Managing Opioids in Poly-Substance Abuse -Icro Maremanni -ISAM 2013, Kuala Lumpur

Dr. Maremanni presented a truly impressive plenary session showing the co currency of opioid addictions with bipolar disorders and cocaine addiction and alcoholism.  He and his team in Italy did a variety of research projects addressing acute clinical concerns.
They found that they could reduce and stop cocaine use in their opiate dependent patients by increasing the methadone. In one study he showed that those who had abused heroin in their youth in later life developed alcoholism. His research was that those who later developed problems often had only been treated with Methadone Maintenance under 60 mg,  He saw the opiate addiction as more successfully treatable than alcohol, because alcohol is so available in Italy and not so easily treated.
There is a cross tolerance with alcohol and benzodiazepine.  He described treatment of the difficult cases involved in  the use of opiate agonist treatment, He uses 2 mg clonazepam twice a day to get patients off alcohol while continuing with opiates.

Methadone Maintenance Therapy and Benzodiazepines

Methadone Maintenance Therapy is the the harm reduction treatment for opiate dependence. It can be used for IV Heroin users or opiate pill takers or those who smoke opiates.  These are commonly purchased on the street.  Oxycontin, so called hillbilly heroin, was a commonly diverted opioid prescription that was withdrawn and replaced by oxy-neo, a form of the the same medication which comes in a delivery system which resists crushing for illegal injection.
Benzodiazepines are a large class of pharmaceutical preparations with many benefits and even life saving potentials.  They are used for the treatment of seizures, sedation, panic attacks and insomnia, just to name a few of their more common uses.  The most known of these is Diazepam, known by it's most common trade name, Valium.  Other common benzodiazepines go by the following names, ativan, lorazepam, clonazepam, rivotril, temazepam, etc.  These were all meant for short term usage, in the range of weeks to at most a few months.  Because of their high effectiveness and benefits they tend to be continued increasingly for psychological rather than the physiological benefits.  They have abuse potential and its common over months to a year of use for people to become dependent on them and chemical dependence can lead to addiction.
Further, it's been recently found that benzodiazepines interfere in the healing of the brain from acute trauma.  They are used most carefully in patients with head injuries and studies suggest that those who had strokes who were on benzodiazepines of any kind were least likely to recover completely from strokes. So here is a potential scenario where a person has a cerebral vascular accident loses the capacity to talk and walk, only to completely heal so that a year later they are back to normal. In contrast a person using benzodiazepines might experience the same brain condition only never get out of bed again, needing life long nursing care, bedridden for life.
The College of Physicians and Surgeons of BC has been carefully following the research on benzodiazepines and noted that those who died on methadone maintenance therapy were commonly taking benzodiazepines. One of the most significantly negative side effects of benzodiazepines, like valium, lorazepam and rivotril is that they depress the respiratory rate, making breathing shallower and slower.  When patients take Methadone they can also lose their alertness if the dosage is not yet correctly established.  Combined a person stops breathing and doesn't know it and doesn't wake up.
The College has been warning about the dangerous combination of Methadone Maintenance Therapy with the use of Benzodiazepines but this last week issued a position paper suggesting they were indeed contraindicated.
This is extremely helpful for clinicians in the front lines and shows that those at the College of Physicians and Surgeons are understanding of the basic plight of the practitioner.  I've had my life threatened many times for refusing benzodiazepines.  mOne of my patients who was on a benzodiazepine 'taper', slowly coming off an extremely high dose of benzos told dozens of people he was going to 'shoot Dr. Hay'.  He occasionally brought a gun to the office and showed me what I was facing.  He was actually a fine fellow just having a little difficulty coming off benzos.  More commonly a woman would threaten the doctor with sexual harassment as is common in our community where people marginalized almost dehumanized  will use whatever tools or weapons they have to get what they deem they need to reduce their obvious suffering.  This is unfortunate because these poor souls then get utilized by the downright evil machinations of others who will seek to profit from championing any cause.
So it's really appreciated when the College of Physicians and Surgeons of BC is indeed proactive rather than a 'monday morning quarterback', as commonly seen in beaurocracies which so easily move towards Mandarism unless checked early.
I have patients who are on 6 mg of clonazepam, the normal dose being only 2 mg a day and 4 mg being excessive. They argue threaten, throw tantrums, shout, scream, disrupt the clinic when I reduce them by .125.  It's like asking an alcoholic drinking 60 beer a day to go down to 59 or asking a 4 pack a day smoker to forego 3 cigarettes.  These people are already struggling with addiction, including, heroin, crack, nicotine or cigarettes, alcohol and we in the methadone maintenance services are not the ones who have made a fortune off the patients selling them all this stuff and being the 'good bartender', 'good drug pusher' or  'good doctor' who gives them candy.  Addiction Medicine doctors are the most maligned doctors on 'rate your doctor' services the world over.
So thankfully this week I can now point to a piece of paper and say 'this is the law', see, 'don't kill the messenger', we have to get you off this stuff slowly or I'll have to not prescribe it for you at all.  I've had a dozen complaints to the college directly and indirectly by patients who I've refused.  Thankfully the College has people who have worked in the front lines and know beyond a certainty that there is no 'nice' way to say 'no' because 'no' is 'no' and to severely disturbed addicted psychotic patients 'no' means 'yes'.
What they do understand is, "I will lose my job if I prescribe you more ativan" or "It's against the law for me to prescribe you rivotril".  "You told me you can buy a 10 mg valium on the street for $10, well if you want me to supply you valium at that rate, I can't. Somebody is doing bulk and I'd have to charge you $100 or $1000 a pill to justify the personal risk I'd be taking and I don't think you can afford that.  I think what you want is a dirty pharmacist or a doctor who has already lost his license. "  We can have reasonable discussions like that but saying that 'benzodiazepines are unhealthy' to a person who is walking dead already, having overdosed many times on drugs and willing to do anything to stop the pain, simply doesn't 'cut it'.  Frankly there are  too many 'silly' people out there who don't know anything about addiction or addicts or the real world outside their ivory towers and well protected neighbourhoods.  Their smug judgementalness is only comparable in stupidity to their indifference to the human condition.  We're all in this together.  It's time we really did make a difference rather than just spouting platitudes and pointing fingers.
Several of us addiction medicine doctors got the College report and almost danced together.  Only last week we'd weaned a methadone patient off clonazepam and they'd gone to a leading local psychiatrist who'd given them 6 mg clonazepam on the first visit.  Thanks to the College our colleagues who avoid working with addiction , and certainly don't have methadone patients, will be aware of the potential life threatening combination and think twice before cavalierly prescribing addictive and dangerous medications to patients with alcoholism and addiction. Hopefully too people will do more thorough histories. In BC there's the pharmanet too which allows doctors to learn what patients are on, because in fairness to doctors, psychiatrists especially,  addicts and alcoholics are 'cunning, baffling and powerful'. When they want drugs from a doctor they're not likely to be upfront with him about their history of abuse and addiction.
I don't want patients to die on my watch. I work with methadone patients because it's an area of greatest need  Addicts are society's 'bitch', to coin a jail term. I like to see patients crawl back from the grave and walk into the light. It's an exhilarating area of work.  I talked to an oncologist and we shared our joy in the thrill of winning against all odds and curing the incurable.  It's a whole lot more fulfilling than treating the common cold or saying 'there, there' to a person having exam anxiety.  All of this is important and in my earlier years I did all of that but today my greatest joy is seeing patients get on in recovery.  I've seen patients get on methadone and eventually have carries, so they can be trusted with their methadone like any patient with a chronic illness.  Some stay on methadone but get their lives back, go to recovery meetings, attend doctors appointment, take care of their health, return to work, and reestablish relationships with their families.  Some get stable on methadone and after a year or so taper off and go on to be wholly abstinent from mood altering drugs in NA and AA 12 step programs, some joining churches or temples or synagoges, and reconnecting with community.  Many do volunteer work.

It's really rewarding too to know that the Minister of Health and the College of Physicians and Surgeons of BC are there understanding and helping front line clinicians do their job.

Joan Bakewell, BBC correspondent, writes on older drinking

Joan Bakewell has written a remarkable column in today's BBC on line. I love reading her. A writer in her 80's she's a breath of air from what some might call a more civilized and refined era. She describes daily drinking with sophistication and yet concern. With all the stress of aging, health concerns, loneliness and 'redundancy' she sees that many of those she knows have 'taken to the drink'. In England there are wards for the compassionate care of elders whose late life alcoholism has become health threatening. She describes doctors and programs that have brought many back from the 'brink'. She says in closing she'll keep the phone numbers handy herself as one never knows 'what age can bring'.
I loved reading Joan Bakewell because there's so much charm and community in the world of 'social drinking' she describes having enjoyed so much with friends. Three units being the maximum for women according to the authorities though she says some times when she is offered a 'topper up' she wonders who are these authorities that are setting limits for the elderly. Perhaps I liked her best because she referred to the young as the 'under 60' group.
Well, in my 60 and under group the concern will be about alcohol and more so, because frankly 'binge drinking' and 'wild behaviour' without the occasion of World Wars, Nazi Death camps or stock market crashes or even the mixed blessing of being Fitzgerald and Hemingway in a "Moveable Feast", our 'culture of narcissism" has been blatantly errant in regards to the 'authorities' and our drinking and marijuana smoking populations are more grim, angry, and entitled. Besides our problems won't just be alcohol but marijuana, crack cocaine, crystal methamphetamine, ecstacy, LSD, mushrooms and heroin. As my group has aged we have moved from wine to wine and reefer and beyond.
This last month the city of LA closed its 'medical marijuana' dispensaries because of the perceived harm this had had on the community as a whole with increased mental illness, unemployment, crime and violence. Marijuania thought to be a 'peace' drug with the white jazz musician set has long been the drug of violence of Africa and Asia. So often a drug is associated with it's context that we forget that Robert Graves long ago wrote of the "mushroom cults' of the medieval era, the main stay drug of the 'berzerks'. Looking at the west coast hippies lying face down in cow shit and mushrooms makes it hard to imagine crazed thousands of medieval warriors hacking at each other hallucinating on mushrooms. Yet that's the truth of history.
Now looking to the future we must ask ourselves how will we individually and as a society deal with an aging population with increasing loneliness and time on their hands, initially disposable income and a veritable potpourri of addictive substances and the maddeningly throngs of drug pushers that go on to be white washed Wall Street entrepreneurs almost daily. I will forever love Steppenwolf's "Goddam the Pusherman" song. When I see the homeless of the downtown Eastside Vancouver it's almost guaranteed that a rich drug dealer's own fine West Vancouver house has been paid for by the impoverishing of these parasites 'victims'. I've already seen my first of aged homeless their 'pensions' gone to the Drug Pusher so I'm perhaps a bit raw about the protection our society gives these 'clever businessmen'.
In my work at a methadone clinic, teen agers come in hooked on heroin prostituting themselves for more but so do the 50 and 60 year olds. It may have made pleasing film footage to see the youth dancing naked at Woodstock but I'm not looking forward to a second coming of this behaviour at the RV park since I'm of an age myself when I'm only the life of the party if the party ends before 10 pm. I don't want my sleep disturbed by a geriatric crack addict with a new drum set and a bottle of viagra to boot.
I liked therefore that Joan Blakewell spoke highly of the British program and medical community that had programs and hospital beds specifically set up for the elderly with addiction. Here we are still struggling to get any resources for the addicts except 'medical marijuana' and I fear that short sighted politicians in Canada will next be offering us "medical crack" as their great 'solution' to what is such a devastation for individual and community life.


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