Obama and the TREAT Act

I just read an article in the Daily Beast that reads like a better version of something I would write about the value of medication-assisted treatment of opioid dependence.  I appreciate Christopher Moraff telling a story that has been untold far too long, and I hope the story raises questions across the country.
But I have something else on my mind that deserves a story of its own.  I am just a small-town psychiatrist in the Midwest, of course, and so I could be missing something.  I watch Veep and House of Cards, but I assume that the political games in those shows are grossly exaggerated.  I’ll offer a bit of background… but if you already understand why people opposed to increasing the buprenorphine cap are idiots, just skip the next few paragraphs.
The Recover Enhancement for Addiction Treatment Act, a.k.a. TREAT Act, is a Bill with bipartisan support written in response to the epidemic of opioid dependence in the US.  If enacted into law, the TREAT Act (among other things) would increase number of patients that a physician can treat with buprenorphine from 100 to 500 and allow nurse practitioners and other ‘mid-level prescribers’ to treat opioid dependence with buprenorphine medications. For newcomers, treatment professionals debate the wisdom of raising the cap on the number of patients treated by each practioner.  Some people argue against medication treatment entirely and claim that abstinence is the only legitimate goal when treating addiction, despite the fact that abstinence-based treatments rarely work.  ‘Rarely’ is in the eye of the beholder, I guess– but even the most optimistic promoters of abstinence-based treatments claim they fail only 70% of the time– within ONE YEAR.   Other addiction docs advocate using medications that dramatically cut death rates, in concert with counseling.  They demand the counseling despite no evidence– none– that counseling improves outcomes in medication-assisted treatments.  But arguing against counseling is like arguing against… milk, I guess.  Who can argue against milk?
Then there are the extremists like me who argue that addiction is an illness that should be treated like any other illnesses and managed with medications, sometimes over the course of a person’s life.  Maybe counseling is indicated, and maybe not– but the need for counseling should not stand in the way of obtaining a life-sustaining medication.  After all, do we withhold insulin from diabetics who don’t receive nutritional counseling?  We extremists point out that there is no ‘cap’ on patients who are prescribed opioid agonists– the type of practice that started this epidemic in the first place.  We point out that literally no deaths have been caused by buprenorphine in patients who were prescribed the medication.  In all of medicine, THAT is the medication that needs a ‘cap’?  Doctors can treat unlimited numbers of patients with cancers, pain disorders, or complicated surgical procedures, but can’t handle more than 100 of THESE patients?!
I don’t see the point of the other groups, so I won’t try to explain their thought processes– accept one example.  Some docs are Boarded in Addiction Medicine– a secondary certification that can be obtained after certification in primary care or psychiatry.  Full disclosure– I am not Board Certified in Addiction Medicine.  I am Board Certified in Anesthesiology and in Psychiatry, and I worked with narcotics as a pain physician and anesthesiologist for ten years.  And I have a PhD in neurochemistry.  From my perspective, I have enough things on the wall. But the docs who DID get boarded in addiction medicine are angry that they get nothing special for their efforts.  The law that created buprenorphine treatment was intended to increase addiction treatment by primary care practitioners.  But that’s sour grapes to the addiction docs, who want the sole right to treat more than 100 patients.  Never mind that 30,000 people die from overdose each year, and buprenorphine could save many of them.  The addiction-boarded docs are angry that they aren’t given special privileges.  Isn’t THAT a problem!
What does all of this have to do with President Obama?  A bipartisan group of members of Congress of worked on the Treat Act over the past 8 months.  Professional societies have come to compromises over the Bill.  According to Schoolhouse Rock, Congress creates laws and then if passed, the President signs them into law.  The President often pulls opposing factions together, encouraging them to get a Bill to his/her desk.  For most of President Obama’s term, about 20,000-30,000 young Americans have died each year– far more than the total number of Americans killed by war, terrorism, hurricanes, and other natural disasters combined.    Until a month ago, I’ve heard absolutely nothing from the US President– no calls to action, no pressure on lawmakers, no requests to call our congresspersons.  But as the TREAT Act was introduced in the Senate, President Obama announced that he will raise the cap by Executive Order.  A supporter of the President would say (I know, because I’ve heard them) that the important thing is that it got done– so who cares how it happened?
Readers of this blog know that I pretty-much dislike everybody… so it is no surprise that I’m not happy.  We have the TREAT Act sitting in Congress, needing a simple majority to be sent to the President’s desk and signed into law.  During an epidemic of overdose deaths, the support would not be difficult to find for most Presidents, even with an ‘obstructionist Congress’, as our President likes to call them.  A change in the law would be relatively PERMANENT, unlike an Executive order– which can be changed with a new President, or with a new set of political calculations by the same President.   And an Executive Order to change rules at HHS requires hearings for citizen comments, which take more time– time when more patients will die.  Shouldn’t President Obama have used the operations that other Presidents used for far-more controversial issues, and changed the law?  This temporary, delayed Presidential action will get kudos from articles like the one in the Daily Beast.  And Obama gets TV time and headlines to describe how he addressed the opioid epidemic, on his own– in spite of a ‘obstructionist Congress.’
What irks me the most, though, is that an Executive Order didn’t need to take seven years.  By 2010 the overdose epidemic was well-underway, and had already killed a couple hundred thousand young people.  Did President Obama need to wait until the TREAT Act was almost at his doorstep before taking ANY action to stem the surge in overdose deaths?  From the sidelines it looks like the deaths themselves didn’t provoke a response.  But the threat of bipartisan action during an election year?  I guess that’s another story!

Kratom, Recovery, Elections

I received a question about Kratom, and searched for a earlier post about that plant/substance.  That post came shortly after Obama’s inauguration, after someone wrote to compare his experience at that event to his experience taking opioids.  Funny how every ‘high’ has its own ‘morning after!’
That Post:
On a message board called ‘opiophile’, a person wrote about being a long-term opiate addict, then taking methadone for a couple of years, then going on Suboxone for a couple of years.  He eventually stopped Suboxone, and had a miserable period of withdrawal… which never, by his recollection, ever totally went away.  He works for the Democratic Party (not secret info– it was in his post) and eventually used opiate agonists again (hydrocodone and oxycodone)… during his time in DC for the Obama inauguration.  He described how wonderful he felt, experiencing the opiate sensations while at the same time ‘being part of history’.
He returned to normal, boring, miserable life… until discovering a source for ‘Kratom’.  Kratom is a plant imported from Thailand that has opiate and other effects;  like many other ‘exotics’ it has not yet been scheduled as illegal by the DEA.  My understanding is that it is hard to find in pure form, and is expensive… there is also the risk of ingesting something (maybe toxic) that was substituted for what you think you are using.
In his post, the person asked if he is ‘clean’– whatever that means.  I don’t mean to be difficult here– I just mean that being ‘clean’ is different to different people.  Some people consider themselves ‘clean’ as long as they avoid their ‘drug of choice’…. the use of marijuana not a concern as long as they are depriving themselves of the Oxycontin that they REALLY want!  I don’t agree with that definition, but I can see the point of at least avoiding the things that are the most likely to cause problems.
He also asked if he was running the risk of returning to the same problems that have been a part of his life for many years.  I think the answer to that question is obvious to everyone reading this blog!  As for my other thoughts, I copied them below.
My Reply:
Kratom contains chemicals that includes mu receptor agonists– the chemicals do not show up (yet) in drug screens, but taking them is no different from activating mu receptors with anything else, legal or illegal. And the fact that Kratom is a plant should not make you think it is somehow ‘different’; if the chemicals in Kratom prove safe enough, they will eventually be extracted, identified, manufactured, and marketed in pill form– and will likely be DEA scheduled at that point.
Please read my article on the relationship between Suboxone and traditional recovery. I am aware of the anger some people have toward buprenorphine, but I think your case is the best argument for Suboxone that one can make.
You have had this endless malaise off opiates, and you seem to blame Suboxone (or if you don’t, I know that many people do– they use opiates for years, then go on Suboxone, then when they stop Suboxone they blame it for endless withdrawal symptoms). But the brain doesn’t work like that; tolerance occurs from agonist or partial agonist stimulation of a receptor, and the tolerance is reversible– at least on the ‘neuronal’ level. There is no reason that one drug, say buprenorphine, would cause a more ‘permanent’ state of tolerance than another drug.
I HAVE seen people with an almost permanent state of opiate withdrawal; I have not seen this so much in relation to specific drugs, as to their degree of ‘addiction’. Listening to your experience with opiates, one thing is clear– opiates are a huge part of your life. Even watching your dream candidate be inaugurated is not ‘enough’ of a kick in life; you wanted more. In fact, by your description, I don’t know which would have been a bigger bummer– seeing someone else getting into the Presidency or being deprived of that ‘buzz’! I’m not taking ‘pot shots’ here–I’m trying to add some insight, and I hope you take it as intended. The ‘person’ that you have become… PERHAPS that person just cannot exist without some level of mu receptor activation. Perhaps that whole ‘psyche’ requires the pleasant warm fogginess of an opiate– and without that, the psyche is miserable. If that is the case, of course you will be miserable off opiates— whether the missing opiates are heroin, methadone, Kratom, or Suboxone. The problem is that at least with the first three of these agents, there is no way to take them without ever-increasing tolerance, which eventually leads to cravings, compulsive use, and greater misery.
We know without a doubt that SOME addicts do recover, most often by using a 12 step program. How do THEY do it? I see the answer as consistent with the idea of a ‘psyche’ that needs opiates vs one that doesn’t need opiates. People who ‘get’ the 12 step programs can live without opiates because they have become completely different people. Treating addiction, we know that a person who simply sees the treatment as ‘education’ is not going to do well; people really need to change who they ARE– completely!
To put it into math form: Person ‘A’ plus opiates = an intact person; Person ‘A’ minus opiates = a miserable person; Person ‘A’ + NA = Person ‘B’ = an intact person. Maybe this last bit was a bit over the top… but hopefully you see my point.
I realize that some people will just never ‘get’ NA or AA; the question is, can those people ever be happy without exogenous opiates? I should add that there are other recovery programs out there that do, or intend to do, something like AA and NA, without the religious dimension– I am including them in the same way as AA and NA, although I don’t know as much about them. But knowing what I know about addiction and recovery, I doubt ANY program will make an addict ‘intact’ through education alone; in all cases I would expect the need for that person to change in a significant way.
In my opinion, the answer to the question is ‘no’– that a using addict, minus the object of use, without personality change, will always be miserable. Enter Suboxone… or more accurately, buprenorphine… and there now is a fourth option besides ‘sober recovery’, using (and misery), and ‘dry misery’. Buprenorphine provides a way to occupy mu receptors at a static level of tolerance, therefore preventing the misery that comes with chronic active addiction. And it allows a person to feel ‘intact’ without the need to change to a different person.
Buprenorphine fits well with the ‘disease model’ of addiction; the idea that an addict needs chronic medical treatment, and that if the treatment ceases, the addiction becomes uncontrolled, resulting in either active use or in your case, miserable ‘sobriety’. As for those who are ‘purists’– who think that every addict needs to get off everything and live by the 12 steps– I am glad that works for you, and others likely will envy you. But note that many, if not MOST, opiate addicts in recovery will relapse at some point in life– maybe multiple times. Recovery programs are not ‘permanent’; they need ongoing attention and activity, or they tend to wear off. There is no ‘cure’ for addiction; we ‘maintain’ addicts either through recovery programs, or now, through medication.
One last comment– I do know a person who was stable on Kratom for several years until suddenly going into status epilepticus with grand mal seizures over breakfast one day, in front of his wife and children. An extended work-up showed damage to multiple organ systems that seem to now be getting better after a couple of years. The studies never determined whether the organ damage came from the Kratom itself, or from some additive or pesticide used in Thailand. Use foreign substances at your own (substantial) risk!
JJ
Suboxone Talk Zone (dot com)