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?

Sunday, May 25, 2014

The Sober Truth: about the recovery industry for your Review a fairly new book


ALCOHOLICS ANONYMOUS WAS PROCLAIMED the correct treatment for alcoholism over seventy-five years ago despite the absence of any scientific evidence of the approach’s efficacy, and we have been on the wrong path ever since. Today, almost every treatment center, physician, and court system in the country uses this model. Yet it has one of the worst success rates in all of medicine: between 5 and 10 percent, hardly better than no treatment at all.
Most of the expensive, famous rehab centers that base their treatment on the Twelve Steps likewise have offered no evidence for their effectiveness. Most of them don’t even study their own outcomes.
One would hope we could turn to science for careful studies of AA and its effectiveness. But science has failed us: the AA question was considered settled almost before it was asked, and what studies exist that claim to substantiate AA have been riddled with problems in both methodology and analysis. Nobody has ever carefully and rigorously reviewed these studies and reported the results to the public. In this book, we do just that.
The failure of addiction treatment in our country is especially discouraging since there are better ways to both understand addiction and treat it, and it’s costing us thousands of lives and billions of dollars. With this book, we hope to begin a more productive conversation.
A Note About Format This book was written by both of us, but because Lance has devoted his career to understanding addiction, we have decided to write it in the first person. Zachary’s equal contributions are everywhere, however, from the quality of the writing to his sharp understanding of good and bad science. Neither of us could have written this book alone.

What Do Prosecutors and Distric Attorneys say about Good Samaritan 911???

What Do Prosecutors and District Attorneys Say About 911 Good Samaritan Laws?


With the drug overdose epidemic still raging, 911 Good Samaritan and Naloxone Access laws are sweeping the country as states struggle to seek solutions that can turn back the tide of deaths. Currently, 18 states have implemented naloxone laws, 14 have medical amnesty laws on the books, and many more have introduced bills to their general assemblies. But while law enforcement, public health advocates, and people directly affected by drug overdose are front and center in these debates, state prosecutors and district attorneys also play a critical role in advocacy efforts -- often for, but sometimes against, these laws.
Within the legislative system, associations of prosecutors and district attorneys carry a lot of clout and their support for a bill can be essential to its passage. Case in point, in 2009 overdose prevention advocates in Washington state helped introduce a 911 Good Samaritan bill, but it quickly encountered opposition from the Washington Association of Prosecuting Attorneys and the Washington Association of Sheriffs and Police Chiefs, two organizations with enormous political leverage. The associations argued that the bill, which granted limited immunity from some drug charges to people who sought help for an overdose, sent the "wrong message" on drug laws. As the 2009 legislative session came to a close, it seemed clear that the bill could not move forward with such powerful opposition, so advocates convened a working group of stakeholders, including lawyers, law enforcement, public health advocates and people who had lost loved ones to overdose, to make the case for the law.
"In the end we were able to change [the associations'] minds," explains Mark Cooke, Policy Counsel with the ACLU of Washington, one of the main advocacy organizations for the bill. "Law enforcement officers and prosecutors realized that most people don't get in trouble for low level possession in overdose situations anyways, and if we can save one life, it is worth passing the law. Also, law enforcement from college campuses were some of the most vocal proponents for the 911 Good Samaritan bill, which was inspired by similar amnesty laws on college campuses."
When the legislative session reconvened in 2010, the Washington Association of Sheriffs and Police Chiefs came out in support of the 911 Good Samaritan bill, and the Association of Prosecuting Attorney's agreed not to oppose it. That year Washington became the second state in the nation (behind New Mexico) to implement a 911 Good Samaritan law, paving the way for a dozen other states to follow suit in the coming years.
Most recently, Georgia passed a similar medical amnesty and naloxone access law through their general assembly. The bill is currently awaiting signature from Governor Nathan Deal, and will take effect immediately. District Attorney Danny Porter says that prosecutors in Georgia opposed the original version of the bill because it included immunity for people who provided the drugs that resulted in an overdose. One of the main arguments of opponents concerned a case in North Georgia where a mother had given methadone to her child because she wanted to sleep. The child overdosed and died.
"We had to work with the author of the bill to reduce the range of immunities to a scope that was acceptable to prosecutors," says D.A. Porter. "We were able to reach an agreement quickly and help move the bill with our political leverage. We had no problem with the underlying social aspect of the bill. Kids who overdose shouldn't be afraid to get help."
Mike Noone, First Assistant to the District Attorney in Chester County, has been part of advocacy efforts for a 911 Good Samaritan law in Pennsylvania. The bill is currently being debated, but Noone is optimistic that it will pass.
"Our office advocates for the law because it's important to encourage people to do the right thing if they are in an overdose situation and people are dying," he says.
Prosecutors' support for overdose prevention laws seems to indicate a paradigm shift away from the harshly punitive drug laws of the late 20th century towards a more health-centered approach to drug addiction. Attorney Corey Davis, Deputy Director for the Network for Public Health Law, Southeastern Region, has been studying and advising stakeholders on naloxone access laws since 2010 and has noticed the shift in attitudes.
"I think there's been a changing tide in perceptions of the war on drugs in general," he says. "We see a growing acceptance of marijuana, both for medical and recreational use, relaxation of the crack/cocaine disparity, and reductions in state prison populations after many years of steady increases."
There are some who argue that the shift has to do with the danger and prevalence of prescription drugs, which are often abused by people of power and affluence. With the crack cocaine epidemic focused mostly in inner cities, or methamphetamine use most popular in poor rural areas, it was easy for people who make and enforce laws to crack down hard on drug users. But now, with drugs and overdose creeping into their own medicine cabinets, their own homes, with the suburban and middle class children of powerful people at risk, the laws are starting to change.
Attorney Mark Sigmon, a lawyer with Graebe Hanna & Sullivan PLLC in Raleigh, N.C., lost a family member from a narcotic overdose and now supports laws that encourage people to seek help for an overdose and increase access to the opiate overdose antidote, naloxone.
"For many years it was widely accepted among lawyers and judges that the penalties for drug crimes were too harsh, but no politician wanted to run on reducing those penalties. However, that ice is beginning to thaw," he says. "I believe that when both common sense and data suggest that we can save lives at relatively little cost [with naloxone and 911 Good Samaritan laws], there's no reason not to do it. To sacrifice those lives because of irrational discomfort or stigma is not just bad policy, it's immoral."
Attorney Davis agrees. "We now have a fair amount of evidence as to what works to reduce the likelihood that a person will commit crime, from quality pre-school and lead abatement all the way through evidence-based drug treatment and structured social learning," he says. "We also have a lot of evidence as to what works to get people who are using drugs problematically, particularly opioids, to start using them more responsibly or stop using them altogether. It's time we started making laws based on evidence instead of centuries-old prejudices."
That prosecutors and district attorneys, who were once 911 Good Samaritan and naloxone law's stiffest opponents, are now often its main advocates, is testament to the winds of change in the United States. What's left now is for advocates to continue to capitalize on this momentum so that policy change translates into real results -- lives saved and families prevented from grieving.

Wednesday, January 22, 2014

This is a great resource for clinicians. They should become familiar with the Treatment Improvement Protocols. That are largely based on research and Best Practice.  Let seem if it pastes as a bottom on html The phone call is Free, the publication is Free, all you have to do is implemented.

Some times SAMHSA and NIDA has soem political agendas, but for the most part the protocols TIPs 1 though 54 are excellent resources.