Pubdate: Sat, 17 May 2014
Source: Cincinnati Enquirer (OH)
Copyright: 2014 The Cincinnati Enquirer
Contact: http://enquirer.com/editor/letters.html
Website: http://enquirer.com/today/
Details: http://www.mapinc.org/media/86
Authors: Carrie Blackmore Smith and Terry DeMio
Bookmark: http://www.mapinc.org/heroin.htm (Heroin)

NO WAY OUT: HEROIN ADDICTS TRAPPED IN DEADLY MAZE

In his California laboratory, Kim Janda is amazed by the amount of 
heroin he can give to rats without killing them.

Janda has created a vaccine that makes rodents immune to huge amounts 
of the drug and reduces the animals' urge to relapse into the dark 
hole of heroin addiction - a place all too familiar to a growing 
number of Americans.

It is a ray of promise in the battle against opiate addiction. Drug 
overdose deaths - fueled primarily by prescription painkillers and 
heroin - have tripled in the United States over the last three 
decades, according to the Centers for Disease Control and Prevention.

The White House and top health agencies now agree: It's an epidemic.

But most treatment options in the United States fail most drug 
addicts, and the barriers to better treatment are substantial and 
slow to change.

Vaccines have potential, many health and addiction experts agree, to 
be cheaper, safer and possibly more effective in preventing relapse 
and death than the medical treatments currently available. But money 
for the development of such vaccines is scarce, said Janda, professor 
of chemistry at the Scripps Research Institute in La Jolla, 
California, who has studied vaccines for drugs of abuse for 25 years.

"Billions of dollars are being spent on all kinds of therapeutics or 
other vaccines, while the cost of drug abuse, as we know, is 
billions," Janda said. "There may be money going toward the 
physicians or facilities (treating addiction), but it's not going to 
researchers, no way ... The last few years are the worst I've ever seen."

Federal spending on drug-addiction research was $320 million in 
fiscal 2013, down 20 percent from the inflation adjusted peak of $402 
million in 2010, an Enquirer analysis of the National Institutes of 
Health budget shows. The 2013 funding level was roughly the same as 
in 2002, adjusted for inflation.

The lack of money isn't the sole reason the treatment system is 
flawed and access for the everyday American is limited.

"This is not the treatment programs' fault," said A. Thomas McLellan, 
a psychologist who has spent his career looking for a better 
treatment model as former deputy director of the White House's Office 
of National Drug Control Policy and adviser to governments and 
nonprofits, including the World Health Organization. "They were set 
up 40 years ago, when we didn't know anything about the chronic 
nature of this disease."

Research by the NAADAC, the Association for Addiction Professionals, 
indicates that only about 10 percent of America's prescription drug 
and heroin addicts have received any sort of treatment, said McLellan.

"Recovery rates are not at all what they ought to be," McLellan said.

Until the public demands a better system, though, no one will invest 
in it, he adds.

An addiction out of control, another life lost

Kenny and Lori Sandlin understand the urgency for access to a better 
treatment model, but it came too late for their daughter.

Desi Sandlin grew up in Florence, about 15 miles south of Cincinnati, 
and became addicted to heroin at 19 after beginning to experiment 
with drugs at 14 and progressing to pain pills. The family spent 
eight years trapped in a maze, trying to find something that would 
get her off drugs.

For every failed attempt at rehab, "that day that you're waiting for 
- - that call - gets closer and closer and closer," Kenny Sandlin said.

"The only way a heroin addict gets off heroin is when they die," he 
told his daughter. His warnings came true last September when Desi 
died of a heroin overdose at just 22.

Desi tried treatment. In fact, she tried seven or eight rehab 
facilities, all court-ordered, her parents said.

Each time she got out, Desi plotted how to get her next fix. After 
every relapse she'd say, " 'Mom, I don't know why I'm doing this. I 
don't want to do this,'" said Lori Sandlin.

"She wanted to get better. That's the saddest thing," her mother 
said. "They don't want to be on it. None of them do."

Scientists now know why some drugs are harder to kick than others - 
and heroin is one of the hardest to shake.

Drugs "work in the brain by tapping into its communication system and 
interfering with the way nerve cells normally send, receive and 
process information," according to the National Institute on Drug 
Abuse, the United States' federally supported research institute.

"The fact is that our brains are wired to make sure we will repeat 
activities, like eating, by associating those activities with 
pleasure or reward," the NIDA literature reads. "Whenever this reward 
circuit is activated, the brain notes that something important is 
happening that needs to be remembered, and teaches us to do it again 
and again, without thinking about it. Because drugs of abuse 
stimulate the same circuit, we learn to abuse drugs in the same way. 
So while the initial decision to take drugs is a choice for some, a 
physical need replaces that choice."

To make matters worse, abuse of heroin, prescription opioids and 
morphine is often followed by wild cravings and agonizing withdrawal 
symptoms, driving many addicts to seek out the drug time and time again.

Stigma: Disease versus moral failing

Addiction has plagued mankind for eternity, and our relationship with 
opium - the source of heroin and prescription opioids like OxyContin 
and Vicodin - dates back to Mesopotamia, 3200 B.C.

Widespread addiction to opium-based drugs has raged off and on 
through the decades, often following war - including the Civil War 
and both World Wars - when soldiers' pain was treated with morphine 
and they became addicted to it.

Still, it wasn't until the 1970s that scientists began to understand 
why the body becomes addicted to drugs. Until then, addiction was 
thought to be nothing more than a moral failing - a belief still held 
by many people.

In the absence of treatments that worked, programs like Alcoholics 
Anonymous and Narcotics Anonymous sprang up, preaching abstinence and 
offering a rigorous yet compassionate network of support for addicts 
and their loved ones.

Today, a growing number of medical professionals and addiction 
scientists is convinced that treating addiction with other medicines 
can give addicts a fighting chance.

In truth, every person is affected by drugs differently, and life 
circumstances - other addictions, depression, homelessness or other 
challenges - must be considered, said Dr. Melinda Campopiano, medical 
officer for the Center for Substance Abuse Treatment at the Substance 
Abuse Mental Health Services Administration, credentialed in 
addiction medicine.

Some people can dabble in drugs and never become dependent. Others 
can quit cold turkey. But too many can't, Campopiano explained.

"I'm sure a certain part of the population doesn't really understand 
the loss of behavioral control that comes with this particular brain 
disease," Campopiano said.

She doesn't knock AA and NA programs; abstinence is the ultimate 
goal, she said. But denying an addict medicine that can help - 
so-called maintenance drugs like methadone, Suboxone and Vivitrol - 
is inhumane, she believes.

"Your No. 1 goal is to keep this person alive. The odds of them dying 
in their uncontrolled addiction is very high," Campopiano said. "No. 
1: Stay alive. No. 2: not to spread blood-borne diseases. No. 3: 
Become as drug-free as possible so you can be a functioning husband, 
wife, parent, brother, sister and employee on this planet."

Given time off drugs - an estimated one to two years - the brain can 
approach normal or near-normal activity, a concept known as 
plasticity, said Dr. Adam Bisaga, a professor of psychiatry at 
Columbia University Medical Center's Department of Psychiatry 
Division on Substance Abuse, who calls abstinence programs for opioid 
and heroin addicts "radical" despite their routine use, even seeming 
preference, in the United States.

"For opioid dependence, this is clearly a substandard approach," 
Bisaga said. "We have effective treatment. We know that."

Yet some people in powerful positions, who hold sway over what sort 
of treatment an addicted criminal receives, continue to reject the 
use of these medicines despite growing evidence that 
medicine-assisted treatment results in better recovery rates for 
opiate addicts.

Kentucky Judge Karen Thomas, who heads the Campbell County Drug 
Court, is one. The state provides money for abstinence-based 
treatment only, and that's fine with her.

"I have real strong feelings about methadone and Suboxone," Thomas 
said. "It's not really a step-down drug. It's another form of addiction."

She also sees the medicines used like any other street drug.

"We have people who sell methadone (on the street) on a regular 
basis," Thomas said. "They're taking it into the jail in their 
rectums. There's something more than a treatment issue going on.

"I really, truly am a believer in an abstinence program."

Medical options for opiate addiction have evolved

Not every drug addiction can be treated with medicine for a variety 
of reasons, but such treatments for heroin and other opiates have 
been around for years.

Methadone, one of the early treatments, was discovered by the Germans 
toward the end of World War II and became used in the United States 
to cure what was then called "opioid abstinence syndrome."

It wasn't until the 1960s that the U.S. Bureau of Narcotics, despite 
strong resistance, accepted it as a drug that could be taken 
routinely to fight addiction.

Many people have kicked heroin because of methadone, but some health 
care leaders are now backing away from prescribing it.

An opioid itself, it replaces heroin, binding to the same receptors 
in the brain that yearn for the drug. Methadone can help addicts 
reclaim "normal" lives - holding down jobs and taking care of their 
families - while warding off the cravings and dope sickness that 
drives so many to relapse.

Also well-documented, however, is methadone's track record of being 
sold illegally, abused and causing or contributing to overdoses.

"Methadone is a loaded gun," said Dr. Mina "Mike" Kalfas, a certified 
addiction specialist from Northern Kentucky, who prefers treating his 
patients with Suboxone or a new drug on the market called Vivitrol.

Suboxone is also a narcotic, but it acts differently in the brain 
than methadone because it includes an opioid antagonist, which blocks 
the ability to get high from other opioids. Some addicts report 
euphoria when taking Suboxone, but it doesn't have the properties of 
methadone that lead to dependence.

Kalfas thinks the best weapon developed yet to combat heroin 
addiction is Vivitrol, which is neither opioid nor narcotic.

Instead of binding to the receptors in the brain, Vivitrol blocks 
them. Even if the patient takes an opiate after Vivitrol, the second 
drug won't take affect.

A vaccine, like the one Janda and other scientists are exploring, 
would disable the chemical properties of opiates before they reach 
the brain, dismantling them in the blood stream.

Vaccines aren't the only scientific developments being studied now. 
Many of the others focus on ways to prevent addiction, said Dr. Nora 
Volkow, director of NIDA, which supplies nearly all of the funding 
for research on substance abuse disorders in the United States.

For one, researchers continue to look at which genes make humans more 
susceptible to addiction; tests are being conducted on an opioid that 
dissolves in the stomach and therefore has no addictive qualities, Volkow said.

"Multiple targets look promising, but we cannot move them (forward) 
because research on medication development is terribly expensive," 
Volkow said. "Overall, the pharmaceutical companies have been 
resistant to get into the space ... There is a sense (drug companies) 
are not going to be able to make much money because drug abusers 
don't have much money."

Compared to our history with opiates, the field of addiction science 
is still young, said Mady Chalk, who began her career working with 
addicted adolescents through a program at Yale University in the 
1970s. Back then, addiction services weren't considered a part of health care.

"Purposefully they made segregated treatment programs. People 
addressed the behaviors they saw, and they addressed the drug use 
with group counseling and therapies, peer pressure and peer-oriented 
counseling," Chalk said.

So few people were "cured" in hospital-based treatments common in the 
1980s and even '90s that insurers stopped paying for treatment, 
further alienating addiction treatment from mainstream health care.

While the majority of today's addiction treatment clinical directors 
- - 57 percent - have a master's degree, just 1 percent have a medical 
degree, and 7 percent have no college degree at all, said Peter 
Luongo, executive director of the Institute for Research, Education 
and Training in Addictions, referring to a workforce survey completed 
in September 2012 for SAMHSA by the Addiction Technology Transfer 
Center Network.

Now that scientists liken addiction to diseases, including diabetes 
and high blood pressure, they also know why earlier treatment 
approaches didn't work: the lack of continued care and monitoring.

"This would be an outrage in any other field of medicine," said 
Bisaga of Columbia University. "It is a tragedy. It's a belief issue. 
It's so difficult for people to believe that addiction should be 
treated with medication."

But Luongo also thinks "we overplayed our hand" in the use of 
medicines and "didn't pay enough attention to the counseling part of 
it," which he argues is just as important.

"Now it's either/or," Luongo said.

He thinks addiction treatment is at a crossroads.

Changes are coming, he said, because the Affordable Care Act now 
covers more preventive and addiction treatments. The White House has 
shifted from fighting the war on drugs with law enforcement and the 
court system.

"If you're going to have a ... health system of primary care that you 
pay for to keep people well, you can't do that if people have 
undiagnosed, untreated substance abuse disorders," Luongo said.

This point reflects still another problem, said McLellan. Right now, 
there is no easy way to find out whether a treatment program has a 
track record for success or is following known best practices.

McLellan and his colleagues have tried to catalog treatment programs 
in the United States, but every provider has declined to share 
information about how they work, he said.

"This idea that you can go in (to treatment) and come out the other 
end like you come out of a washing machine and you're squeaky clean - 
now abstinent for the rest of your life - it doesn't work that way," 
Chalk said.

"Success doesn't happen for a very long time. (You need) five years 
of monitoring and family intervention, then let's talk about what you 
mean by success."

Their organization, the Treatment Research Institute, is now 
connecting with state governments that regulate the programs to 
create the database, which McLellan - whose son died of an overdose 
years ago - hopes to make available someday to the public.

While McLellan and countless others work on improving the system we 
have, Janda continues to toil away in his California laboratory.

After 25 years of building vaccines to various drugs - nicotine, 
cocaine, methamphetamine - he says the heroin one shows the most promise.

It obviously can't reach addicts soon enough, said Janda, adding that 
addicts and their family members contact him constantly to ask about 
participating in clinical trials.

"I just got one," Janda said of an email that popped into his inbox 
during a phone interview. "I get them all the time. I write back and 
say, 'We're trying. Thanks for your interest and sorry for the plight 
of your family.'" ?

Staff photographer Carrie Cochran contributed.

Opioids - such as heroin, morphine and oxycodone - accounted for 
two-thirds of all overdoses in Ohio that year.

Source: Ohio Department of Health

How different drugs work

Drugs are chemicals. They work in the brain by tapping into its 
communication system and interfering with the way nerve cells 
normally send, receive, and process information. Different drugs - 
because of their chemical structures - work differently. In fact, 
some drugs can change the brain in ways that last long after the 
person has stopped taking drugs, maybe even permanently. This is more 
likely when a drug is taken repeatedly.

Some drugs, such as marijuana and heroin, activate neurons because 
their chemical structure mimics that of a natural neurotransmitter. 
In fact, these drugs can "fool" receptors, can lock onto them and can 
activate the nerve cells. The problem is, they don't work the same 
way as a natural neurotransmitter, so the neurons wind up sending 
abnormal messages through the brain.

Other drugs, such as amphetamine, cause nerve cells to release 
excessive amounts of natural neurotransmitters or prevent the normal 
recycling of these brain chemicals (cocaine and amphetamine). This 
leads to an exaggerated message in the brain, ultimately wreaking 
havoc on the communication channels. The difference in effect is like 
the difference between someone whispering in your ear versus someone 
shouting in a microphone.

All drugs of abuse - nicotine, cocaine, marijuana and others - affect 
the brain's "reward" circuit, which is part of the limbic system. 
Normally, the reward circuit responds to pleasurable experiences by 
releasing the neurotransmitter dopamine, which creates feelings of 
pleasure, and tells the brain that this is something important - pay 
attention and remember it. Drugs hijack this system, causing 
unusually large amounts of dopamine to flood the system. Sometimes, 
this lasts for a long time compared to what happens when a natural 
reward stimulates dopamine. This flood of dopamine is what causes the 
"high" or euphoria associated with drug abuse.

Source: National Institute on Drug Abuse,

http://teens.drugabuse.gov/drug-facts/brain-and-addiction

Heroin overdose deaths in Kentucky

Increase from 2011 to 2012

207%

(42 in 2011, 129 in 2012)

NKY heroin-related overdose deaths in 2013

Preliminary count: 79

Kenton Co. 37 | Boone Co. 27 | Campbell Co. 15

General overdoses in 2013

(267 with heroin found in the bloodstream)

Number of people in heroin overdose saved by St. Elizabeth Healthcare 
Emergency Departments in Northern Kentucky

Rise in Ohio overdose deaths in 2012

Hamilton Co.

6.7%

159 deaths

Butler Co.

15%

92 deaths

Clermont Co.

14.3%

56 deaths

Warren Co.

18.5%

32 deaths

$600,000,000,000

Addiction costs in the United States top $600 billion in increased 
health care costs, crime and lost productivity, according to the 
National Institute on Drug Abuse.
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MAP posted-by: Jay Bergstrom