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. - --- MAP posted-by: Jay Bergstrom