Monday, October 28, 2013

Advice to Mental Health Clinicians (take it will you. Your patients lives depends on them

Advice for Mental Health Clinicians

Mark Willenbring, MD at Substance Matters: Science and Addiction - 2 weeks ago
A clinician recently sent me this email: *Dr. Willenbring,* * * *I read an article in the New York Times from early this year discussing Effective Addiction Treatment that in part highlighted your comments and Alltyr's mission to be a 21st century model for addictions treatment.* * * *As a therapist in an outpatient practice not specializing in addictions treatment--but who nevertheless encounters co-morbidity with substance abuse on a pretty regular basis--it can be confusing to know how to approach the psychosocial aspects of treatment. I believe in a multimodal approach for chron... more »






I also suggest that people read Drs. Scott O. Lilienfeld William T. O'Donohue  book
"GREAT IDEAS of Clinical Science: 17 Principles that Every Mental Health Professional Should Understand"

This two guys and others have been trying (I think some times in vain  but they are making some headway, to me just do not seem to be fast enough) to convince clinicians to become scientist first and then practitioners. Suggest you follow them and if you get existed start reading the references study in the back of the books.


I got mind use and very good condition from ABebooks  http://www.abebooks.com/ (I don't get a toaster for announcing them, I do not care where you get the books  from)

Another one read by Scott is 

Brainwashed: The Seductive Appeal of Mindless Neuroscience [Hardcover]


 

too much rubbish being written about Neuroscience and this book ought to help you to be more critical about what is being said by Professionals who are extrapolating way beyond the data available.  I don't always agree with what they have to say but scoot specially is Definitely a clear thinker.

Thursday, July 18, 2013

Your feedback and Statements are always. Welcome.

My statistics on this blog, shows that there is a fairly high rate of visits to this site. Since I opened it a years or so ago. I has had over 1,500 visits or so a year.  My stats do not state whether your are visiting by mistakes, or you are actually reading the articles. But I would surely welcome what
you have to say. Whether you agree with me or not. I try not to take my "believes" very seriously
although I take it with commitment to the improvement of.

I am in the process of reading a book that has been confirming quite a  bit of what I think about
our current Rehabilitation of Substance Use Treatment.  The book is "Inside Rehab.: The Surprising Truth About Addiction Treatment-and How to Get Help That Works" by Anne Flesher not written by
a professional but by an investigative reporter.  She is quite nice about some of the error that these
rehabilitation facilities are doing. I would be a lot more confrontative given the fact of the devastation that they can cause in patients lives. Too frequently some (not all of these) facilities make rules, regulations, and policies that are based for the facilities conveniences not for the best interest of the patients.  And they can do quite a bit of damage in individuals if they have not done it in large groups of people

So do me a favor, and react to some of these articles that I place in this blog. AS YOU MAY NOTE, not of all of the articles are written by me. I give credit and they are written by other sources.

How to switch from methadone to buprenorphine from Jonaburson's blog

How to Switch from Methadone to Buprenorphine (Suboxone)
janaburson at Janaburson's Blog - 4 days ago

I’ve helped about thirty or forty people switch from methadone to buprenorphine. Some were patients at my office, where I do office-based treatment with buprenorphine (formerly known as Suboxone or Subutex), and some have been patients at one of the two opioid treatment programs where I work. Most of the time, the transition goes smoothly; […]

Thursday, July 11, 2013

Methadone Dosing: Use the Evidence

From: Janaburson's Blog


While Methadone and other medical replacement therapy has been badmouth by most if not
all member of organization like X Anonymous.  Methadone and Bupernorphine, for opiates
as well as Naltrexone for Alcoholics.
http://www.dpt.samhsa.gov/pdf/NTXWPFinalPDF.pdf
  Scientific evidence discoveries have shown that medication replacement therapy are substantially more effective (and safer) than Alcoholic Anonymous or Narcotics Anonymous. The animosity by members of these organizations is reprehensible given that they do not have any evidence except their own bias and poorly conceived opinions.

http://janaburson.wordpress.com/2013/07/07/methadone-dosing-use-the-evidence/

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Methadone Dosing: Use the Evidence

methadone
methadone
The most successful opioid treatment programs and the most successful patients in those programs use evidence-based dosing of methadone. Many studies over the last 40 years show patients do better on adequate doses of methadone. They have better outcomes when they’re on enough methadone to block physical withdrawal signs and symptoms than when they’re on insufficient doses.
In the past, methadone clinics often had dose caps. Some clinics told their patients they didn’t need any more than 60 or 70mg of methadone per day. But over the last 40 years, we have multiple studies showing poorer outcomes at clinics with these low dose caps, as opposed to individualized dose determination. Numerous studies show higher drop-out rates in patients on doses less than 60mg, as well as more illicit opioid use and higher rates of HIV infection, as compared to patients on 100mg or more. For most patients, the blocking effect is seen in the neighborhood of 80 to 120mg of methadone per day. (In Tennessee, there are still dose caps. In that state, doctors have to get approval from a non-physician at the state’s Department of Mental Health to take a patient’s dose above 120mg.)
Patients vary widely the way they metabolize methadone. A patient with slow methadone metabolism may do best on 30mg of methadone per day, and a fast metabolize may need much more than 120mg per day. This rate of methadone metabolism is probably determined by our genetics. When patients ask me how much methadone they should be taking, my answer is, “Enough.” I’m not advocating taking doses higher than they need to be, but if the patient looks like they’re in withdrawal, and they feel like they’re in withdrawal, it’s best to take the dose up. We want to use the lowest effective dose.
There are still misguided opioid treatment programs that try to keep methadone doses low. Sometimes clinic staff can send shaming verbal or nonverbal messages, and imply patients who ask for an increase in their dose are somehow trying to get one over on the clinic. Staff shouldn’t shame patients who ask for a dose increase; staff should defer decisions about methadone dosing to their medical personnel.
Sometimes patients don’t want to increase their dose of methadone because they have mixed feelings about their treatment. If they feel guilty about being in a methadone program, they may want to keep their dose low. Sometimes family members, with the best of intentions, will demand the patient stay on a low dose, not understanding that their loved one is less likely to do well on an inadequate dose.
Frequently I see patients who are feeling bad, not sleeping, and achy all over in the mornings, and dosing at 40mg. I ask them if we can increase their dose, and they say something like, “No, I promised myself I wouldn’t go higher than 40mg.” Too often, patients don’t increase their dose for fear that coming off methadone will be harder to do at higher doses. This may be partly true. It may not be harder to come off of, but it take longer to taper off a higher dose. But the patient won’t do as well while they’re in treatment, so what’s the point?
Some patients prefer low doses because they want to have just enough methadone per day to keep them out of terrible opioid withdrawal, but not so much to block the euphoria they get from using an illicit opioid later in the day.
I tell patients that methadone is a little like chemotherapy. For chemo to work, you have to take a big enough dose to do the job. It’s the same way with methadone. It’s not a perfect analogy but patients get what I’m saying.
Let’s turn to the other side of dosing. I’ve seen some clinics with many patients on what I would consider very high methadone dosing. It’s hard to criticize, because I do think there are some patients who need doses higher than 250mg, particularly if they’re on certain medications, or are pregnant. But that’s rare, and at some clinics, many patients seem to be on these big doses. Since these patients have their dose increased slowly, they build a tolerance to the methadone, so such patients aren’t sedated. There’s no long-term damage to the body with very high dose methadone, but higher doses can cause some problems.
It may be hard for a patient on a very high dose to transfer to another clinic. Some methadone clinic medical directors are hesitant to accept a patient in transfer if they’re on 200-plus milligrams of methadone, unless there’s evidence that this dose is required. For example, I was looking over the records of a patient on 290mg, in preparation for transfer. This man was on no other medications and otherwise healthy. When I saw the peak and trough data, I was puzzled, because they were both high, and this was done at 200mg of methadone. So why was the patient taken to 290 milligrams? I know peak and trough levels aren’t the only factor to be considered when determining the right methadone dose, but there was scant information about why the doctor decided to raise the dose, or even if the patient had even seen the doctor recently. I wasn’t particularly concerned the patient would be sedated, because the dose had been raised slowly, over months. But I was concerned that the patient was on more methadone than he needed, especially since many of the patients at this clinic were on doses of more than 200mg per day.
Some studies have shown higher doses of methadone affect the way electrical impulses are transmitted through the heart. In some studies, higher methadone doses are more likely to produce prolongation of the QT interval than lower doses. (2) This QT prolongation does put patients at risk for a potentially fatal heart rhythm problem. The medical literature at present suggests that periodic EKG screening of patients on doses above 100mg is probably a good idea, but there’s still disagreement on this issue.
There is another factor to be considered. This may offend some readers, but we need to acknowledge the nature of addiction. It’s a disease who tells its sufferers, “More is better!” I think it’s important to acknowledge this point, and discuss it openly, but not in a shaming way. This psychological part of addiction doesn’t always go away within the first few weeks.
My approach to a patient on a relatively high dose, who desires an increase in methadone, is to meet with the patient, preferable prior to dosing. Sometimes I like to meet the patient two hours post-dose if I’m worried about sedation. I ask about withdrawal symptoms and check for pupil size and reaction, and other signs. I check the last drug screen. If the patient doesn’t describe withdrawal symptoms, and I don’t see objective signs of withdrawal, I’ll ask the patient how they expect to feel on an ideal dose of methadone, and if it’s possible their addiction is driving the desire to increase. I’m surprised that most patients aren’t offended, but welcome the opportunity to talk openly. Some patients say they honestly can’t tell if they are in withdrawal, or if their addiction tells them they are in withdrawal. My job is to help decide which it is.
Some patients feel “high” for the first few days after a dose increase, but tolerance builds quickly to this feeling. Some patients mistakenly believe they should always get that high after dosing. If the addiction is driving the patient’s way of thinking, the dose may never be “enough.” When I explain this to patients, most understand.
1. http://international.drugabuse.gov/sites/default/files/pdf/methadoneresearchwebguide.pdf
2. Krantz, Lewkowlez, Hays, et.al., “Torsade de Pointes Associated with Very-High Dose Methadone, Annals of Internal Medicine, Sept. 17, 2002, Vol 137(6) pp 501-505.

Saturday, June 22, 2013

FREEEEEEE Suboxone Treatment in South Florida


If you live in South Florida or can get there for the number of times that are required by the researchers. There is a Suboxone Treatment starting now in June 2013. You receive the treatment by participating in the studies (and you get paid $500 instead of you paying for the treatment).The study is sponsor by a different pharmaceutical company, not Reckitt Benckiser Pharmaceuticals.

The researcher Segal Institute conduct approximately 300 multi-centered, so there maybe one research center near you that maybe doing the study. The pharmaceutical sponsor for this study is using a different variation of the initial formula. This formula ought to make the Buprenorphine Naloxone more effective and to last longer in the nervous system. To make an appointment in South Florida please call Segal Institute at 1 877 734 2588. When they answer the telephone and you tell them that you want to participate in the new Buprenorphine study, please also tell them that Franco referred you to the study and provided with this initial information. At the end of the number of weeks the studies, (I believe it is 40 but I will double check this number) having participated in the study will approve you for a longer participation. I believe that the sponsor is willing to provide participants with one year of Buprenorphine treatment.

Soon they are also preparing to do a study on medications for cocaine dependence. Perhaps this is the first medication for this ailment.

There are a number of other paid studies now available most of them in Mental Health and Substance Use treatment. When the list becomes available, the list will be made available here. And always tell the researcher that Franco referred you to the study. Let Franco know that you contacted the Segal Institute for Medical Trials. http://www.segaltrials.com there are also studies for Bipolar Disorder; Constipations due to use of Opiate Medication (such as methadone); If you are accepted into one of their studies, I will give you a tip if you informed them of my referring you to them. Please email contact Franco so that arrangements can be made. Franco33139ca@hotmail.com


(to be continuo)

Monday, June 3, 2013

New post on Janaburson's Blog / Case Report of Death from Ibogaine Ingestion

http://janaburson.wordpress.com/author/janaburson/

Case Report of Death from Ibogaine Ingestion

IBOGAINE
IBOGAINE
In the latest issue of the American Journal on Addictions (Volume 22 (3) May/June 2013, p. 302) was a one-page case report of a death due to ibogaine, ingested for the purpose of curing heroin addiction.
Ibogaine is a hallucinogenic psychoactive substance found in some species of plants that grow in Africa. It’s been used in religious ceremonies, chewed to give a mild stimulant effect. With increased doses, this substance has hallucinogenic effects. Ibogaine is a sloppy drug, affecting at least three types of brain receptors. Ibogaine’s metabolite, noribogaine, has serotonin reuptake inhibition properties, like found in many antidepressants. It also has a weak opioid effect on the mu opioid receptors and a stronger effect at the kappa opioid receptors, causing less dopamine to be released. It also has effects on at least two other receptor types.
Limited studies show that since the drug does block the release of dopamine, it may have some benefit in the treatment of addiction to these drugs. Both animal studies and case reports suggest ibogaine may reduce withdrawal symptoms of opioid addiction and craving for cocaine. But so far there have been no good scientific trials of the drug. This drug has been outlawed in the U.S. and in most European countries due to concerns about the drug’s side effects and case reports of death. Ibogaine’s supporters claim this drug can cure addiction to alcohol, cocaine, opioids, and nicotine.
In this case report, the decedent was a 25-year old male with heroin addiction and a history of supraventricular tachycardia, meaning he had an underlying heart problem that caused episodes of rapid heart rate. This man took ibogaine 2.5 grams over 3 hours, and then had hallucinations, difficulty with balance, fever, and muscle spasms. He improved over the first day, but by the next day he developed problems breathing and had a respiratory arrest. Despite cardiopulmonary resuscitation, he remained in a deep coma and died after two days of multi-organ failure.
This death was of course a tragedy, but I’m not sure this case and other similar cases mean ibogaine won’t ever have a place in the treatment of opioid addiction. It surely gives us information that patients with underlying heart disorders are at increased risk of death from ibogaine.
I still think there’s a need for further (careful) research on ibogaine. This can’t be done at present in the U.S. or Europe, but perhaps other counties can do necessary trials.
Yes, this is a medication that can kill, but then, addiction kills, too. And many medications routinely used in the medical treatment of various illnesses can be deadly at the wrong doses or in the wrong patients. For all medical treatments, the risks have to be weighed against the benefits. Right now, we don’t have a full idea of the benefits or the risks of ibogaine.
Like many treatments for addiction, there are also people who make unsubstantiated claims in favor of ibogaine, and sell it via the internet or in countries where it isn’t outlawed, as a miracle cure for opioid addiction. The evidence for this claim is lacking, to put it mildly. This case report reminds us that ibogaine can be deadly. Until/unless we have more knowledge about the risks/benefits of ibogaine, evidence-based treatment of opioid addiction with methadone and buprenorphine are much better options and should be recommended.
For further information of the state of ibogaine research, here’s a great reference:
http://www.ibogaine-research.org/Ibogaine-Research-Project/Areas/Media/JAMA.htm

Thursday, May 23, 2013

Organization of American States OES Report on history of Drug Policy

This article comes from Stop the War.org

 

OAS Releases Historic Report on Drug Policy Alternatives [FEATURE]

 

Posted in:
 
The Organization of American States (OAS) Friday released a ground-breaking report on hemispheric drug control that includes not only an assessment of the current state of affairs, but also looks at a number of alternate scenarios for future directions in drug policy, including explicit analysis of possible regulation and legalization regimes.

Colombian President Santos (l) receives the report from OAS head Insulza in Bogota Friday (oas.org)
The report comes even as the US military is expanding its drug war in Latin America.The military is deploying assets to Central and South America, and US military assistance in Latin America has quadrupled in the last decade -- even as the region faces no external and diminishing internal threats.
The report, The Drug Problem in the Americas, was commissioned at last year's Cartagena Summit of the Americas, where a number of Latin American leaders led by Colombian President Juan Manuel Santos criticized existing drug policies and called for a discussion of alternatives. On Friday, OAS head Jose Miguel Insulza hand-delivered the report to Santos in Bogota.
Prepared by researcher and analysts at the Inter-American Drug Abuse Control Commission (CICAD) under the supervision of the OAS, the report is divided into two discrete sections, an analytical report and a scenarios report. It is the scenarios report that addresses possible directions in drug policy, including the formal consideration of legalization and regulation regimes.
The scenarios report envisions four possible (and not necessarily mutually exclusive) policy directions and how each scenario "understands" the drug problem, what the attempted response would be under that scenario, and the opportunities and challenges involved in acting on those scenarios.
Two scenarios, "Together" and "Resilience," represent largely traditional responses to drug use and the drug trade, with calls for the strengthening of weak states and their judicial institutions or addressing underlying social problems and strengthening communities to fight violence and addiction, respectively.
It is the other two scenarios, "Pathways" and "Disruption," that represent innovations in thinking at the policy-making level. In the "Disruption" scenario, the violence and instability created by the drug trade under prohibition is so severe that authorities "cut a deal" with traffickers in a bid to achieve social peace. This might, more or less fairly, be called "the Mexican scenario," given that previous Mexican PRI governments are almost universally assumed to have made such bargains with trafficking organizations, and given widespread speculation these days that the current PRI government may be considering something similar.

drug seizure, Mexico (sedena.gob.mx)
In the "Pathways" scenario, CICAD "understands" the problem as "the current regime for controlling drugs through criminal sanctions (especially arrests and incarceration of users and low-level dealers) is causing too much harm." The response is "trying out and learning from alternative legal and regulatory regimes, starting with cannabis."
The opportunities presented under the "Pathways" scenario include "development of better drug policies through experimentation, reallocation of resources from controlling drugs and drug users to preventing and treating problematic use, and shrinkage of some criminal markets and profits through regulation," while potential problems include "managing the risks of experimentation, especially with transitioning from criminal to regulated markets (including possible increases in problematic use), dealing with contraband, and new inter-governmental tensions that result from differences in regimes between jurisdictions."
The report is being welcomed as marking a true advance in the drug policy dialog at the hemispheric and international levels.
"The review explores what can be done in a post-drug war world," said Kasia Malinowska-Sempruch, director of the Open Society Global Drug Policy Program. "This report envisions a number of possibilities that will broaden the current debate on drug policy reform."
"As part of the scenarios team, we worked to make it clear that another reality is indeed possible, that our countries can move orderly toward regulated drugs markets, and that there are possibilities to achieve better results," said Lisa Sanchez, coordinator of drug policies at the Transform Drug Policy Foundation and Mexico Unido Contra la Delinquencia, who worked on the report. "It is clear that the state should no longer ignore its responsibility to guarantee the health and security of all its citizens, and to do this, it needs to regain control over the drug markets which are currently illegal."
"While leaders have talked about moving from 'criminalization' to 'public health' in drug policy, punitive, abstinence-only approaches have still predominated, even in the health sphere," said Daniel Wolfe, director of the Open Society International Harm Reduction Program. "These scenarios offer a chance for leaders to replace indiscriminate detention and rights abuses with approaches that distinguish between users and traffickers and offer the community-based health services that work best for those in need."

methamphetamine user under arrest, US (wikimedia.org)
"This is the beginning of an international conversation on a new approach to drugs," said David Holiday, senior regional advocacy officer for the Open Society Latin America Program. "We can hope this will move policies from those currently based in repression to strategies rooted in public health and human rights."
That international conversation on drug policy will get going next week, when the OAS report will be presented and discussed at the bi-annual CICAD meeting in Washington, DC. Two weeks after that, the report and discussions over drug policy in the Americas will be the main agenda item -- "Toward a comprehensive anti-drug policy in the Americas" -- at the annual session of the OAS General Assembly, which is attended by foreign ministers in the region. Advocates are hoping that these regional discussions will also be taken up at the 2016 United Nations General Assembly Special Session on Drugs.
"Never before has a multilateral organization engaged in such an inclusive and intellectually legitimate analysis of drug policy options," said Ethan Nadelmann, executive director of the Drug Policy Alliance. "Indeed, it would have been inconceivable just two years ago that the OAS -- or any multilateral organization -- would publish a document that considers legalization, decriminalization and other alternatives to prohibitionist policies on an equal footing with status quo policies. Political pressures by the US and other governments would have made that impossible."
But much has changed in just the past few years, Nadelmann noted. In 2009, former presidents Fernando Henrique Cardoso (Brazil), César Gaviria (Colombia) and Ernesto Zedillo (Mexico) joined with other members of the Latin American Commission on Drugs and Democracy in saying the time had come to "break the taboo" on exploring alternatives to the failed war on drugs.
In 2011, those presidents joined with former UN Secretary General Kofi Annan, former U.S. Secretary of State George Shultz, former Federal Reserve Board chairman Paul Volcker, former Swiss President Ruth Dreifuss and other members of the Global Commission on Drug Policy in calling for fundamental reforms to national and global drug policies. Former presidents Jimmy Carter, Ricardo Lagos (Chile), Vicente Fox (Mexico) and Aleksander Kwasniewski (Poland) were among those who seconded their recommendations.
Late that year, sitting presidents began to join the calls of their predecessors. These included President Santos in Colombia, Otto Perez Molina in Guatemala, José Mujica in Uruguay and then-President Felipe Calderonof Mexico. Simultaneously, the victorious marijuana legalization ballot initiatives in Washington State and Colorado transformed a previously hypothetical debate into real political reform. Other states will almost certainly follow their lead in coming years.
"The OAS scenarios report thus represents the important next step in elevating and legitimizing a discussion that until a few years ago was effectively banned from official government circles," Nadelmann said. "It is sure to have legs in a way that few reports by multilateral institutions ever do."
Bogota
Colombia