Dr. Greg Boehm Updates CPA on Opiate Epidemic in America

February 20, 2012

On January 9, 2012, Dr. Greg Boehm M.D. presented to our group on the topic of “Opiates in America.”  He described the current epidemic in opiate addiction and abuse in our culture.  As he traced the history of opium use and abuse through the centuries, he clarified that throughout time, the primary determinant of use and abuse of addictive drugs is and has always been:  availability.

From 1991 to 2010 the total number of opioid prescriptions dispensed by U.S. pharmacies increased from 76 million to 210 million.  Not all of these drugs are consumed as directed. Consequently, this leaves plenty of pills to accumulate in family medicine cabinets and become low-hanging fruit for addicts or small-entrepreneurs who may visit.  What percentage of illicit opiate users obtain them for free from family, friends, neighbors? 56% !

 The reasons for the increase in prescriptions are multiple and complex.  The drugs are powerfully effective in the treatment of pain.  Recent developments have made them much easier to tolerate than older forms, so there are fewer side effects such as nausea, vomiting, or dysphoria.  In addition, some people feel “energized” by opiates, which makes it even harder to stop using them..  Over 500,000 chronic pain patients in the U.S. are on stable doses of a narcotic medication, which help them to function optimally.  However, the pharmaceutical companies also contributed to the vast increase in prescriptions by falsely advertising that the newer, slow-release forms of oxycodone were less addicting and less easily abused than the formerly marketed forms. (They were sued successfully, but continue to profit: over $1 Billion yearly from oxycontin alone.)  The drugs have also been refined, so that smaller amounts are effectively stronger, and thereby more addictive.

               In addition, Mexico has in the past five years increased its production of heroin six-fold, so the illegal drug is suddenly much more easily accessed than when it was primarily manufactured in the middle- and far-east. This heroin is more highly purified, up to 70% pure from 30% five years ago.  This increased strength greatly contributes to the alarming rate of accidental lethal overdoses.

Aside from addiction, there are multiple other adverse reactions to these opium-based drugs, many potentially lethal.   They include:

CNS suppression

Potentially fatal interactions with other depressants such as benzodiazepines (Valium, Xanax, Ativan), THC, alcohol, sleep aids, muscle relaxers, etc.

Tolerance: since it builds and dissipates fast, it is easy to OD on a relapse

Hyperalgesia: they make a person more sensitive to pain

Withdrawal: Although the addict feels like dying, withdrawal from opiates in itself is not lethal (as withdrawal from alcohol and benzodiazepines can be)

The rate of deaths due to accidental overdose to drugs from 1970 to 2006 increased from 1 to 9 in 100,000, tripling in the last 15 years.  In 2007 deaths due to accidental overdoses surpassed those due to motor vehicle accidents, and the rate continues to rise at 15% a year.  Drug related emergency room visits have also tripled in that time, as have episodes of drug treatment for opiates.

Treatment for opiate addiction is difficult, intensive and time-consuming, but doable and extremely rewarding.  It starts with detoxification to ease the pain of withdrawal, usually at a detox center such as Stella Maris.  Detoxification involves a gradually tapered dose of a drug with similar properties, such as ultram, in addition to clonidine and valium.  Over the course of seven days, the patient is weaned gradually until drug-free, but then confronts the hard part of drug treatment: staying clean.

Dr. Boehm’s treatment protocol requires active involvement in Alcoholics Anonymous in addition to other treatments appropriate to the patient’s needs.  Many people may stay clean with therapeutic support and AA right from detox.  Others do very well with an opiate substitute such as Suboxone, which can be managed on an outpatient basis with psychiatric sessions tapering to once a month once stable.  Methadone maintenance requires daily visits to the clinic.  Relapses indicate a need for more intensive services.  Intensive Outpatient Treatment involves nine hours a week of groups for at least six weeks.  Inpatient treatment lasts typically 30 days in a hospital or day hospital setting.  Multiple relapses indicate a need for a more controlled environment for a longer period of time.

        Y-Haven, for homeless alcoholic/addicted men, is one of the best kept secrets in Cleveland.  For free,  recovering men receive three months of daily 4 hours group therapy, followed by up to two years of continued residential treatment, including continued education opportunities, job training and help establishing a household after treatment. Funding for such intensive treatments is unfortunately restricted to the wealthy, who can afford it out of pocket, or the homeless and indigent, who qualify for county and federal support.  Successful treatment is still less expensive to the community than housing addicts in criminal facilities, and treatment often returns addicts to being productive members of their communities.

Gregory X. Boehm, M.D. is Board Certified in Psychiatry and Addiction Medicine.  He is on the faculty of Case Medical School.  He is Medical Director of Stella Maris Treatment Center, Medical Consultant to Y-Haven and Volunteer Psychiatrist at the Free Clinic of Cleveland, in addition to collaborating with his wife, local psychologist Nancy Duff-Boehm, Ph.D. in their private practice in Beachwood and North Olmsted.