Opiates

New powerful painkiller has abuse experts worried

Far be it from me to comment in public about the ethics and morals of people I haven't even met, so the less said the better.

justice.gov

NEW YORK (AP) — Drug companies are working to develop a pure, more powerful version of the nation's second most-abused medicine, which has addiction experts worried that it could spur a new wave of abuse.

The new pills contain the highly addictive painkiller hydrocodone, packing up to 10 times the amount of the drug as existing medications such as Vicodin. Four companies have begun patient testing, and one of them — Zogenix of San Diego — plans to apply early next year to begin marketing its product, Zohydro.

If approved, it would mark the first time patients could legally buy pure hydrocodone.

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When You Relapse, Do You Lose All Your Sobriety?

I get letters in another venue from people in early recovery, asking for information about the variety of symptoms and problems common to all of us when we were newcomers.  I was quite taken with the following letter, because it illustrates an extremely common issue — family members who don't understand what we need, or who passively try to sabotage our recovery.  I thought I'd share the letter and my response with you here.  It has been redacted to remove some unrelated information, and to protect the identity of the writer.

I have abused opiates on and off for four years. Went through detox two times when I had insurance, just from being so afraid of withdrawal. Went to counceling once. Of course my abuse continued to grow. I got to the point of being just sick of it. I quit and used a recipe I found online using vitamins an amino acids. I went to get change from my husbands “spare change cup” and found eight pills there (he takes them because he needs hip replacement). By the end of the night I had taken eight to ten pills out and took the pills over the next 24 hour period. This was on the 101st day of being clean. I am so disappointed in myself and feel miserable, but I am determined to pick up the pieces and move on. …[Your] article was very helpful to me. I realize I need to be in a program and will look in to it. I guess my question is, Have I lost the time of 100 days I put into sobriety, after a one day binge? Have I lost all recovery ? I so want to be rid of this deamon and your article has helped.

Thanks,

“Jenny”

Dear Jen,

Quite the contrary: that 100 day investment may turn out to have been one of the most valuable experiences in your quest for sobriety. You now know that you cannot trust your disease. It is going to be with you — in spirit, as it were — for a long time. Recovery is about learning that, and learning to live without drugs.  Addiction is a disease of relapse.  Those who have done so one or more times are far more common than those lucky ones who made it on the first try.

Your picking up should have taught you three things:

  • You must speak with your husband about keeping strict control of his medication so that you will not be tempted “accidentally” again;
  • You need a support group that you trust enough to call and talk through urges to use, and that will help you learn to cope with life — comfortably — without using;
  • Life goes on. Beating ourselves to death for being human and giving in to temptation is not productive. Learning from our mistakes is, however, imperative.

Relapse occurs long before we pick up; using simply makes it official. If we keep ourselves in a healthy state of mind and body, follow suggestions and generally live our lives as someone who is IN recovery, as opposed to someone who is thinking about being in recovery, we do not reach the state of mind that will make it easy for us to pick up the random pill laying around the house.

As the song would have it, “Pick yourself up, dust yourself off, start all over again,” using the very important lessons you've learned to help avoid further slips.  Addicts have to be extremely careful about falling down to begin with, because sometimes we find ourselves unable to get up. The good news is, as long as we learn not to make the same mistake again (and, hopefully, none similar as well) we can profit from them.

I’m seeing some wishy-washy thinking here: “I realize I need to be in a program and will look in to it” needs to be “I will call and find the location of a meeting immediately and get to it as soon as possible.” Please get to some meetings! You cannot do it alone. Your best thinking got you where you are, and you need some fresh input. The lifelong friends you will make in the process are a bonus.

Remember one other truism: Anything that you place ahead of your recovery, you will eventually lose.

Keep on keepin’ on,

Bill

I’ve heard that opiate overdoses often occur when users relapse. Is this true? What’s the deal?

It is true, but in order to give you a good overview, let's talk about overdoses (ODs) in general.

Most overdoses are caused by people mixing drugs such as heroin, alcohol, methadone and benzodiazepines (Valium, Xanax, Ativan and similar “tranquilizers”). These drugs are all central nervous system (CNS) depressants. When used together, there can be a synergistic effect, where the presence of both drugs creates more CNS depression than either could alone — sort of a 1+1=3 effect.

In an OD, they cause unconsciousness, slow the heartbeat and depress breathing. In lethal doses (LD), the user dies from suffocation when breathing ceases entirely. However, a lethal dose of a drug or drugs is not necessary in order for you to die. If you are lying on your back and unable to swallow because of CNS depression, a small quantity of liquid, such as vomit, can cause suffocation. This has killed many people who would probably have survived the OD otherwise.

There is also the matter of misjudging the amount of drugs in your system. Most drugs taken by mouth reach their highest levels in the body quite some time after they begin to have a noticeable effect — as long as 30 minutes to as much as 4 hours. You can easily become dissatisfied with the effects and continue to swallow more, then down the line the blood levels continue to rise and give you more than you bargained for. It is not uncommon for this to happen when mixing oral and injected drugs. The pills aren't getting the job done, so you crush and inject and — whammo!

Finally, we get to the issue you asked about. Opiate tolerance drops rapidly when you're not using. People who have abstained from drugs during detox and treatment, or while in jail or prison, end up with a very low tolerance in comparison to what they had when they stopped using.

If a person who has been abstinent for several weeks relapses, they will require much smaller doses in order to get high. This kills thousands of addicts every year, because the lethal dose (LD) drops as well. If they go back to using anything close to what they used previously, an OD is not only possible, but likely. People most at risk are those getting out of detox and treatment, or out of prison.

The best defense, of course, is to hit meetings, use your supports and stay clean. But if you think you need another run, be really careful or it may be your last.

Is Medical Detox Really Necessary?

I received an email from a hard-nosed recovering addict/alcoholic who stated, in essence, that inpatient detox isn’t necessary, that he did it on his own, and that all anyone needs is a (little of this, little of that) to get through it just fine, and he knows a bunch of folks who did it that way, and…blah, blah, blah.

I replied, politely, that everyone is different, and that just because it worked for some does not mean that it will work for everyone, and that detox is too important to take a chance on getting it wrong (or killing someone).  I refrained from asking how many of his acquaintances had a successful detox, culminating in long-term happy sobriety with no relapse.

In my years around the 12-step rooms I’ve heard similar comments every now and then.  Some guy (it’s nearly always a guy) makes some remark to the effect that if it was good enough for him and Christopher Columbus, it ought to be good enough for all these young whippersnappers.  Somehow I don’t see how surviving the threat of seizures, heart attack, stroke, DTs, profound depression and a variety of other jackpots (depending on the drug or mixture of drugs) proves anything, except that you were one of the lucky ones, but maybe that’s just me.

Just about any drug that will alter your mood noticeably can be addictive, including weed.  Getting off any of them can create enough withdrawal symptoms that it can be really difficult to make it through a self-detox, although not all are physically dangerous.  (Of course you could argue that things like possible psychotic episodes and profound depression are physically dangerous, but we'll let that go for another time.)

The bottom line, though, is this: Under the supervision of medical personnel who are trained to administer the proper medication and equipped to handle any problems, detox can be surprisingly comfortable.  Lacking that, there can be some nasty surprises.  Not everyone has complications, which explains the position of the scoffers, but enough folks do that it’s not worth taking a chance if you don't have to.

Why Do Addicts Keep Using Despite The Consequences? — Part 2

Previously we mentioned that the pleasure center is a portion of the brain over which we have no conscious control, and that it can be stimulated by a variety of chemicals — some of them produced inside our bodies and some that we introduce from outside.  We said that the pleasure center rewards us for activities that it interprets as contributing in some way to our survival, whether they be social interactions, exercising, or more prosaic things such as eating.  We also stated that these pleasurable feelings, when pursued too far or for too long can create problems.  Now we need to examine how that happens.

While the actual mechanism of addiction is terrifically complicated, the underlying principles are reasonably simple.

  1. When we use drugs or are involved in pleasurable activities, they stimulate (or cause the stimulation of) receptor sites in the pleasure center and other areas of the brain. This causes us to feel good.
  2. With constant stimulation, the brain begins to adjust to the higher levels of brain chemicals by making physical changes that involve, among others, the growth of additional receptor sites to accommodate the excess neurotransmitters.  This leads to tolerance: needing more stimulation in order to achieve the same effects.  Tolerance is one of the first signs of developing addiction.
  3. As tolerance develops, we reach a point where our brain needs the presence of the stimulation in order for us to feel normal.  If we cease whatever is causing the stimulation, whether it be alcohol, other drugs or stimulating activity, for very long we begin to feel uncomfortable because all those extra receptors are telling us they need to be filled up.
  4. Eventually, we reach a point where any pleasure is short-lived, and we simply need the stimulation to keep going.  When we don’t have it, we experience withdrawal, feelings that, as a general rule, are the opposite of whatever good feelings the stimulation caused.  If we were using cocaine or other central nervous system stimulants, we feel depressed; if using downers, agitated; if we are a thrill junkie, bored and/or depressed, etc.  Because of the changes in other parts of the body there are often other symptoms.  For example, opiate withdrawal is like the worst case of flu you can imagine, doubled, combined with overpowering anxiety, nervousness and generally feeling terrible both physically and emotionally.
  5. At the point of marked, prolonged withdrawal in the absence of the drug or activity, we are definitely addicted.

But why can’t we quit?  We know using is causing us life problems, and we know withdrawal doesn’t last forever.  There are even medications to help.  What’s with the constant failures to stop using?

Remember that we said the pleasure center is a part of the brain over which we have no conscious control.  This part of the brain, because it is survival-oriented, interprets failure to meet its needs as survival issues.  We have created an artificial situation in which the brain needs extra stimulation to feel normal.  Therefore, when it does not get the extra stimulation, it sends messages to our subconscious that our very survival is threatened.  Addicts continue to use because their subconscious, over which they have no control, tells them that if they don't they're liable to die.

Those messages alone are enough to make it extremely difficult to stop using.  When reinforced with physical withdrawal, they are sometimes impossible to overcome with conscious effort because — again — we have no control over the feelings or the symptoms except for the use of more drugs.

Of course there is more to it.  The stresses created in our lives by addiction-related problems (and perhaps problems that preceded the addiction) make it even more difficult for us to allow ourselves to return to reality.  We must first detox from the drug, and then we need a lot of support and help while normalizing our social, emotional and health issues during the first months and years of sobriety.  We also need help getting through the “post acute withdrawal syndrome” (PAWS) that occurs while the brain and rest of the body are rebuilding and getting back to something like normal.  This can take a long time, and the issues associated with PAWS are a frequent (if not the most frequent) cause of relapse.

That, however, is a subject for another article of its own.  For now, understanding that addicts are subject to powerful emotional and physical experiences over which there can be no direct control will clarify a lot about addiction and the problems of getting clean.

15 arrested in strike against ring smuggling prescriptions to Mexico – The Washington Post

Dealers in Southern California provided hydrocodone prescription drugs to pharmacies in TJ, for resale to primarily American tourists.

Hydrocodone, nearly as powerful as morphine, caused 2,499 deaths in the United States from 1998 to 2002, the most recent data analyzed by the Drug Enforcement Administration. The DEA says there were 130 million prescriptions written in 2006, up nearly 50 percent over six years.

APNewsBreak: 15 arrested in strike against ring smuggling prescriptions to Mexico

How does Suboxone work?

Sunrise uses Suboxone for opiate detox.  You'd probably like to know how it works, without getting into all the fol-de-rol about agonists, antagonists, mu opioid receptors and all that.

Buphrenorphine (Suboxone's just a stage name) doesn't quite act like other drugs.  It stimulates one place in the brain the same as heroin, methadone, oxycodone and the other opoid (opium-like) drugs, but it has the opposite effect on most of the other receptor sites that opiates use where, instead, it neutralizes the opiates' effects.

In addition to buphrenorphine, Suboxone contains a drug called naloxone.  It is also an opiate antagonist, and it enhances the neutralizing effect of the  buphrenorphine.

What this all boils down to is pretty simple, once you get past the neurology and chemistry: Suboxone's neutralizing effects get the drugs out of the system, while its stimulating effect eliminates withdrawal symptoms.  If you give someone a dose of naloxone alone, it throws them into immediate and severe withdrawal.  However, the two drugs working together allow us to detox from our opiate of choice, and allow it to happen in relative comfort.

Completely changing our brain chemistry around can never be symptom-free, and if you've ever done an opiate detox “cold turkey,” you know that it's one of the most miserable experiences imaginable.  No one wants to go through that again.  With Suboxone, you don't have to.  Along with the medical and emotional support of a first-class detox facility, Suboxone treatment makes the early stages of recovery from opiate addiction physically and emotionally more comfortable, removing one of the biggest obstacles to getting clean and sober.