AMT - addiction management therapy. Drug assisted. Also called MAT - medication assisted treatment

Are We Treating One Drug For Another?

It is not treating one drug for another, as commonly believed. Buprenorphine transforms lives, and the data is there. Those incarcerated that use, heroin most commonly, lost their underlying tolerance. When released, they went back to their "regular" dose. No tolerance, overdose, death. Get them buprenorphine, get them back into society.

Craving controlled, and desired substances, is a return to heroin, and should be extinguished. Another study separated opioid addicts into two groups in treatment. Both had good psychosocial support. One group was treated without buprenorphine, but also had receieved outpatient therapy, and they went head to head without patient support therapy and buprenorphine. Result - buprenorphine-free group started dropping out in a week. Their tolerance was diminished or gone. All dropped out eventually. The buprenorphine group however stayed in treatment. And this robust trend occurred over a year. With no way to prevent cravings, the group that receieved outpatient therapy developed and only thought of "heroin" and is a lesson. If plan A doesn't work and is a failure, cross over quickly, particularly in the world of addiction. The buprenorphine-free group had four deaths when they left. The message is this. With pharmaceuticals, forces of reason don't always match need.

The federal government acknowledges a severe opioid epidemic (it's really a fentanyl heroin epidemic, the prescription pill problem is that, but look at fentanyl heroin). The claim that more people die from prescription drug overdoses than from car accidents is a fallacy of generalization. More on this later. A healthcare provider can write (prescribe) and historically encourage too, indefinite doses of opioids. On the other side of treating this self-defined epidemic, physicians are limited to a small number of patients that may rec lifesaving buprenorphine, and must be approved to do so. A complete logic failure. Most prescription opioid addicts were prescribed by a provider with no pain training, and scant knowledge regarding opioid management. I believe that non-steroidal anti-inflammatory agents may eventually share a common fate. These drugs are taken from our armamentaria because the fallacy of false generalization, once again, is reinforced by bad information.Overdose, What Killed

Special acknowledgement Sandy Silverman MD.

It usually starts like this....

Exposure

An individual is given a substance. The substance is reactive and creates a physiologic event. Let's call this substance a drug. The drug effects a change in biochemistry, dynamics, and experience. In the scientific world, it creates this physiologic response, effecting the recipient and its biology. In this case, it's a human.

Pharmacokinetics is pharmacodynamics is, and we need them both. We react, now the drug has to go. Elimination, transformation, excretion. This substance has a personality. Like a bad house guest it stays too long, where the joy is fleeting, and influence like a brief love affair. Or influences.

Will I see you again? I'm falling for you. Some leave and the place is a mess, bad feelings, a hangover only repelled by a re-invitation, baggage and all-I need you. I want/must have you. The heat races, pounds, the eyes tear, the gut recites an unpleasantry, and you shake.

Of the millions of potentially habit forming compounds, only about 100 natural ones exist that are habit forming. Not many. Some have been added to the list by the wonders of chemical design, but the theme, and the common thread is the same. Exposure, then dopamine ...

Dopamine

Gasoline makes the car move. Dopamine feeds the stupid center, the nucleus accumbens. The brain, behind the ear is phylogenetically old and primitive. Illogical, and full of desire. The basic desires are fed by dopamine through a reward circuitry.

VTA, ventral tegmental area, nucleus accumbens, a few other places, and it proceeds the prefrontal cortex. Fed by dopamine. Desire, craving, illogical behaviors may revolt if dopamine runs low, or under performs. Mood, actions, physiologic consequences follow. I need more dopamine, and this is dependence, on the way to addiction. There is dopamine out there and I know how to get it.

Dependence

This is not addiction. It is a physiologic response to lack there of what? No Starbucks?

Tolerance is not addiction. Tolerance is a process of familiarity. And adjustment. Boredom. I saw your single shot of latte, now I want a double, a double or you'll feel bad. Hedonic, melancholy.

Hedonic tone

If tolerance tells one I need more so I don't feel bad, and dependence has a normal adjustment to a drug, where is addiction? Well it's a bunch of places. Addiction is about you, where you come from, and what you took. I do not like this feeling, where's my (blank) Fill in the blank.

Once a day, many times a day, some people have never felt really normal, or content, until their first exposure to a favored drug. Now as I need more for this feeling, tolerance, and I don't want to feel crazy, that hedonic tone, I need my chemical. It doesn't get me the high anymore, but I'm chasing that feeling, come on dopamine, come on.

When dependence is blurred into addiction, which can occur anytime, it is a central nervous system event. It might be the first exposure to meth, heroin, oxycodone, or tobacco. I loved that feeling, I must have it, craving, and beyond logic I am acting emotionally to obtain that front row seat. When I don't have it, I leak. Eyes water, nose runs, nausea, vomiting, diarrhea.

I will have more work today, find more money, somehow, probably an addict. Tomorrow rinse and repeat. Eventually a lost job, declining health, hopelessness, helplessness (the four C's of craving.) I am an addict now. Emotional, driven to self destruction, bad choices, relationship and job fail.

This synergy of wellbeing and life quality is fractured, and I need more period. More is bad, but leaking is worse-withdrawal is awful. I now take other drugs to ease the craving, and I'll find the fix. The drug is now all four of the C's. More bad choices. Moral slips, legal problems await. The old saying that I didn't wake up one morning and say "I want to be an addict", does not speak to my reality.

Taming the dragon

Opioids, benzos, meth, cocaine, whatever pushes dopamine. That's the real drug. The pleasure monoamine and a common denominator of addiction.

Tame your dragon

Fun movie. A story. Stories have a character, theme, drama, epiphany, action, reaction, consequence, and a wrap up. Most have a smoking gun. I went to a party ... I hurt my knee ... Someone said try this ... Another classic is Enter the Dragon.

Bruce Lee is an iconic martial arts figure, still idolized and evaluated 40 years after his death. The dragon killed him. Overdose. The dragon overcomes tolerance, demands relapse, imprisons the soul in its layer. But, all is not lost, sometimes there is advantage in adversity. The dragon has a soul as well it can be tamed, and the dragon can save your life.

The irony of addiction

This affliction is all in your head.It is a brain disease. It is real, and the dragon is a living breathing uncontrolled untamed, and it can kill you. Understanding it, in peace and serenity of control is possible. Nothing worth anything is free.

Sobriety has a cost it must be sobriety or nothing at all. Substituting one drug for another is not sobriety. Studies have shown us that quitting one is good for all. It is wise to quit the benzos with the opiod and alcohol all at once. Quit the cigarettes too. The dragon can have many heads, and souls.

The story of change teaches us precontemplation is dangerous, commitment or action, will save your life and soul. If you really relapse get back up, and use your dragon to fight back. Sandy Silverman MD asked a good question and teaches us why absolute sobriety is not an option it is mandatory.

Question to the pathologist

Sandy-So, toxicology reveals alcohol, benzos and opioid, what killed him. Fill in the blank here- him, many of thousands of years.

Pathologist-I don't know.

This is the cruel reality of addiction. It is ironic we don't really know. I'll bet it's reported as an opioid overdose though. Quit them all. Tame your dragon. Rest your soul, before you rest in peace.