So You Thought You Could Get Off Suboxone?

Why is there no official medical protocol to detox addicts off of Suboxone? The Fix goes to the pharmaceutical companies for answers.

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By Dawn Roberts

09/04/14

Maybe the headline in the press release for Bunavailsays it all: First and Only FDA-Approved (Buccal Formulation) of Buprenorphine and Naloxone to compete in the $1.7 Billion and Growing U.S. Opioid Dependence Market.

$1.7 billion and growing, they got that part right. Heroin and prescription opiate addiction are massive, under treated and under reported conditions in the U.S. By2013 estimates there are over 669,000 opiate addicts in the United States. It's jarring to see a press release referring to opiate addiction as a high competition market for pharmaceutical companies. That, however, is the case, and the heart of the issue when it comes to understanding why Big Pharma enthusiastically went after the market in 2002. That's when the first buprenorphine/naloxone combination (Suboxone, from Reckitt-Benckiser Pharmaceuticals) received FDA approval.

During the time before Reckitt-Benckiser Pharmaceuticals received the green light to bring Suboxone to market, the company was one busy bee. They lobbied congress to create the Drug Addiction Treatment Act of 2002 (DATA) and worked with the National Institute on Drug Abuse (NIDA) and FDA to lay the groundwork for the successful introduction of their product into a needy marketplace. DATA's passing created a waiver for physicians with specific certification to provide schedule III, IV or V narcotics for detox and ongoing treatment. Buprenorphine (the powerhouse ingredient in Suboxone) was developed back in 1969 by Reckitt & Coleman (now known as RBP). They were attempting to develop an opiate derivative, harnessing pain-killing properties and sidestepping its potential for addiction. This required ten years and millions of dollars to cultivate the formula and an additional 13 years to bring Suboxone to market.

The emergence of the most recent opiate derivative can be framed in a historic context. Since the synthesis of opium in 3400 BC, mankind has danced with the devil, attempting to utilize the drug's benefits and avoid getting burned. Morphine was created in 1817, codeine in 1832, and in 1874, heroin. For a time each of these compounds was thought to be a less addicting substance. By 1914 heroin became available only by prescription, and in 1924 was classified as an illegal narcotic. The narrative of today's heroin addict moved in tandem with the activities of pharmaceutical companies. Oxycontin came to the US in 1996 and was aggressively marketed as (guess what) a less habituating alternative to morphine. By 2001 it was number one with a bullet, the highest selling narcotic pain reliever. In 2010 the formula was altered making it more difficult to crush, snort or inject. The combination of high street prices for Oxycontin and the lower cost of heroin moved some prescription drug abusers to jump the fence.

Vermont Pulls the Covers on Heroin Addiction

The Governor of Vermont dedicated his entire 2014 State of the State speech to heroin addiction. The syndrome has a chokehold on his state. In the bucolic home of Ben and Jerry's ice cream, maple syrup and same sex marriage, the Governor’s entire narrative goes to opiate dependence? You can be sure the problem has gone mainstream. Heroin addiction has swung from being an inner city to a suburban and rural crisis. The demographic shift from young, poor and brown-skinned to post-collegiate suburban and white continues to shock the media.

Globally there are an estimated 9.2 million heroin users. According to the World Health Organization this is triple the figures from 1985. One of the difficulties in quantifying the scope of opiate addiction is that reporting tends to come from treatment centers and other institutions.

In the United States accurate data is also hard to come by. WHO estimates the number of opiate addicts (including heroin) to be two million. Figures from The National Alliance of Advocates for Buprenorphine Treatment (NAABT) puts that figure at 5.5 million. We don't need charts, graphs and annual reports to tell us that opiate addiction is a disaster. Communities around the country once naive to the consequences of active addiction have been thrust into the squall. The Center For Disease Control (CDC) reports opioid analgesic consumption increased 300% between 1999 and 2010, and death rates for poisoning involving opioid analgesics more than tripled between 2000 and 2010. In 2014 the skyrocketing number of 911 calls and overdoses related to heroin and prescription drugs are traumatizing communities they never touched before, and the problem is not going away.

The Scope of the Buprenorphine Market

According to RBP's 2013 annual report, Suboxone had sales of $1.2 billion. It is ranked at #39 of the top 100 drugs prescribed in the U.S., placing it above Viagra, Adderall and (generic) hydrocodone. To give this sum context, Suboxone revenue is three times that of Super Bowl advertiser/provocateur Go Daddy, and dwarfs brands including Urban Outfitters and Ameritrade. In the U.S. more revenue was generated by Suboxone sales than the entire digital music download business. Other companies have arrived or plan to enter the market including Orexo (Zubsolv) and BioDelivery Sciences (Bunavail).

Getting Off Suboxone

RBP created and dominates the buprenorphine/naloxone market. Some patients who have been prescribed the drug decide they want to discontinue it. The reasons vary, ranging from financial pressures arising out of the cost of doctor visits and medication to side effects, potential future side effects and finally, the patient who wants to be 100% drug free.

Regardless of the reason one has for ending replacement therapy, making the choice presents a whole new set of challenges. Suboxone is a hard drug to kick. The medication's long half-life combined with its tight adhesion to opiate receptors makes tapering particularly difficult. From anecdotal reports, the least disruptive way to achieve a Suboxone-free life is to cut down the amount used very slowly week by week until titration is complete.

This scenario is complicated by two facts:

The lowest strength Suboxone comes in is 2 mg. (”Jumping” from a 2 mg dose can be a drawn out and debilitating process that takes months to recover from);

RBP warns against cutting Suboxone strips into smaller amounts, and maintains that the medication is not equally distributed in the preparation.

If you ask the doctor who has been prescribing you the drug for months or years, you may find him/her woefully lacking in experience or a plan for tapering. Some physicians continue to murmur the mantra of RBP, that a majority (95%) of patients who go off the remedy will return to active addiction. The overall statistics on recovery from addiction reflect this same figure. The fact is that a high percentage of people who try to get clean fail. Some fail many times before achieving freedom, and some die. Confusing the rhetoric of a pharmaceutical company with studies on the outcome of addiction treatment is a mistake.

This perception is changing. Four doctors I spoke to while researching this article told me they have successfully tapered patients formerly on replacement therapy. A successful taper requires adopting a combination of daily cardio exercise and mindful nutrition to repair and rebuild body and brain. For some a spiritual program is central.

While there are lower strength formulations of buprenorphine on the market (that would make tapering a more simple and accurate process) they are created for pain management and are illegal to prescribe to recovering addicts. Physicians routinely prescribe medications for "off label" use, but there are many laws directed towards prescribers of buprenorphine and they have serious repercussions. A doctor could lose his/her license for prescribing a Butrans patch to help taper a patient off of Suboxone.

Getting certified to prescribe buprenorphine is remarkably easy. It requires completion of one eight hour online course. The amount of time in the course agenda dedicated to taking patients off off the drug is nil. No doctor I spoke with recalled the topic of withdrawal from Suboxone being mentioned during the certification process.

Many doctors have found that prescribing Suboxone is akin to installing an ATM in their waiting rooms. It’s the perfect storm. Patients are desperate when they come in, willing to pay significant sums of cash for services, and rarely shop around for the perfect fit between patient and practitioner. In many cities there is a waiting list to get in to see a doctor able to prescribe. No background in addiction medicine is required to take the course. This creates a wide berth for physicians who may be opportunists to cash in on the vast and growing population of opiate addicts frantic for a solution.

Wrestling with Big Pharma

The difficulty of compelling a pharmaceutical company to take suggestions from the public is directly related to the power Big Pharma wields in the United States. Pharmaceutical companies spent almost three billion dollars lobbying the U.S. Government in the last five years. Pharma is thelargest of all 121 lobbying entities and donated over $90 million dollars to federal candidates and political parties.

Advocates for an exit strategy from Suboxone have the weight and effect of a single fly in the chardonnay of Big Pharma. There are some lobbying groups working on issues of addiction treatment, and the numbers of these groups are growing. New York, Florida and Pennsylvania have advocacy groups, but their efforts tend to be focused on broader stroke issues. With an entire health care system in transition, obtaining any treatment for addicts is the fight these groups are concentrated on.

Big Pharma's Inconvenient Truth

Pharmaceutical companies gross massive annual earnings; a whopping $950 billion dollarsglobally. It is an industry of Goliath momentum and political reach. Relying upon recipients of lobbying influence to look their gift horse in the mouth? In the battle of ethics and commerce, conscience rarely rears its inconvenient head. Like Jesse from Breaking Bad, we might ask “What about science, bitches"? Where are the impartial and sovereign scientists? The reality of scientific investigation means taking marching orders from drug companies. For more on this topic read Jacky Law’s examination in her book, Big Pharma - Exposing The Global Healthcare Agenda.

Knee Deep in the Muck

With these facts in mind, I reached out to RBP, Orexo, and BioScience Delivery International. My outreach to RBP is particularly pertinent, since they are both the creator of Suboxone and the market leader. It’s key to understand that the first company to bring a pharmaceutical product to market jumps through extra hoops in order to obtain first entrant advantage. The company had to work closely with the FDA and NIH to first prove that there was a need for the drug. They also worked together to establish dosage protocol, and in the case of Suboxone, on establishment of a certification program so that physicians could legally prescribe the drug (using a narcotic to treat narcotic addicts was against the law until DATA was created in 2002). The intimate relationship between RBP, the NIH, NIDA and the FDA raised a red flag in my mind.

The initial safety and dosage protocol studies created to bring Suboxone to market have not been revisited since 2002. Since the drug has been in the market for 12 years, it seems prudent to have a look at how people on long-term maintenance are faring.

There are no FDA regulations requiring re-evaluation of a drug and its side effects over time. In the past new studies were prompted by negative outcomes not identified during clinical trials. Post-marketing investigation uses a number of methods to check on the safety of drugs: reporting databases, prescription monitoring, electronic health records, patient registries, and linking records between databases. In the U.S. post-marketing surveillance is overseen by the FDA through MedWatch where doctors or the public can report adverse reactions to drugs.

Gambling in High Places

Addiction to gambling is not exactly the same as an addiction to a substance, but the compulsion it inspires and the wreckage it creates are on the same level.Shutterstock

By Kathleen Phalen Tomaselli

09/03/14

A Guide to Gambling Addiction

Can a Pill Cure Gambling Addiction?

Children At Risk From Online Gambling, Expert Says

Death of a GamblerWhen the parishioners of St. Mary’s and St. Mark’s, two small western New York Roman Catholic churches, dropped their dollar-filled envelopes into the collection plate each Sunday, they entrusted Sister Mary Ann Rapp with their donations. After all, the gray-haired nun had devoted 50 years to serving others. So the unquestioning donated, and the nun pilfered, diverting nearly $130,000 into slot machines at various western NY casinos. Sister Mary Ann Rapp was sentenced last year to 90 days in jail, five years of probation, 100 hours of community service, and restitution of stolen funds. 

In a similar scenario, Monsignor Kevin McAuliffe, referred to as Father Kevin by his parishioners at St. Elizabeth Ann Seton, a parish in the Las Vegas Roman Catholic Diocese, tapped $650,000 from votive candle offerings and gift shop funds to finance a video poker and casino gambling obsession. Father Kevin was sentenced in 2012 to three years and one month in prison, plus three years of supervised release and $650,000 in restitution. 

And what about Maureen O’Connor, the former San Diego mayor who devoted years to serving the city? A political phenom, O’Connor secured a city council seat just three years out of college and later a two-term run as the first female mayor of California’s second-largest city. But her swift and honored ascent collided with a nine-year gambling obsession which she described in a CBS-interview as heroin-like. 

Her wagers at San Diego, Las Vegas and Atlantic City casinos burgeoned along with her video poker obsession and daily losses easily topped $100,000. As O’Connor’s debts grew, she initially liquidated her inherited $50 million personal fortune. But like Father Kevin and Sister Mary Ann Rapp, O’Connor eventually plundered reserves allocated for those less fortunate, bankrupting the charitable foundation of her late husband—Robert Peterson, Jack-in-the-Box founder—the R.P. Foundation. 

But unlike the nun and the priest, O’Connor was able to make a deal with the court to avoid prison time if she is able to repay the foundation in two years; something she says she always intended doing.

“I think they may rationalize that they are borrowing the money,” says Carole Lieberman, MD, a Beverly Hills psychiatrist who treats gambling addicts. “But it rarely gets paid back.” 

It is not uncommon for public officials to also be compulsive gamblers, because for both types, the aphrodisiac is power. It is essentially a gamble for someone to run for public office, investing a lot of money and time on the chance that they might win. Then, once elected, their access to public coffers makes it very tempting to steal, in order to feel another powerful high by gambling at the usual games of chance. 

Addiction to Gambling differs from alcohol or other drugs

Differences 

Gambling connected to fantasy 

Gamblers favor suicide, alcoholics helpless and hopeless 

Fully functional until hitting bottom 

Money seen as drug and power 

Gambling disease model harder to accept 

Cannot measure gambling through blood, urine, or hair 

Gambling sponsored by religion and government 

Bailout or big win temporarily can stop self-destructive cycle 

Gambling win seen as solution to problems 

Gamblers tend to do it alone 

More difficult to define gambling 

No saturation point for gamblers 

Gambling recovery often requires significant financial restitution 

No hangover 

No preventative medication 

Often overlooked by professionals until late stages

Source: National Council on Problem Gambling

What makes one person become a gambling addict and another a politician? “Both may come from the same place, past traumatic or painful experience. The child who grows up with nothing may compensate for that as an adult by going into public service so that s/he is never at the bottom again,” says Constance Scharff, PhD, senior addiction research fellow and Director of Addiction Research, Cliffside Malibu. “S/he may bring others up at the same time as a fighter for social justice. Another person may respond to the same situation by trying to make fast money; one way is through gambling. In other words, the same past can drive different behaviors.”

Experts suggest a prevalent belief that they will not get caught. “I would imagine that this comes from a sense of entitlement and feeling above the rules, as some leaders can feel, or even be,” says Scharff. “As far as gambling away the public coffers, people with gambling addiction gamble any money they can get their hands on – from public coffers, private corporations, charities, family members – you name it, if they can gamble with it, they will. That is the peculiarity of the gambler. The gambler, like the politician, always believes s/he’s going to win, even if the odds are against you.”

In recent years scientists have debated the origins of gambling addiction, with some pointing to neurological pathways and others linking it to a behavior addiction. Johns Hopkins’ neuroscientist David Linden, PhD, says that neural signals regulate how and why we feel pleasure, calling it the pleasure path. In Linden’s book, The Compass of Pleasure: How Our Brains Make Fatty Foods, Orgasm, Exercise, Marijuana, Generosity, Vodka, Learning, and Gambling Feel So Good, he says that the dark side of pleasure is addiction. “It is now becom­ing clear that addiction is associated with long-lasting changes in the electrical, morphological, and biochemical functions of neu­rons and synaptic connections within the medial forebrain plea­sure circuit,” he says. “Per­haps, most important, analysis of the molecular basis of enduring changes in the brain's pleasure circuitry holds great promise for developing drugs and other therapies to help people break free of addictions of many sorts, to both substances and experiences.”

Conversely, others look to certain behaviors. According to a study published in the Canadian Journal of Psychiatry, researchers from the Ontario Problem Gaming Centre studied 1,171 pathological slot machine gamblers identifying four gambling subtypes.

Type I pathological gamblers had poor impulse control, were uncooperative, and held mystical or spiritual beliefs. This group had the most severe gambling behavior, the highest level of other psychological disorders, and the highest level of substance abuse. 

Type II pathological gamblers were characterized by materialistic, controlled, avoidant behavior and aloofness. They had the highest level of alcohol abuse. 

Type III pathological gamblers started gambling as teens, sought high sensations, and were impulsive and overspending. This group was highly sensitive to reward and tended to persist on tasks. They showed no other psychological issues. 

Type IV pathological gamblers were considered high-functioning. They began gambling later in life, showed low levels of impulsiveness and sensation seeking, and they had responsible and goal-directed behavior. Few had other psychological and substance use disorders.Some may recall the 2003 film, Owning Mahowny, starring Philip Seymour Hoffman as the true life Canadian banker, Brian Molony, a self-admitted compulsive gambler who embezzled millions from the Canadian Imperial Bank of Commerce. Molony was arrested in 1982, the day after he lost $1 million at Caesars Atlantic City Hotel and Casino. Interestingly, Molony placed his first bet at the race track when he was 10 and acted as a bookie for friends in school.

In the film, Hoffman offers an excellent portrayal of the intensity of purpose, power and a sense of oneness with the cards. According to Scharff, the question is really about what gives some people drive that is far above and beyond the average person. 

“Think about what it takes to become a state governor or President of the USA. It’s more than ambition. It’s almost a type of quest. On a path like that, you’ve got to be a risk taker. You’ve got to be bold and empowered and think a great deal of yourself. You have to believe in yourself despite the odds,” she says. “We’re talking about people who desire power. These are all traits you’ll find in a problem gambler. Again, I don’t want to draw a link; there is no data at this point to suggest that politicians are more likely to become gambling addicts than anyone else, but you can see the parallels between the personality types. I think gamblers would understand politicians very well, and vice versa.”

The nun, the priest, the mayor and the banker are not alone in their gambling crimes: 

A Dallas-based firm, Affiliated Computer Services, hired Thomas H. Koch in 2001 to pursue medical insurance cases for the company’s clients. But the Wisconsin attorney, over several years, duped the firm out of $2.5 million to fund his slot machine wagers at Potawatomi Bingo Casino in Milwaukee. According to court records, the judge sentenced Koch to two years in prison, followed by four years of extended supervision. Koch must continue with Gamblers Anonymous and psychiatric treatment. He has been banned from entering any kind of gambling establishment anywhere and prohibited from gambling online. Koch must pay $2,421,768.57 in restitution, even though Assistant District Attorney Kurt Benkley said Koch has no assets and likely will never pay the money back. 

Keith Soderquist, mayor of Lake Station, Indiana, was indicted on three counts this spring, following an extensive FBI, IRS and ISP investigation. According to the U.S. Department of Justice release, Soderquist, 44, and his wife, Deborah Soderquist, 55, who was employed as the administrative assistant to the mayor allegedly used funds from the Lake Station Food Pantry account to finance gambling at casinos in Indiana and Michigan, among other charges. Their trial is slated for October. United States Attorney David Capp said, “These indictments are part of this office’s ongoing public corruption investigation.”

Casino surveillance footage shows former Braddock, PA Manager Ella Jones withdrawing more than $40,000 stolen from taxpayers to feed her gambling addiction. Braddock fired Jones from her $45,000-a-year job after she pleaded guilty to stealing $178,000 from 2008 to 2009 from taxpayer-fed accounts. A judge this month sentenced her to nine years of probation, and she must pay restitution.

Anne Elizabeth Dalton, 65, manager at the Family and Youth Services in Australia was found guilty of 271 counts of deception. She stole $100,000 from emergency funds applications for bogus victims of domestic violence, supposedly to help them find alternative accommodation. She was sentenced to five and a half years in prison and must pay restitution.

Cheri A. Logue, 42, Claysville, PA received a 22-month federal prison sentence for embezzling $90,000 in government money provided to the Southwestern Pennsylvania Legal Services Corp. She used an ATM card registered to the corporation to withdraw more than $12,000 at or near casinos on 56 occasions, investigators said. 

Nancy J. Brown, 62, is awaiting trial on charges of stealing nearly $389,000 from payroll accounts in Springfield Township, PA where she worked as township secretary. Her lawyer said she lost most of the money at Presque Isle Downs & Casino near Erie and other casinos.Treatment for these high-powered addicts can be a challenge, according to recent research. “Yes, our experience shows that 'smarter' people are harder to treat. All addicts try to work the system at one point or another,” says Scharff. “Those who are smarter can work the system better, and this works to their disadvantage when it comes to getting healthy. “

“Research shows all addicts (substance abuse or process disorders – like gambling) need highly individualized, evidence-based care,” Scharff added. “The residential phase of treatment generally lasts 90-120 days with the remainder of a year being spent in intensive, non-residential aftercare. Twelve- step programs, while certainly a good adjunct to treatment or prong of an after-care plan, are not treatment. They are support groups and while they have definite advantages, they cannot take the place of quality, evidence-based care. “

Kathleen Phalen Tomaselli has written for the Washington Post, the LA Times, USA Today and American Medical News, among other publications. She last wrote about the state of addiction funding research.

The Link Between Alcohol and Depression

Which comes first? Does depression lead to addiction or is it the other way around?

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By A.J. Dugger III

09/03/14

In the history of drug and alcohol abuse and depression, one can't help but ask the age-old question: Which comes first? Is it generally the depression that leads to addiction, or does the addiction lead to the depression?

According to a study by the National Institute on Alcohol Abuse and Alcoholism, depression usually precedes substance abuse. The study revealed that depression is often rooted in childhood. Frequently, traumatic childhood situations such as divorcing or abusive parents, molestation, or similar events trigger depression, and when the child reaches adolescence or adulthood, he can easily find an escape from his feelings by using drugs or alcohol. Children who were not depressed during childhood are less likely to start abusing alcohol or drugs, although this is not always the case. Actor and Comedian Jim Carrey used different medications to cope with a traumatic childhood. As an adult his depression worsened due to failed marriages and relationships and it continues to threaten his peace of mind, according to a source on tribune.com. "Jim has suffered from severe depression in the past, and you have to worry those fearful days are coming back again,” revealed the source. “When you talk to him, he’s not as animated as he used to be. He seems [to be] at a low point — like a ship without a rudder.”

Even as adults, depression can lead to alcoholism or addiction. Paul Williams, an original member of the legendary Motown group The Temptations, committed suicide in August 1973. Things began to go downhill for him when The Temptations began to have creative and financial problems with the Motown label during the late 1960s. According to founding member Otis Williams (no relation), the stress and frustration of the situation weighed heavily on Paul, who went from drinking milk every day to drowning his sorrows in booze. In just a few short years, Williams went from being the most wholesome member of the Temptations to one of the most addicted. When the alcohol hurt Williams' ability to perform on stage, he was removed from the group, and that's when he began to rely on the bottle even more. When Williams committed suicide he was $80,000 in dept.

There are other famous examples of depression leading to alcoholism. Former professional wrestler and actor Dwayne “The Rock” Johnson went into detail about how depression and alcohol affected his father, legendary wrestler Rocky Johnson. In Johnson's autobiography, The Rock Says.., Johnson explained how his father turned to the bottle as his wrestling career began to fade. “For a long time I never knew that he struggled with the demons of a strange world in which he lived, just like all professional wrestlers. It's a world in which aching joints are anesthetized by the roar of a crowd, and the loneliness of life on the road is soothed by the sweetness of alcohol and drugs and the touch of strange flesh.” Johnson further explained that his father had always been a casual drinker, but post-retirement was not a good period for him. “By the summer of 1991, it was clear that he was losing his battle with the bottle. Dad was basically out of the business by then, and he was having a terrible time coping with the tremendous void in his life. His pride was battered. His way of coping was to drink. For a long time, like most alcoholics, my father denied that he had a problem. But as the drinking escalated and he spent more time in bed recovering from hangovers... as the half-empty bottles piled up around the house..it became increasingly obvious that he needed help. Or he would die.”

Depression may have led to Rocky Johnson's addiction, but for other people it was the other way around. The late Whitney Houston had it all before using drugs and hitting rock bottom.However, the rumor of her ex-husband Bobby Brown introducing her to drugs is far from the truth. It was actually her older brother Michael who introduced her to drugs, something he regrets to this very day. "Every day...every day. That's something I've got to live with for the rest of my life," a guilty Michael Houston said in an L.A. Times article last year. “But you gotta understand, at the time, the '80s, it was acceptable.... In the entertainment industry it was just like, available. It wasn't like a bad word like it is now. You know what I'm saying? We didn't know. We just didn't know." Michael noted that when he and his sister first tried drugs, the singer was in her late 20s, already famous, selling hit records, and was still years away from marrying the controversial Brown. According to many who knew her, Houston was in denial about her addiction during her last decade of life. However, the more depressed she got about her sagging career, the more drugs she took. When Houston was found dead, Benadryl, Xanax, marijuana and Flexeril were found in her system.

According to several studies, alcohol abuse increases the risk for depression because of theneurotoxic effects of alcohol exposure to one's brain. According to some researchers, heavy alcohol consumption may lead to prolonged periods of depression.

Depression was once considered a “woman's disease.” But men can suffer from depression too, though they may exhibit different symptoms. While women are expected to cry or show their despair, men can be hesitant to do so and instead withdraw into themselves or become aggressive. Also, some men won't even realize they're depressed because they're unaware of the symptoms. According to a study in the Psychology of Men and Masculinity journal, men who are not afraid to show their emotions have higher self-esteem than those who do not openly express themselves. The journal cited the case of football players unafraid to cry after losing a game as an example of self-esteem being correlated with emotional self-expression. "They felt secure enough to shed tears in front of their teammates and seemed less concerned about peer pressure," wrote Derek Whitney of psychcentral.com. Of course, many men will sublimate depression and unpleasant feelings by turning to drugs and alcohol.

According to a post on webmd.com, men may deny problems because they're expected to be strong. “American culture suggests that expressing emotion is largely a feminine trait. As a result, men who are depressed are more likely to talk about the physical symptoms of their depression - such as feeling tired - rather than symptoms related to emotions." Furthermore, "The CDC reports that men in the U.S. are about four times more likely than women to commit suicide. A staggering 75% to 80% of all people who commit suicide in the U.S. are men. Though more women attempt suicide, more men complete the act of actually ending their lives. This may be due to the fact that men tend to use more lethal and violent methods of committing suicide, for example using a gun rather than taking an overdose of pills.”

John and Roberta Powell are a married couple living in Millington, Tennessee, a town outside of Memphis. After the sudden loss of their first child, the depressed couple fell into the trap of drugs and alcohol, which threatened to destroy their marriage. “Our baby Lena died from Sudden Infant Death Syndrome seven years ago,” said Roberta. “She was six months. John was always a casual drinker but just couldn't cope with it. He felt so helpless and became an alcoholic. It was his only way (to cope). I started getting high all the time using lortabs and marijuana. We were both a mess but the addictions were the only way to escape from the nightmare. Lena was our first child...our baby. And she was suddenly gone without warning. I'll never forget finding her dead in her crib.” Powell's husband says that it was the absolute worst period of their lives but with counseling and rehab they made it through. “The depression is absolutely what led to the addictions. Roberta and I are not addictive people but we were on the verge of insanity. Just seeing Roberta cry and cry...I didn't know what the hell to do. But things are much better now. We'll never forget our angel Lena, but we do have three beautiful children now.”

Sometimes a person may be depressed and use drugs and alcohol to escape their troubles, which was the case with the Powells. Other times, a person can become addicted and then lose grasp of everything and fall into a deep depression. The link between depression and addiction will always be strong. Treatment for either condition should always take into account the likelihood of co-occurring disorders.

A. J. Dugger lll is a journalist based in Clarksville, Tennessee. He recently published his first book, The Dealers: Then and Now. Recent stories were on the prescription drug epidemic in his home state and the meth lab next door to you.

PRO-ACT Family Addiction Education Program helps families address drug and alcohol addiction

Next free sessions start Oct. 1, 2 or 7 at various locations in five counties

When someone is addicted to drugs or alcohol, the disease affects the entire family. Each month PRO-ACT (Pennsylvania Recovery Organization–Achieving Community Together) hosts a free Family Addiction Education Program to help individuals and families recognize and address an addiction problem in a spouse, parent, child or other loved one. Led by trained volunteers who have been in the same situation, these information and support programs begin the first week of each month and run one evening a week for three consecutive weeks. Each session lasts two hours.

Programs are offered at several locations throughout the five-county southeast Pennsylvania region:

· Tuesdays—From 7 p.m. to 9 p.m. in Media and Northeast Philadelphia.

· Wednesdays—From 6 p.m. to 8 p.m. in Pottstown; from 6:30 p.m. to 8:30 p.m. in North Philadelphia; and from 7p.m.to 9 p.m. in West Chester.

· Thursdays—From 6:30 p.m. to 8:30 p.m. in Northern Liberties; 7 p.m. to 9 p.m. in Bristol and Colmar.

Sessions are free and confidential—first names only. Pre-registration is required. To register, call 800-221-6333, weekdays 9 a.m. through 5 p.m., or visit http://councilsepa.org/programs/pro-act/family-education-program/

Can You Still Buy Illegal Drugs Online? You Bet!

In the wake of Silk Road's demise, online drug marketplaces have become smarter and are offering a wider variety of illegal products.

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By Paul Gaita

09/11/14

From 2011 to 2013, Silk Road was widely considered the“Amazon.com” of online black marketplaces,selling an incredible variety of drugs and drug-related paraphernalia, including heroin, LSD and marijuana to users around the globe. By the summer of 2013, the site had reportedly earned $1 billion in sales,all paid through the bitcoin cryptocurrency. But within a few months, Silk Road was in tatters, its alleged owner Ross William Ulbricht arrested on suspicion of drug trafficking and soliciting murder, among other charges; most recently, bitcoin company ownerCharlie Shrem pled guilty to charges of aiding and abetting Silk Road, and faces up to five years in federal prison. The site mounted a brief comeback in a “2.0” mode in late 2013 but was again shuttered by February 2014 by hacker attacks. But as Silk Road sunk into oblivion, a new array of online drug markets rose to take its place, each offering a unique challenge to U.S. and international drug enforcement agencies.

The World Drug Report 2014 issued by the United Nations Office on Drug and Crime (UNODC), notes that the online marketplace for illegal drugs has grown not only larger but more willing to risk arrest by selling a wider and more dangerous array of substances. While Silk Road 2.0 was under siege in early 2014, a new site, DarkList, stepped into the void to connect buyers and dealers in a Yelp-style arrangement, but was soon surpassed by Agora which, as of September 2014, offered more product listings, including weapons, than any other online black market. Both were followed by such pirate vendors as Deepbay, Sheep Marketplace and Black Market Reloaded, which dubbed itself “Silk Road without morals” (for making available weapons and child pornography to buyers), all of which took pages from Silk Road by only accepting bitcoins for payment and protecting its users with the anonymity software Tor. Sales figures are impossible to determine, given the levels of encryption utilized by these sites, but they are estimated to be a small fraction of the global drug trade, which brings in an estimated hundred billion dollars. A portion of that amount would still result in staggering levels of income.

Not all of the sites have struck gold on the black market – Atlantis Market, once touted as the heir to Silk Road, closed up shop and made off with its customers’ payments shortly after Silk Road’s first shutdown. But as online drug sale figures clearly show – according to the UNODC, seizures of marijuana sales delivered through the postal service have escalated 300% in the last decade – web sites will continue to use the darker areas of the Internet regardless of the potential danger. For law enforcement, this new environment nullifies much of the traditional methods of tracking down and arresting drug traffickers.

Key to the challenge in corralling the online black market is the method of payment – bitcoin – and the means of accessing dealers through the Tor network. The virtual currency is very difficult to trace, while the Tor network – short for The Onion Router Network – connects users and website owners through a two-fold means of security. Users who wish to conceal their online footprints log onto Tor and have their data dispersed throughout the Internet, concealing the origin of their search. Website owners use Tor’s “hidden services,” which open up a “dark net” that makes traffic untraceable, even to Google’s spiders. Also posing a problem for law enforcement: the geographic spread of dealers selling on sites. At the height of its power, Silk Road offered 13,000 listings that originated from 10 different countries. The Federal Bureau of Investigation (FBI) has admitted that no concrete data exists on the exact location of dealers selling on black market sites.

Online sellers and marketplaces aren’t completely untouchable – Ulbricht, who operated under the moniker “Dread Pirate Roberts,” led the FBI to his door by connecting the Silk Road service to a Virtual Private Network and not Tor, though some suggest that the agency used malware to hobble his servers. But the sites that followed Silk Road’s rise and fall are learning from its mistake, and improving their own levels of encryption to prevent such vulnerabilities from compromising their business. Though online drug sales are only a small part of the worldwide narcotics industry, the UNODC predicts that it may be the shape of things to come. “If the past trend continues,” it noted in its World Drug Report, “[online black markets] have the potential to become a popular mode of trafficking in controlled substances in years to come.” 

Paul Gaita is a Los Angeles-based writer. He has contributed to The Los Angeles Times, LA Weekly, Amazon and The Los Angeles Beat, among other publications and sites.

13 Valuable Alternative Treatments for Addiction

The Fix lists some outside-the-box modalities that are playing increasingly important roles in substance abuse treatment.

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By Jeanene Swanson

09/08/14

It’s safe to say that alternative treatments for addiction are no longer, actually, alternative in the “outside of the mainstream” sense. These days, many treatment facilities and therapists offer an array of these types of "supplemental" therapies, including acupuncture, equine (horse) therapy, neurofeedback, biochemical restoration, hypnotherapy, yoga, watsu (water therapy), meditation, ropes courses, sound therapy, and many more. Additionally, researchers are proving that experimental treatment with psychedelic drugs—though still illegal in the U.S.—can have profound effects on reducing cravings and preventing relapse. 

There still remains controversy among many recovery professionals as to whether "alternative" treatments can hold their own. The dominant view in the profession is that such treatment modes can be highly effective complements to traditional treatment, helping recovering addicts and alcoholics to muscle through early sobriety. But these techniques can’t do the recovery job alone; a “holistic” therapy such as meditation, for example, should be used in conjunction with traditional treatment-as-usual approaches. “I am not aware of any research supporting the sole use of holistic treatments for chemical dependency,” says rehab center program director Leslie Sanders. 

Even so, advocates of many of the treatment modes argue they can have a profound if not crucial influence on recovery. What follows is a guide to some of the dominant and most promising alternative treatment modes and the evidence of their effectiveness, either as stand-alone or supplementary treatment strategies. 

NAD

Nicotinamide adenine dinucleotide (NAD) is a coenzyme derivative of vitamin B3 - otherwise known as niacin—found in all living cells. NAD is a key agent in metabolism, as well as many other basic cellular processes. Because it is essential to the production of energy in our bodies, it has become a valuable resource for helping addicts, especially when used in mega-doses, for rapid detox. In many cases of substance abuse, the body’s reserves of protein and vitamins—precursors to NAD—are low, resulting generally in low energy.

The mega-dose treatment is in IV form. It is thought to reduce cravings and withdrawal symptoms in patients without using replacement therapies. According to reports, it has been used successfully to treat addictions to prescription drugs including opiates, benzodiazepines, and stimulants, alcohol, cocaine, marijuana, suboxone, and methadone. Results may include improved mental clarity, increase in cognitive function, returned focus and concentration, more energy, better mood, and more positive outlook. Advocates claim it opens addicts up to participate in effective therapy. Bill Wilson, the founder of AA, became an advocate of large doses of vitamin B and once claimed that it was the most effective help he had ever received. The AA board refused his appeal that AA should promote the concept to its members.

Neurofeedback

Neurofeedback is a process by which electroencephalography (EEG) sensors are attached to one’s head which allows the brain’s activity to be fed back into a computer that displays brain waves in real time. The subject can then interact with her brain waves in order to alter them, directly impacting their frequency.

The procedure is a form of biofeedback, and it has been used for treating a variety of conditions, namely PTSD. Over the past five years, neurofeedback has been gaining traction as a form of alternative treatment at leading recovery and rehab centers. Some addicts claim that it helps with everything from anger to insomnia—key triggers for relapse. The limited science on it is positive but funding for a range of credible controlled studies has been hard to come by. 

In essence, neurofeedback can increase or decrease states of arousal—a level of neural activity linked to brain wave frequency. An anxious person would obviously aim for a calmer state (a lower frequency) in a neurofeedback session; someone depressed would seek to create higher frequency and more neural arousal. “It can help keep [addicts] from leaving treatment early,” says Matt Morgan, a neurofeedback treatment specialist. While neurofeedback has a 40-year history, it is still in its infancy as a treatment form for substance disorders. Morgan says there is “no medication out there with such a wide [therapeutic] use.”

Ibogaine

Ibogaine is an alternative treatment for opiate addiction. The product of the root bark of an African rainforest shrub, Tabernanthe iboga, ibogaine is used ceremonially by the Bwiti tribe of Western and Central Africa to induce visions and shamanic experience. While it has been categorized as a psychedelic, it is more intense and longer lasting than LSD or mushrooms. It can have dissociative effects as well as sometimes serious effects on motor control, similar to those of the anesthetic ketamine. In the brain, it affects multiple neurotransmitter pathways, making it difficult to discern which effects are most significant.

While animal and human research data show that ibogaine undoubtedly does relieve opioid withdrawal—and the drug is now being used in dozens of clinics around the world, often illegally—it is important to know that ibogaine is apparently not as safe as was once believed. It mixes poorly with many pharmaceuticals as well as narcotic drugs and alcohol. It is illegal in the U.S., although Canada, St. Kitts and Mexico have government-regulated facilities that offer it legally. In Mexico it is considered an “experimental” drug and the most advanced medical clinics only use it with patients who have passed a battery of medical tests. 

Outside the U.S. it is used to treat addiction to methadone, heroin, alcohol, cocaine, methamphetamine, anabolic steroids, and other drugs. Ibogaine is also used to treat depression and PTSD. Derivatives of ibogaine that lack the substance’s psychedelic properties are under development.

Meditation/Mindfulness Practices

Meditation is the art of practicing mindfulness, and 12-step programs and counselors alike recommend it as a method to prevent relapse. Gaining mindfulness helps substance abusers become aware of their thoughts and feelings, good and bad, but not react to the negative ones—a key step forward in preventing relapse.

Mindfulness meditation is also a good way to help regulate mood. It can lower the levels of stress hormone cortisol, increase immune system compound interleukin, and assist in the body’s ability to detoxify itself of harmful chemicals, which can affect neurotransmitter receptors and alter mood.

Different types of mindfulness meditation exist. Vipassana meditation teaches the mind not to react to the emotions and thoughts that result in harmful behavior. Some adherents claim that with enough practice, it’s possible to become permanently free of all negative behaviors—addiction included. The Transcendental Meditation organization claims that controlled studies demonstrate that TM “compared to other forms of meditation and relaxation significantly reverses physiological and psychological factors which lead to substance abuse. Compared to control conditions, TM significantly reduced the use of alcohol, cigarettes and illicit drugs in general population as well as among heavy users. Over time abstinence was maintained or increased.”

In fact, an increasing number of studies indicate that mindfulness-based relapse prevention techniques do reduce cravings and prevent relapse as well as, if not better than, traditional treatment. The journal Substance Use & Misuse published an entire special issue in April, 2014, focused on mindfulness-based interventions for substance use disorders. Katie Witkiewitz, an associate professor of psychology at the University of New Mexico, published two studies this year that found that mindfulness-based relapse prevention was more effective than a traditional relapse prevention program in decreasing substance use and heavy drinking up to one year later. “There have been several randomized clinical trials, as well as smaller controlled studies, that have found meditation to be as effective or more effective than existing treatments for addiction,” she says.

Biochemical Restoration and Nutrition 

A new type of treatment, biochemical restoration, aims to repair the biochemical imbalances that cause cravings, depression, anxiety, and the unstable moods that lead to—and perpetuate—addiction.

There are certain biochemical imbalances that make a person more prone to addiction and which this treatment—a form of chemical nutrient therapy—strives to improve. These include imbalances of neurotransmitters in the brain, nutrient deficiencies, amino acid imbalances, hypoglycemia, inflammatory and oxidative stress, and adrenal fatigue.

Once biochemical imbalances are assessed, an individualized biochemical restoration plan can be established. This can include a personal nutrition plan, a micronutrient supplement including amino acids (sometimes with a futuristic approach of micronutrient injections), and prescribed physical activity and relaxation. Once balance is restored, other addiction treatment modalities such as counseling and relapse prevention can be tackled more effectively. 

David Wiss, a Registered Dietitian Nutritionist who operates a consulting company, Nutrition in Recovery, in Los Angeles, believes the single most ignored aspect to treating addiction is treating nutritional deficiencies. Many other nutritionists second this. Recovering addicts tend toward highly palatable foods that can provide a temporary reprieve from negative feelings. These are almost invariably processed foods with added sugar, salt, and vegetable oil fats; refined carbohydrates, and caffeine—rather than high-nutrient foods. Unfortunately, these foods destabilize blood sugar, spur inflammation, and deplete the brain of essential neurotransmitters that play a large role in stabilizing moods.

Wiss believes that “nutritional interventions [should be] based on real food rather than supplementation.” He recommends a “never hungry, never full” approach of eating six small meals a day, or every two to four hours. Addicts should strive for more protein, fiber, and healthy fats like those found in fatty fish, nuts, and flax seeds. Certainly, learning about nutrition, how to cook healthful meals, and making good food choices are accessible options for the majority of people in recovery.

From a nutritional perspective, an individual in early recovery can improve mood and fight off depression, anxiety, and stress by incorporating foods that contain an ample amount of omega-3 essential fatty acids, complete proteins, and antioxidant and anti-inflammatory vitamins and minerals. These foods will also help the recovering addict’s mind—provide essential building blocks for depleted neurotransmitters, for example—as well as the body, promoting healing of all systems and tissues damaged by malnutrition.

For a superb, science-based chart of eating do’s and don’ts click to see nutrition investigator David Asprey’s "Bulletproof Diet Roadmap." 

Yoga

Yoga, which means “union” in Sanskrit, combines three aspects: physical postures, breath work, and meditation. The philosophy of yoga is to bring the mind, body, and spirit together in a united alignment. This can promote a state of inner peace that might assist recovering addicts in preventing relapse. Many studies indicate yoga can relieve anxiety, stress and depression.

The physical aspect teaches bodily awareness and how to release pent-up emotions and stuck energy. For many in recovery, there has been a disassociation from the body through the use of drugs, alcohol, food, or other substances. Through practicing the physical “asanas,” recovering addicts can become aware of their outdated behavioral patterns and make the conscious decision to change. 

Breath work can be a key aspect of healing and recovery from addiction. The lungs are the link between the circulatory and nervous systems, and they provide detoxification, energy, and a built-in relaxation response.

Meditation is important because it allows recovering addicts a deeper sense of self-awareness. By becoming less influenced by the world around them, addicts can learn to shrug off cravings and embrace their inner strength without the need for external validation through substances.

A network of yogis called Yoga of Recovery offers courses and retreats for recovering addicts at leading yoga centers all over the country, including Sivananda and Yogaville. 

Exercise

Daily exercise, even in small doses, can boost mood—what most recovering addicts need in the absence of their substances of abuse. Starting an exercise regimen can help fill the void of using,lending a sense of purpose and offering a substitute, but natural, high.

Generally speaking exercise, whether aerobic or otherwise, has well-known health benefits, including improvements in the function of the cardiovascular, pulmonary, and endocrine systems. Physical exercise has many cognitive benefits that can specifically help recovering addicts. For one, it leads to increased neurotransmitter levels, improved oxygen and nutrient delivery, and increased neurogenesis in the hippocampus. It can have a positive effect on learning and memory. Executive control processes—working memory, multitasking, and planning—are more positively affected in comparison to other regions of the brain.