 2,000 currently receiving methadone, which costs about $10/day and is not supported by the state. Government supported methadone clinics charge only $2.50 per day for an initial period of time but the number admitted to these programs are very limited and depend on funding cycles. The South Texas VA has no methadone program!
There are estimated to be at least 1,000,000 heroin addicts in the U.S., and only 20 percent are, at any one time, under treatment on methadone. In America and in Texas, heroin users are more likely to be educationally disadvantaged, male, Hispanic or Black and young, but the demographics are shifting to more Caucasian, older and female users.
One in four heroin abusers has co-morbid depression, anxiety, PTSD or psychosis. About four years after beginning use, the psychosocial and physical consequences of drug use become manifest. Although the documented major income source for 30 percent of drug users is public assistance, it is seen that many heroin addicts must steal or prostitute to support their habit. Interestingly, about 70 percent of heroin addicts self-refer for methadone or buprenorphine treatment usually because they are exhausted or “sick,” in financial and social ruin, with Hepatitis C, HIV or other associated health problems. They have “lost control of their lives” to the opiates. They said “it is like arm wrestling with King-Kong!”
Presciption Opiate Analgesic Abuse
Abuse of prescription opiates should be suspected when:
a) There is a pattern of early and/or frequent refills opiate containing analgesic medications
b) There are inappropriate therapy or dose escalations of opiate analgesics
c) There are reports of frequent lost, spilled or stolen medications.
d) The patient is taking large amounts of analgesic opiate medications and exhibits behavior which is consistent with abuse or dependence criteria. (See Appendix)
Note: Illicit prescription writing is currently under intense investigation by the DEA, especially the medication filled by offshore internet pharmacies.
When you suspect analgesic opiate abuse
• As part of the history, review all medications given for pain and contact other clinics, pharmacies or physicians as necessary.
• If the patient has hepatitis or HIV, look for needle tracts.
• Use the criteria for Substance Abuse and Dependence (Appendix )
• If your patients are on high doses of opiates and meet the criteria for abuse or dependence, consider referral for drug testing, substance abuse consultation, methadone or buprenorphine/naloxone maintenance
Methadone Maintenance Treatment (MMT)
Methadone maintenance therapy offers major pharmacologic benefits, such as alleviation of physical withdrawal, opioid craving and blockade of the euphoric effects of outside opioids. MMT Programs are all licensed by the state and federal government. Not only is methadone dispensed at the MMT or Opiate Treatment Programs (OTPs), but also provide monthly licensed counseling sessions and regular physician visits.
Psycho-social issues and medical treatment issues also are discussed and referrals to agencies and specialists arranged. Quality evaluations of all MMTs are required by all credentialing agencies such as CARF or JACHO just like hospitals, although they receive no funds from Medicare or Medicaid in Texas.
Research for more than 40 years on methadone use consistently shows improvements in family stability, decreased number of hospital admissions, more regularity of medical and dental care among clients, decreased criminal activity and incarceration; and increased percentage of clients entering vocational rehabilitation.
In methadone clinics, patients come daily for doses averaging about 65 mg per day, but can receive regular take home doses up to one week if they meet certain strict criteria which include regular urine drug testing that is clean of use of other drugs.
Methadone is still the treatment of choice for pregnant opiate dependent patients.
There are more than 90 methadone
clinics in Texas, and five are in San
Antonio. The newest clinic, located
near the South Texas Medical Center at
3780 NW Loop 410, is STOP-SA, LLC.
Office Buprenorphine Treatment Now Available
In 2002, the FDA division called Substance Abuse and Mental Health Service Agency (SAMHSA) approved
2 sublingual formulations of a new Schedule III opiate partial agonist medication Subutex, (buprenorphine) and Suboxone (buprenorphine/naloxone) for office-based use by physicians. The approval of this drug for prescription use was in part due to the alarming increase in opioid analgestic abuse, which has more than doubled in the last 10 years.
Buprenorphine can be used on an outpatient basis by physicians who take a one day course and apply for a special DEA designation on their BNDD number.
Suboxone is a partial agonist at the Ì (pain) receptors. As such, it activates the receptor, but does not produce as great an effect as does a full agonist, like methadone, especially as the dose is increased. Since the therapeutic ceiling can be reached at moderate doses it is much safer, yet very effective. Physicians who use this drug find it the best treatment for all opiate addiction. Unfortunately, it is currently more expensive than methadone for those without health insurance. Most insurances, including Medicaid cover the drug “off-formulary.”
Suboxone is given sublingually, is combined with naloxone, and if diverted, cannot be ground up and injected. Since the naloxone is a full antagonist to opiates, it will cause a violent withdrawal if given IV. Physicians who qualify to prescribe this drug currently are limited to a maximum of 100 patients under treatment at any one time.
Criteria for the Diagnosis of Substance Abuse/Dependence
A. Abusemaladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by (one or more in a 12 month period) of the following:
1) Failure to fulfill a major role at school, work or home
2) Results in physically hazardous situations
3) Results in legal problems
4) Results in recurrent interpersonal, social or legal problems
B. Dependence also is characterized by a maladaptive pattern of substance use leading to clinically significant impairment or distress, but is manifested by (three or more in a 12 month period) of the following:
1) Tolerance – an increasing amount of the substance needed to achieve intoxication or the same effect or the markedly diminished effect with continued use of the same amount.
a) If there are characteristic withdrawal symptoms for that substance or,
b) If the same substance is taken to relieve/avoid the withdrawal symptoms.
3) The substance is taken in larger amounts over a longer period than expected.
4) There are repeated unsuccessful attempts to cut down or quit.
5) There is much time spent on activities necessary to obtain the substance, use the substance or recover from its effects.
6) There are important social, occupational or recreational activities that are given up or reduced because of substance use.
Community Outreach and Preventive Education (COPE)
More than 50 percent of Texas high school students have used one illicit drug, more than 25 percent have used 2-3, and more than 10 percent have used more than four! Experts talk about the need to begin drug prevention education for 8 year olds!
STOP-SA has initiated this non-profit program Community Outreach & Preventive Education (COPE) Project which has as its goals:
• to teach youth and adults about the negative consequences of drug use
• to help those already using drugs get treatment through timely referrals
• to help those on treatment avoid returning to drugs by establishing mentoring relationships
• to build a team of community outreach workers
Laura Perches-Roberts MD, is a boardcertified psychiatrist and the medical director of STOP-SA.
Bertram W. Roberts, MD, DrPH, MHA, is administrator of STOP-SA, LLC, and an associate professor of medicine at UTHSCSA.