Monday, April 20, 2015

You see what I mean, even effective treatment can be done wrong

Methadone is a very effective treatment, substantially tested by SAMHSA and other federal agencies as well as university.  Still some doctors can do it wrong because they do not read up on the way the protocol is suppose to be administered.  This is not a rare condition amongs mental health practitioners who often claims to be practicing, for example Cognitive Behavioral Therapy and the practitioners is not familiar with the research nor has ever taken a course in the use of the methodology.  At best the practitioner may have read a book, but it is not totally familiar with all of what is suppose to be known. So often they practice the protocol wrong.  Dr. B here gives us some ideas of how that might happen.


by janaburson
aaaasplit dose
Recently I’ve had patients write to my blog describing how their opioid treatment program doctors are using methadone blood levels to determine the correct dose. What they described to me was worrisome; patients’ doses rarely need to be checked with methadone peak or trough blood levels. Due to tolerance, a methadone blood level may be adequate for one patient, but far too low for other patients.
A patient’s dose of methadone needs to be determined on clinical grounds. This can include the patient’s description of withdrawal symptoms and their timing related to dosing, physical exam just before the patient is due for a dose, and evaluation of the patient three to four hours after dosing. It may also include an evaluation of ongoing illicit opioid use, other medical issues, and other medication or illicit drug use.
Opioid treatment program physicians rarely need to check methadone blood levels. I usually check peak and trough blood levels when I suspect a patient may be a fast metabolizer who may do better with split dosing. In such a case, the patient describes feeling fine for the first part of the day but in awful withdrawal by night time, despite taking a relatively higher dose. Then if the patient’s peak (highest level) is twice the trough (lowest level) I know they may feel better with twice a day dosing. Certain medications can induce the metabolism of methadone, making the patient metabolize methadone more quickly and drop the blood level. Often in this situation, split dosing helps.
I cringe when patients say things like, “my doctor checks a methadone blood level on everyone when they get to 80mg to see if they need to increase the dose or not.” For the vast majority of patients, getting this blood level won’t be helpful. If it’s used to determine the patient’s dose, it could be harmful. Many patients will still feel withdrawal while dosing at 80mg, even though they may have what would be considered a moderate blood level.
Our patients are tolerant to opioids. For this reason, methadone patients who are doing well, feel fine and have normal lives can have so-called “toxic” blood levels of methadone. A level that would kill someone unaccustomed to methadone may be just what my patient needs.
Some doctors think all opioid addicts want to go higher on their methadone dose than they need, and that these addicts would want limitless dose escalations unless the doctor stops this. In some patients, addiction may drive the addict to ask for dose increases even when not needed. Addiction often tells the patient “more is better.”
I’ve seen this problem too, but not as often as one might expect. More often, I’m the one advocating for a higher methadone dose. Don’t get me wrong, I do want to use the lowest effective dose. Some patients, due to fear of methadone and the stigma against it, are afraid to increase their dose. I point out that studies show patients do the best in methadone treatment if they are on a high enough dose to block the withdrawal symptoms and block the euphoria from other opioids. Particularly if the patient is still using illicit opioids, I recommend a dose increase.
Lab tests aren’t an adequate substitute for talking to the patient and examine the patient. As we used to say when I was in medical school, about a billion years ago, “Treat the patient, not the lab result.”

Friday, April 17, 2015

What? Methadone and Suboxone is Substance Use Medical Treatment

     Methadone patients need not to apologist.

     Here is a treatment for Opiate 'Addiction' that have highly criticize and consider controversial by the 12 Step and most abstinent based residential rehabilitation facilities.  Of course most of these people who criticize these medically assisted recovery are science illiterates who wouldn't no the difference between efficiency and safety and what really does  not work.  They do not know about Confirmation Bias the basic reason why we need to do research.  You see when you think you know something for sure that gets in the way of discovery and exploration. An attitude require for most scientific oriented minds.  Most doctors practice discovery or looking for the reason of your ailments or symptoms.   Correlation Illusion  is another reason why research is necessary. You see most of these individuals and a substantial amount of professionals in mental health practice and make claims which are based on Face value (or Validity
Most people operate on the illusion that because it appears to be a good idea or a claim seem to be true, it most be true.  Although this is so sometimes, it is not all of the time.  Face value is good to develop hypothesis to be tested but by itself has a lot of room for error and in fact it is frequently

Clinical judgment in psychology and mental health is frequently inaccurate, in fact too many are right down faliable

The lack of science and ignoring evidence based treatment is keeping mental health and substance use in the stone age.

No body cares about alcoholics and drug addicts.  Enough misinformation is enough

There are tons of science based information, why is it being ignored by mainstream mental health and substance use treatment staff. I believe that when treatment is not based on medical science. Other types of treatment that has never been proven to be effective and safe is considered malpractice. In the law of tortsmalpractice is an "instance of negligence or incompetence on the part of a professional".  In fact most of these science based information is published by the federal government, yet  the public and potential patients are missing the facts because it is not being provided.

The State Methadone Treatment Guidelines were first printed and published in 1993. The methadone treatment facilities ran by Miami Dade Office of Rehabilitation Services were oblivious of its existence.  when I brought it to their attention the supervisors response was "Oh, they are only guidelines" obviously he most have thought that the ignorance of science is bliss. Eventually, Miami DADE COUNTY ORS finally stopped providing this type of treatment in favor of the religious indoctrination of alcoholics anonymous.  A program that when it was first implemented in the late 1970 and 80 had not been tested for effectiveness and safety (read Why Bogus Treatment appears to work. A problem that is widely connected with mental health and substance use treatment.

Why Bogus Treatment Appears to Work

Why are attorneys missing out on this area of malpractice can only be because they are just as prejudice, and bigots.

Here is a treatment that is outright effective and safe and seems like patients have to beg and hope that they will be accepted.


Original article appeared in:

Methadone and Buprenorphine 101: A Guide for Law Enforcement

Posted: 04/15/2015 10:41 am EDT Updated: 04/15/2015 10:59 am EDT
Lately, with all the talk about rising rates of opioid use and addiction, we are hearing more about opioid treatment programs (OTPs). OTPs provide opioid-dependent patients with behavioral therapy and medication, such as methadone or Suboxone (buprenorphine), sometimes called medication assisted therapy, (MAT), to control cravings for illicit opioids and help them resume normal lives. Although opioid treatment programs have been around for decades with verified results, information about these programs can be confusing for members of law enforcement and communities. Do these medications cause driving impairment? How do OTPs affect the criminal justice system? What safeguards are in place to prevent abuse?
To get some answers, I spoke with Tad Clodfelter, PsyD, President and CEO of SouthLight Healthcare in Raleigh, North Carolina. SouthLight provides behavioral health care and treatment for addiction and mental illness, including methadone and buprenorphine (Suboxone) treatment for opioid dependence. Here are some of his answers to law enforcement FAQs on opioid treatment programs.
What are OTPs?
Opioid treatment programs (OTPs) combine behavioral care services with the delivery of medications that help control cravings for opioids. OTPs are the only FDA recommended treatment for opioid dependence. They are historically equated with methadone treatment, but over the past 5-10 years these programs have evolved to include other methods of medication assisted treatment (MAT), such as Suboxone (buprenorphine).
What is the difference between methadone and Suboxone?
Suboxone and Methadone are both synthetic opioids and used to treat patients with opioid dependency or addiction; however, they are not necessarily used interchangeably, and there are differences in their effects. Methadone is a full opioid agonist, which means it binds to opioid receptors in the brain to take away the physiological cravings for opioid drugs and abuse, allowing the person to function well in their day-to-day lives without being intoxicated, hold down a job and reclaim their families. Methadone is typically given to persons with heavy opiate habits. Suboxone is a partial agonist that affords similar results, also allowing people to resume normal lives. Different people respond better to one versus the other of these effective medications.
Can OTP medications be abused?

Methadone and Suboxone can be abused and diverted, but are far less likely to be than street opioids or prescription pain medications. OTPs have tight restrictions to limit the likelihood of diversion. SouthLight has a good track record of preventing abuse, as do many reputable clinics.
What are the safeguards in place to prevent diversion and abuse?
At Suboxone clinics the staff do pill counts. Sometimes they have patients come back to the clinic and bring in their pills, which are counted to make sure the patient hasn't taken more than their prescribed dose. With methadone, the patients come to the treatment facility daily to receive their dose under staff supervision. Once they have demonstrated commitment to the program and established a good track record, they earn the privilege of taking home medication in a locked box. The person is mandated to return the medication any time there is any suspicion or concern that they might be abusing it. OTPs check for suspicious behavior using urine drug testing, observing any changes in behavior, and checking the Controlled Substance Reporting System to see if the person might be getting other prescriptions from doctors that might be a concern. A person can qualify for take-home doses after 3 months, but that privilege can be taken away for noncompliance.
Do OTP medications cause driving impairment?
Not when taken as prescribed. Someone leaving a methadone or Suboxone clinic who has just taken their normal dose should not have trouble driving. In a clinic setting, patients are observed closely. A patient is not allowed to leave the clinic if a concern, i.e., intoxication, ever exists.
Do OTPs just substitute one addiction for another?
No. Methadone or Suboxone is essential in opioid treatment. These medications, in combination with evidence-based behavioral therapies, are the FDA-recommended standards of care for opioid dependence. In essence, medication assisted therapy substitutes a controlled synthetic opiate for opiate drugs of abuse. The scientific, medical literature is clear in recommending these treatments for opioid dependence. Why? Sustained or long-term opiate use chemically alters the brain and negatively impacts the sensitivity of the body's opioid receptors. In order to begin the recovery process from opioid addiction, medication assisted or replacement therapy is critical to healing the brain and body. Further, the number of opioid dependent persons who can successfully quit drug use "cold turkey" is extremely low due to intense cravings and withdrawal symptoms, which are part of the opioid dependence syndrome. MAT is used to sustain a person and prevent relapse as well.
At SouthLight Healthcare, we serve 400 people at any given time and have a good track record of solid results during and after treatment. The standard of care works very well if treatment regimens are adhered to by patients. Of course, treatment doesn't work flawlessly in every case, but neither does treatment for any chronic, relapsing disease, which substance dependence is. As such, opioid dependence, like other chronic, relapsing medical disorders, requires a combination of treatments, including medication and behavioral modification or change, in order to achieve impactful and sustained treatment results.
What are some of the benefits of OTPs for patients and the community?

OTPs benefit the communities they serve in tremendous and deep reaching ways, many of which are below the radar. They are real and tangible. The vast majority of our clients are in the workforce with documented jobs, paying taxes and giving back to the community. When people are in treatment and stable and reclaiming or simply living their lives, jobs and families, they are less likely to encounter the criminal justice system. That is a major cost savings to society. Our jails are filled with people who are addicted or mentally ill or both; many have committed nonviolent crimes. Such citizens are better served by treatment, which helps them to mend relationships and realize professional goals - the things that makes life worth living.
The Centers for Disease Control (CDC) lists the following benefits of methadone treatment (MMT):
• reduced or stopped use of injection drugs; 
• reduced risk of overdose and of acquiring or transmitting diseases such as HIV, hepatitis B or C, bacterial infections, endocarditis, soft tissue infections, thrombophlebitis, tuberculosis, and STDs;
• reduced mortality - the median death rate of opiate-dependent individuals in MMT is 30 percent of the rate of those not in MMT;
• possible reduction in sexual risk behaviors, although evidence on this point is conflicting;
• reduced criminal activity;
• improved family stability and employment potential; and
• improved pregnancy outcomes.
Cost savings
• the annual costs of methadone maintenance treatment are much lower than the annual costs of either untreated heroin use, incarceration or drug-free treatment programs
• criminal activities related to heroin use resulted in social costs that were four times higher than the cost of methadone maintenance treatment;
• for every dollar spent on methadone maintenance treatment there is a savings to the community of between US$4-$13.

This service is being provided by the South FLORIDA Chapter of NAMA  National Alliance for Medication Assisted Recovery  


Tuesday, April 14, 2015

The Stigma Must Stop

Anti-drug czar: 'Every life is worth saving'


COVINGTON – The stigma of drug addiction, the stigma of using medicine to treat it, the stigma of needle exchange and the idea that a life-saving drug shouldn't be used for overdose victims all need to end.
Michael Botticelli, the director of White House Office of National Drug Control Policy, delivered these messages when he visited Northern Kentucky on Thursday.
Botticelli made it clear while at the Metropolitan Club in Covington at the invitation of the Northern Kentucky Chamber of Commerce that he is in favor of using naloxone to save lives. The non-narcotic blocks the effects of heroin or prescription painkillers and can restore breathing in overdose victims.
"Every life is worth saving," Botticelli told an audience member who questioned whether the drug enables addicts to continue to use heroin. He added that there is no indication that drug addicts will feel safer using heroin because they have access to naloxone.
Botticelli urged a holistic approach, providing both prevention lessons to young children and families and using every treatment and counseling option to help addicts.
He lauded the Northern Kentucky Chamber of Commerce's efforts in the regional heroin fight saying he knows of no other chamber in the nation that has stepped forward to help manage the crisis.
U.S. Sen. Mitch McConnell, R-Ky., said he brought Botticelli to the region to learn about its plight with the opioid and heroin epidemic that is plaguing the nation and, particularly, coursing through Northern Kentucky.
"I am here with the director of drug control policy (appointed by President Barack Obama) because this is beyond partisan debate," the Senate majority leader told chamber members, families advocating recovery, treatment and public health officials at the event.
Listing statistic after statistic, from the tripling of St. Elizabeth Healthcare's emergency care of overdose victims since 2011 to Kentucky's 1,049 lost lives to overdoses in 2013, McConnell said, "In Northern Kentucky, we're at the epicenter" of the crisis with heroin and prescription painkiller addiction.
Earlier in the day, Botticelli was given a private tour of St. Elizabeth Healthcare – Edgewood, where he visited the Neonatal Intensive Care Unit to see newborns with Neonatal Abstinence Syndrome. He heard from Dr. Lynn Saddler, director of the Northern Kentucky Health Department; Jason Merrick, chairman of Northern Kentucky People Advocating Recover; Bonnie Hedrick, coordinator of the NKY Prevention Alliance and others who have joined in the local fight against heroin.
They said Botticelli offered ideas on how they can tap into federal funds available for community substance abuse prevention and support.
In an exclusive interview with The Enquirer, Botticelli said drug courts, treatment centers and corrections systems need to provide medicine assisted treatment, and not just abstinence programs.
"Evidence is strikingly clear that people with opioid disorder do remarkably better with medication assisted treatment – along with counseling," Botticelli told The Enquirer. "It's our hope that medication assisted treatment is the standard of care."
Toward that end, the anti-drug czar said, his office has changed its policy – and has made the inclusion of medicine assisted treatment a condition for state drug courts to receive federal funds.
Kentucky has come under criticism because its drug courts – with the exception of Pulaski County's – require abstinence. Judges even require addicts who have been prescribed medicine for their addiction to taper off of it as a condition of remaining in drug court. But Northern Kentucky drug courts are primarily funded by the state. Only a few counties – none in Northern Kentucky – use federal funds, and that is for training, according to the Kentucky Administrative Office of the Courts.
Botticelli said the federal government is also urging treatment centers to use "every option" available to treat those with addiction, and noted that for opioid and heroin addicts, scientific evidence shows medicine-assisted treatment often works best.
Kimberly Wright of Cold Spring, an activist in the heroin fight and mother of a daughter who is a recovering heroin addict, said she hopes that Kentucky listens to the message.
"We need medicine assisted treatment in Kentucky drug courts. We need an overhaul of our rehabs (to include it)," Wright said.
Joan Arlinghaus, a member of NKY People Advocating Recovery, believes Botticelli's visit was valuable for the region.
"I think it will raise a lot of awareness," she said, "and erase some of the stigma that comes with addiction."

Monday, March 2, 2015

Why Bogus Therapies Seem to Work.

Most treatment in mental health but specifically in Substance Use is totally created from hunches, "educational intuition"<whatever that means, and outright pure guessing.  That is bad enough, except as I state in the introduction to this blog, only about 28% of all mental health practitioners ever read any science. That means that the substantial majority of mental health practitioners are SCIENCE ILLITERATE, they might have well be totally illiterate because most of them probably can not read the  eight grade level, and sure they can not do make any Critical Evaluation of Scientific Journals of their profession. To me that is shameful and not in the best interest of their patients. If you know anyone in mental health get an idea of what they know about science, for the most part they will not answer your questions or give you some horse rubbish that is not consistent with the truth. 

Mental health practitioners like most persons in our society enjoy the benefits of science, but are ignorant of the science they enjoy. They can be bamboozle easily by their professors at the University that are just as likely to be science illiterate.  Here is an article about what makes good science  treatment.

There are numerous reasons why we get bamboozled into believing some mental health treatment and assessment are real and are valid and reliable.  I will try to provide some educational information with references in the next few blog article. For thirty year the profession have been talking about "Evidence Based Treatment" (meaning based on scientific research).  I have reason to believe that most practitioners haven't the faintest idea what Evidence Based means.

Why Bogus Therapies Often Seem to Work

                                                      Barry L. Beyerstein, Ph.D.

Subtle forces can lead intelligent people (both patients and therapists) to think that a treatment has helped someone when it has not. This is true for new treatments in scientific medicine, as well as for nostrums in folk medicine, fringe practices in "alternative medicine," and the ministrations of faith healers.
Many dubious methods remain on the market primarily because satisfied customers offer testimonials to their worth. Essentially, these people say: "I tried it, and I got better, so it must be effective." The electronic and print media typically portray testimonials as valid evidence. But without proper testing, it is difficult or impossible to determine whether this is so.
There are at least seven reasons why people may erroneously conclude that an ineffective therapy works:
1. The disease may have run its natural course. Many diseases are self-limiting. If the condition is not chronic or fatal, the body's own recuperative processes usually restore the sufferer to health. Thus, to demonstrate that a therapy is effective, its proponents must show that the number of patients listed as improved exceeds the number expected to recover without any treatment at all (or that they recover reliably faster than if left untreated). Without detailed records of successes and failures for a large enough number of patients with the same complaint, someone cannot legitimately claim to have exceeded the published norms for unaided recovery.
2. Many diseases are cyclical. Such conditions as arthritis, multiple sclerosis, allergies, and gastrointestinal problems normally have "ups and downs." Naturally, sufferers tend to seek therapy during the downturn of any given cycle. In this way, a bogus treatment will have repeated opportunities to coincide with upturns that would have happened anyway.
3. The placebo effect may be responsible. Through suggestion, belief, expectancy, cognitive reinterpretation, and diversion of attention, patients given biologically useless treatments often experience measurable relief. Some placebo responses produce actual changes in the physical condition; others are subjective changes that make patients feel better even though there has been no objective change in the underlying pathology.
4. People who hedge their bets credit the wrong thing. If improvement occurs after someone has had both "alternative" and science-based treatment, the fringe practice often gets a disproportionate share of the credit.
5. The original diagnosis or prognosis may have been incorrect. Scientifically trained physicians are not infallible. A mistaken diagnosis, followed by a trip to a shrine or an "alternative" healer, can lead to a glowing testimonial for curing a condition that would have resolved by itself. In other cases, the diagnosis may be correct but the time frame, which is inherently difficult to predict, might prove inaccurate.
6. Temporary mood improvement can be confused with cure. Alternative healers often have forceful, charismatic personalities. To the extent that patients are swept up by the messianic aspects of "alternative medicine," psychological uplift may ensue.
7. Psychological needs can distort what people perceive and do. Even when no objective improvement occurs, people with a strong psychological investment in "alternative medicine" can convince themselves they have been helped. According to cognitive dissonance theory, when experiences contradict existing attitudes, feelings, or knowledge, mental distress is produced. People tend to alleviate this discord by reinterpreting (distorting) the offending information. If no relief occurs after committing time, money, and "face" to an alternate course of treatment (and perhaps to the worldview of which it is a part), internal disharmony can result. Rather than admit to themselves or to others that their efforts have been a waste, many people find some redeeming value in the treatment. Core beliefs tend to be vigorously defended by warping perception and memory. Fringe practitioners and their clients are prone to misinterpret cues and remember things as they wish they had happened. They may be selective in what they recall, overestimating their apparent successes while ignoring, downplaying, or explaining away their failures. The scientific method evolved in large part to reduce the impact of this human penchant for jumping to congenial conclusions. In addition, people normally feel obligated to reciprocate when someone does them a good turn. Since most "alternative" therapists sincerely believe they are helping, it is only natural that patients would want to please them in return. Without patients necessarily realizing it, such obligations are sufficient to inflate their perception of how much benefit they have received.

Buyer Beware!

The job of distinguishing real from spurious causal relationships requires well designed studies and logical abstractions from large bodies of data. Many sources of error can mislead people who rely on intuition or informal reasoning to analyze complex events. Before agreeing to any kind of treatment, you should feel confident that it makes sense and has been scientifically validated through studies that control for placebo responses, compliance effects, and judgmental errors. You should be very wary if the "evidence" consists merely of testimonials, self-published pamphlets or books, or items from the popular media.

Related Topics


Dr. Beyerstein, a member of the executive council of the Committee for Scientific Investigation of Claims of the Paranormal (CSICOP), is a biopsychologist at Simon Fraser University in Burnaby, British Columbia, Canada. A more detailed discussion of this topic is one of six superb articles on "alternative medicine" in the Sept/Oct 1997 issue of CSICOP's Skeptical Inquirer magazine, which costs $7.50. An introductory (six-issue) subscription at the special Internet price of $16.95 can be obtained by calling (800) 634-1610.
This article was posted on July 24, 2003.

New York in Crisis and Policy Makers Ignore the Science

When I say Substance Use Treatment is the Worst Treatment I Ever Had, is not because the treatment itself when done scientifically with appropriate medical protocol is bad. My complain is that most methadone clinic continuo to ignore the Federal Guidelines and rarely if ever read science and follow science evidence of effectiveness and best practice, but rather because of the clinics and the policy makers IGNORE THEM and the patients are the ones that suffer.  I happen to believe that this is medical malpractice, but can never find an attorney willing to take this clinics and policy makers on. After all we are the most HATED patients in the system.

Here is an example, please do not ignore the since and stop acting capriciously.

New York Plunging into a Disaster
New York like many other states across the country is in the middle of a heroin epidemic.  Last Fall Governor Cuomo launched a Combat Heroin Campaign and this week Senator Schumer called on more Federal funding to combat the growing heroin epidemic. So what does the NYS Office of Alcoholism and Substance Abuse Services (OASAS) do; the agency in charge of treatment in the state?  They are closing 5 methadone programs in the Bronx!  Methadone treatment has been demonstrated to be the most effective treatment for opiate addiction.
The owners of Narco Freedom have been indicted on criminal charges of insurance fraud, money laundering, bribery and grand larceny.  The state has removed them from managing the program and that leaves us with the patients. These 3200 patients at NARCO FREEDOM are in comprehensive treatment consisting of medication in conjunction with counseling and other appropriate services. Many have gotten their lives back together and are engaged in productive activity. What is the state’s best solution for the health and well-being of these patients? Close the 5 programs down, take away any privileges the patients have earned over the course of their treatment, assign them to Interim Treatment. 
Interim Treatment requires patients to come daily for medication without the required comprehensive services. Interim Treatment was developed over 20 years ago during the HIV epidemic because many OTPs had waiting lists and to get drug users at least the minimum of treatment until a place was open on a comprehensive program. It was never intended to move patients from a comprehensive program into minimum treatment.
Whenever a program closes typically 10-15% of the patients do not make it to their new program. They relapse to active drug use.  Even those patients that manage to make the transition will have to rearrange work and school hours to come to Interim treatment every day. In addition the state which currently has no Sunday treatment is planning on sending these patients to our already overcrowded emergency rooms to get their Sunday medication.  This is not a solution to the problem.
The National Alliance for Medication Assisted Recovery (NAMA-R) urges that the Governor Cuomo step in and order OASAS to find new ownership to take over these programs.
This is by far the best solution for the patients and will cost the state nothing!

Wednesday, June 25, 2014


When someone else reflections says what I would have wanted to say but they did it first I do nothing but copy it and give them credit.


Medical journals, news outlets, and the internet have been exploding with new articles about naloxone. As awareness of this opioid overdose antidote grows, more people are pushing for this drug’s wider availability.
I’ve posted blogs about how the Project Lazarus kits have saved lives in my Appalachian corner of the world, but now let’s review some of the science behind naloxone.
Naloxone is an opioid antagonist, which means the drug binds to the mu opioid receptors in the brain, but instead of stimulating these receptors to produce euphoria and pain relief, naloxone does the opposite. It occupies the receptor and prevents opioids from attaching to these receptors to cause euphoria and pain relief. Naloxone has a high affinity to the mu opioid receptors, meaning it sticks like glue to them, but it does not activate these receptors.
If you give naloxone to an average person with no prior opioid use, not much will happen. Because naloxone can block our body’s own opioids, endorphins, that person might feel a little achy, tired, and irritable. But for the most part, when naloxone is given to a non-user of opioids, nothing happens.
If the patient has used opioids just once, recently, the patient won’t have withdrawal when given a dose of naloxone, since the body isn’t used to having opioids anyway. Naloxone in this case restores the body to its usual state. This’s why naloxone can be useful in a patient given opioids for surgical anesthesia. After the surgery is over, doctors can use naloxone to reverse the opioid anesthesia if they want the patient to wake up more quickly.
But in a patient with opioid addiction (or in a chronic pain patient) who uses opioids daily, naloxone causes opioid withdrawal. With long-standing opioid use, the body makes adjustments to counteract the chronic presence of opioids. When these opioids are whisked away with naloxone, this balance is abruptly upset, and the patient goes into precipitate withdrawal, if enough naloxone is given.
Naloxone is the opioid buzz-kill drug… and it’s also the opioid overdose life saver.
People die from opioid overdoses because the brain gets saturated with opioids. The part of the brain that tells us to breathe during sleep, the medulla, also gets saturated, and eventually shuts off. This usually occurs gradually. The respiratory rate slows over one to three hours, until all respirations stop. Then tissues of essential organs like the brain and heart die from lack of oxygen.
If naloxone can be given during this process, the opioids are tossed off brain receptors, and the medulla fires urgent orders for the body to resume breathing. The patient wakes up, so long as irreversible damage hasn’t yet been done to the brain and heart. In some cases, the patient goes into full precipitated opioid withdrawal, but usually the naloxone doesn’t reverse all of the opioids on board, just enough to save the patient’s life.
It’s a dramatic event. I’ve seen this in the emergency department during my Internal Medicine training. A patient can be lying on a stretcher, dead… then one dose of naloxone…. and they are sitting up, asking what happened to them. And sometimes they vomit. That’s another thing I learned in training. After giving a dose of naloxone, take one step back. Even better, place the patient in the “recovery position,” illustrated at the top of this blog, so that if they do vomit, they won’t aspirate the stuff into their lungs.
Naloxone is a relatively cheap drug, and it can be administered in several ways: intravenously, as doctors and EMS workers have always done, intramuscularly, subcutaneously, and intranasally.
Project Lazarus uses this last method. Their overdose kits contain two vials of naloxone 2mg each, and are in a syringe with a nozzle that is attached to the end of the syringe. This causes the medication to spray when the plunger of the syringe is pushed. It’s sprayed up in the nose of an unconscious person, and gets absorbed quickly. In fact, the response rates of all methods of naloxone administration are about the same – two to three minutes. If the patient doesn’t respond after a few minutes, the second dose can be given. Or if the patient initially responds but then gets sedated again, the second dose can be given.
The Harm Reduction Coalition gives out kits with a vial of naloxone and a 3cc syringe and needle. It takes some skill to administer naloxone intravenously, but this kit can be used intramuscularly or subcutaneously. All the rescuer has to do is draw the medication from the vial into the syringe, then stick the needle into the thigh muscle and push the plunger. Usually that delivers the medication into the muscle, unless the person has a great deal of fat between the skin and muscle. But that doesn’t matter, since this medication also works when injected into the subcutaneous tissue.
Each version of a naloxone kit has its advantages. The intranasal kit doesn’t require a needle, so there’s no risk of an accidental needle stick by the rescuer. But it’s a little more expensive. The intramuscular kits are really cheap, but some people in the community worry about handing out a needle and syringe that could be used to inject drugs. I don’t worry about that, since needle exchange should be done in every community, but that’s a bit of a tangent. More practically, addicts don’t use 3cc syringes; they’re too large. Addicts would miss their shot, and too much of their drug of abuse would get left behind in that big syringe.
I don’t think it matters what kind of kit is made available to addicts, their families, and first responders. We just need to get some kind of naloxone kit to these people.
Of course, all these kits contain the recommendation to call 911 immediately. But those precious minutes before EMS arrives may mean the difference between life and death. If naloxone can be given, the patient may be saved. Their brain function may be saved.
To be continued…

Neurobiological buzzword

Another borrowed post from a worthwhile blog. If we really knew what were are doing we would be getting
better outcomes.

The whole article can be read at:

Thoughts & reflections on psychiatry 

Psychiatric uncertainty and the neurobiological buzzword

by Steven P Reidbord MD

April 17th, 2014

A few years ago I wrote that uncertainty is inevitable in psychiatry.  We literally don’t know the pathogenesis of any psychiatric disorder.  Historically, when the etiology of abnormal behavior became known, the disease was no longer considered psychiatric.  Thus, neurosyphilis and myxedema went to internal medicine; seizures, multiple sclerosis, Parkinson’s, and many other formerly psychiatric conditions went to neurology; brain tumors and hemorrhages went to neurosurgery; and so forth.  This leaves psychiatry with the remainder: all the behavioral conditions of unknown etiology.  Looking to the future, my fervent hope that researchers will soon discover causes and definitive cures for schizophrenia, bipolar disorder, and other psychiatric disorders comes with the expectation that these conditions will then leave psychiatry for other specialties.  We will always deal with what is left.  At minimum we psychiatrists should accept this reality about our chosen field.  After all, there appears to be no alternative.  Some of us go beyond this to embrace uncertainty as intellectually attractive.  We like that the field is unsettled, in flux, alive.
Yet many of us clutch at illusory certainty.  Decades ago, psychoanalysis purportedly held the keys to unlock the mysteries of the mind.  It later lost favor when many conditions, particularly the most severe, were unaffected by this lengthy, expensive treatment.  Now the buzzword is that psychiatric disorders are “neurobiological.”  This is said in a tone that implies we know more than we do, that we understand psychiatric etiology.  It’s a bluff.
Patients are told they suffer a “chemical imbalance” in the brain, when none has ever been shown.  Rapid advances in brain imaging and genetics have yielded an avalanche of findings that may well bring us closer to understanding the causes of mental disorders.  But they haven’t done so yet — a sad fact obscured by popular and professional rhetoric.  In particular, functional brain imaging (e.g., fMRI) fascinates brain scientists and the public alike.  We can now see, in dramatic three-dimensional colorful computer graphics, how different regions of the living brain “light up,” that is, vary in metabolic activity.  Population studies reveal systematic differences in patients with specific psychiatric disorders as compared to normals.  Don’t such images prove that psychiatric disorders are neurobiological brain diseases?