The death of celebrites drives home facts about addiction – the dangers of combining downer drugs with alcohol. Potentiation and synergistic effects are names for the combination, which can be deadly as in the recent death of Corey Monteith. We also talk about the potentiating effects of antihistamines. Corey was in addiction treatment recently, and we are reminded the tolerance factors change – rapidly – by abstaining from drugs – then relapsing, which often causes overdoes when the person returns to his drug of choice, at the same dosage level as before. We go on to discuss the importance of treatment followup and aftercare. And many states have put medicaid limits on pain medication, which may cause even more problems then no addressing someone’s pain. We discuss 12-Step treatment in the context of treatment, and new research in brain functions and addiction.
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Howard: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. What is all over the news this week is the tragic death of Cory Monteith, star of the hit TV show, “Glee”, he died from a combination of heroin and alcohol. What I want to talk about here is the combination of heroin and alcohol and also the fact that Cory had been in treatment a number of times since his teen years and had just recently been in treatment. And so I want to talk about treatment follow-up. So, Darryl, let’s start with the consequences of combining heroin and alcohol. We know, of course, that opioid use has almost quadrupled in the last 10 years or so and most of that is Oxycontin and Vicodin abuse. As we have discussed a number of times, the availability and high cost of those prescription drugs led to an increase in heroin use. So, Darryl, how deadly is the combination of heroin and alcohol?
Darryl: The consequences of combining drugs are frequently overlooked by the drug abusers themselves and everybody else actually. People need to be aware that when drugs are combined, you get additive and synergistic and potentiating effects .when you use drugs together, oftentimes the combinations don’t result in a simple additive like 1 plus 1 equals 2 , instead it is something like 1 plus 1 equals 8. Mixing results in delivering a much greater effect and we know that when you add the speed ball mixture of heroin and cocaine or heroin and methamphetamine, you get actually an increase in the effect. You would think they would cancel each other out, but they actually potentiate each other or give each other a greater effect in terms of feeling good and greater potential for overdose and danger because they work on different parts of the brain to lull you into a false sense of confidence that you’re not too rummy because you’ve taken something like an opiate and you’re not too over the top because you’ve taken something like cocaine, so you tend to take more and it leads to overdose. In the case of mixing downers – opiates and alcohol, heroin and alcohol which is what Cory Monteith did as do a lot of other people actually we mentioned recently that more women are dying from prescription opioid abuse but what we didn’t report is that a lot of the deaths were the result of combining downers. A lot of women who drank alcohol and took their prescription opiate a combination of benzodiazepines such as Klonopin or Valium or Xanax or Ativan …when you add the benzodiazepine with the heroin, you get a synergistic effect, it is greater than 1 plus 1. The chief medical officer of our county, Dr. Jim Shames, believes that the major cause of death from methadone and opiates in this state as well as in the country is due to this combination and doctors actually prescribe them together – the benzodiazepines and the opiates, like methadone or Oxycontin or even Suboxone. In the case of alcohol and heroin, it’s common knowledge ever since I got in this field, that they are a major contributor to death. When you combine them, they are a minimum of additive, meaning they add to the potential sedation of each other they work on different parts of the brain causing sedation and so they have a greater effect when taken together and it might even be potentiation like in the case of benzodiazepines which greatly magnifies the effects of opiods or alcohol – this is known as synergism or potentiation…. where the expected effect is greatly exceeded. And if we look closely at these cases of overdose – of heroin and methadone, of Oxy, Vicodin and the other opiate drugs that are now the major cause of drug death in the United States, I think we’ll find that they are mainly a result of combining drugs like downers and downers or even uppers and downers, rather than the result of just a single drug.
Howard: And certainly it’s very, very, very common to take alcohol with any drugs.
Darryl: Right. And, addicts do it on purpose. If they become tolerant they don’t feel as good from the heroin as they used to and they learn quickly that if you just add antihistamine, an over-the-counter medication like Benadryl, the combination results in delivering a much greater effect. We saw this happen in Vietnam, soldiers were getting the best quality heroin around, but as they got tolerant, they started adding antihistamines. In the 1970’s and 80’s people were adding Benadryl and other antihistamines to prescription opiates and other medications to make them stronger and in the United States….especially the youth…we see the phenomenon of things like cheese heroin in Texas and other places. This is a combination of Tylenol PM which is basically Tylenol and Benadryl – smashed up with tar heroin to give a much bigger punch. This is well known on the street and deliberately combined to make it stronger. Reports indicate that Cory was probably was just trying increase the effects. Unfortunately tolerance to the pleasant euphoric effects of a drug actually grows more rapidly than tolerance to the toxic effects on the body or the overdose effects. The longer a person takes a drug and the more it is taken in combination the closer and closer a user is to reaching the amount that will kill them. This is not completely understood by people who are abusing these drugs.
Howard: A lot of treatment programs require abstinence the impact of that is to lower a person’s tolerance, is it not? And if they go back to taking the dose that they were accustomed to – all of a sudden they are at death’s door.
Darryl: That’s an absolute fact, Howard, and although I’ve never written a paper on it, I’ve certainly spoken about it. I have believed for years that people die more often during relapse than during their heavy addictive days because of exactly that fact. When you start rehabilitation or you go into treatment and you go into an abstinence based program, you get clean and sober and your tolerance to the toxic effects as well as to the drug itself, quickly is lost. You lose it overnight. And if you start using, you’re going to reach that tolerance level a lot more rapidly than you did when you first quit, but that first hit is the problem we’re talking about. I always warn clients that relapse is a part of this condition. Relapse is part of any major chronic persistent disorder and the thing addicts routinely fall victimize to is the fact that they were shooting say maybe a bag of dope or a spoon of dope or 3 grams of dope or whatever of heroin when they quit because they had gained tolerance to that amount of heroin. They go into rehab for 30 days or even a couple of months and maybe they stay clean for a year and then something triggers them and they go out and use again. They often use the same amount of the drug they were using when they quit and that first dosage is too much – they take it, they overdose and die. Now, if they start using again with a lower dose, they’ll oftentimes gain back the tolerance at the level they were at before the quit, much more rapidly. But – it’s usually the first dose that kills them. The clients I’ve lost over the years, patients that have died have died in relapse mode, not while they were in the actual heavy addiction mode.
Howard: Some of the comments I’ve read about Cory Monteith’s death have questioned the lack of follow-up from treatment …is that true overall? Are treatment programs missing that essential component?
Darryl: If follow-up is missing from programs, it’s the fault not of the program and not of the clinician, it’s the fault of our system. It’s the fault of insurance companies. It’s the fault of funding, ….anybody who works in this field recognizes addiction is a chronic persistent disorder. It’s not something you turn on and off like a light switch – people don’t become cured of addiction just because they went to a program for 2 years or went to jail for 10 years they are never cured. What is always stressed in treatment programs is the strong need for after care the strong need for continued treatment and rigorous treatment throughout a person’s whole life, not just for a month or two or a year or two. Addiction is a chronic persistent disorder like diabetes and we don’t cure diabetes. We don’t cure asthma. We don’t cure hypertension. You treat those conditions your whole life in order to remain healthy and it’s the same with addiction. We stress the need for that but oftentimes addicts don’t have the financial resources to pay for ongoing treatment and programs can’t offer it for free because of the costs involved. Some addicts believe that once they acknowledge they have a problem and decide to take care of it by going through a treatment program they don’t have to worry about it anymore and they stop participating in treatment. It really is painful for clinicians to see people graduate from the levels of care and then all of a sudden, totally we lose that person. There’s no contact. There’s no feedback. It’s really painful because more often than not, we know that if there’s no follow-up with us or with any other program, a major relapse could occur and every relapse has the potential to result in death. It’s a painful thing to see. People tend to get the best care if they hook up with one of the peer organizations they become 12-steppers the go to meetings every day of their life or once a week for life or even once a month. If they continue to participate at some level throughout their life they are addressing their addiction. The same thing, I think, was available for Cory. Perhaps he felt he didn’t need it any more lots of times treatment fails because people don’t believe they really have an addiction problem. They’re embarrassed to label themselves as addicted. They’re too busy or think they’re too busy to show up at meetings or to see a counselor or do the things they have to do because it really is a lifelong process and in this society, we want instant gratification. We want an instant cure. It is “okay, I’ve got a problem .fix me and then I’m done” and that’s not the case with a chronic persistent disorder. It’s something you have to deal with throughout your life.
Howard: Right. There was another story in the news this week reporting that there is a Medicaid limit in most states for pain killers or opioids which doesn’t sound logical because as you just said, it’s a chronic and persistent disease and there is no limit on asthma medicine or high blood pressure medication.
Darryl: I testified in California when the state was trying to limit or remove things like codeine from the formulary because the sleeping pill that people were taking on their Medicaid prescriptions or Medical prescriptions with empirin codeine or Tylenol codeine #3 ended up, they say, almost bankrupting the state Medical budget, my position has always been – ” “you can’t do that” people need these medications. But – we also have to recognize the addiction aspect – and managing pain and addiction are two separate things but they intertwine together when you’re dealing with prescription opioid pain medications. And they are very different thought and the opiate addicts that I know who love prescription Vicodin and love prescription Oxycontin or even love the methadone programs, you know, they in their honesty to me, they’re willing to put up with the pain in order to have enough medication, prescription medication, so that they can save it up to take a bolus or a high amount at one time to catch the buzz. They’re interested in the addictive qualities rather than the pain relieving qualities. And that’s what we are trying to get on top of understanding this nexus of pain and addiction to opiates and trying to come up with some viable way of melding the two together to deliver effective treatment to the addict and to the patient in pain that relieves both of suffering, but deals with their condition. The we now know that hyperalagesia, an abnormal sensitivity to pain can develop due to long term use of opiates – and allodynia is pain caused by something that does not usually cause pain. So, if a person continues to take opiates for pain, the pain will get worse not better. In order to control pain, a person must control their addiction so opiates will remain effective over their lifetime. Opiates should be taken only to relieve pain and not because ” gee, you know, I’m not feeling that good today maybe I should take two”, or because you’re not feeling functional.
Howard: Part of the reason it costs the state so much is because the pharmaceutical companies don’t sell these drugs cheap. They’re not rock bottom bargains like hypertension medicine is for instance.
Darryl: They are an easy sell for pharmaceutical companies. If a pharmaceutical comes up with a medication for diabetes, say it’s priced 10 times more than other diabetic medications, do you think patients are going to buy that? Heck no they’ll take the generic stuff or something that is cheaper. But if is a medication that contains 10 times as much of an addictive drug like Oxycontin or hydrocodone patients will buy it. It’s an easy sell and doctors are going to feel good about prescribing it because when they ask their patient, “how did it work?” The patient may say – “it worked great doc, but I think I need another prescription for that again” – it’s all within that system that’s a nasty system, but one that’s made to promote capitalism and making money from drugs.
Howard: Right. Let me ask you your assessment of 12-step programs and the like in this era of brain research and our new understandings of the process of addiction – the way the different parts of the brain are affected and the connections between the behaviors. How do you see that?
Darryl: Well, Howard actually I’m glad you bring it up because I’ve been so what’s the word, smug maybe is a bad word for it, but feeling validated and feeling that we are correct in our writings and our research because many of the conference speakers have presentations based on this. I recently presented this on this very topic at the Virginia Summer Institute of Addiction Studies. People around the country are beginning to look at addiction and the process of addiction very much in the same way – that it is a brain anomaly. It’s a difference in the brain of certain people who are vulnerable and importantly, there is recognition that it’s multi-faceted or at least multi-leveled in the brain not just the cognizant brain, but also the unconscious brain. It’s the neocortex versus the mesocortex and clinicians and counselors across America must focus on understanding the new medical approaches because those are going to address the unconscious processes of addiction. But what the medical people have to recognize is that this has been effectively dealt with not 100%, but maybe 40 to 50% of people eventually are able to embrace long term recovery through the neocortex part of addiction, the aware part, the cognizant, the part of the brain that can be taught, the brain that can be educated, the brain that can learn how to make decisions and analogies. The third component that we haven’t stressed as much is the spiritual aspects of addiction not the “spirituality equals God” kind of thing, but spirituality in terms of self actualization just recognizing that you can be your best self – the best that you can achieve for yourself – a spiritual awakening to becoming the best human being you could ever be. And towards that end, the 12 steps are there from the beginning to provide a structure, in a way it is a road map with mile markers for people to gage how they are progressing and get reinforcement and most importantly, break through the isolation that they feel. It’s funny the Glee actor, Cory, comments about the failure of the current treatment system because people don’t want to be saddled with the label of addiction and don’t want to be seen like other addicts when in fact, for most addicts, it’s a revelation once they understand that they are not alone with this condition. It affects a great number of people and it’s not about who you are or what you want, but it’s about how your brain is affected, and that’s what 12 step programs do. They give you a forum where you can interact and be with others who have the same struggles and learn from them what works and what might help you maintain your recovery. Some criticize 12 step programs because they hear horror stories. They hear everybody telling their war stories about how they fell into addiction and how much of a problem it was and some participants just don’t identify with that. Well, unfortunately we find that it’s important .we don’t want to introduce it too early, but addicts, if they’re detached from the fact that addiction is not consequential, they have very little hope of getting clean and sober.
What I mean is, with addiction, like with diabetes or any other chronic persistent disorder, there are many consequences related to this condition that occur if you don’t keep yourself healthy. If you deny it, you ignore it, if you don’t do the things that are going to maintain your health, you aren’t going to get any better. You’re going to get worse and worse and have more severe consequences. I love how Dr. Nora Volkow (Director of the National Institute on Drug Addiction) classifies consequences from diseases – she says well, with diabetes, you’re certainly going to lose your toe and your foot and your kidneys and your sexuality and your nervous system, your eyesight, your heart all those things are going to go if you don’t pay attention to yourself. But, she says, with addiction, you will suffer catastrophic consequences, as if those aren’t catastrophic enough!
Howard: Right, right.
Darryl: You know, she might be right because what is most important to people are relationships you know, your significant other, your children .you’re going to lose those. You’re going to lose your freedom. You’re going to lose your self esteem, your self respect, ….those are things you don’t usually lose when you have diseases like hypertension or epilepsy or diabetes. So, she might be right addiction does have more catastrophic consequences. Addicts oftentimes wall that off or deny it that it happened and it sometimes takes listening to the stories of others to see themselves. Realizing that if they don’t do something about it, they’re headed in that direction. I’m not so sure how valid the criticism that treatment failed Cory Monteith. I think treatment professionals do the best they can with the resources they have available and overall, I still believe when we compare the outcomes of treatment for addiction, that they fare just as well as the outcomes of treating any other chronic persistent disorder .we get as many positive results treating addiction as they do treating diabetes or hypertension or anything else and I still stick by that. So, I think we’re going the right way, but we still have a long ways to go and the science of addiction will close that success gap even more because we see 40 to 50% of people achieve success with what we currently have in place.
Today we see a huge development in the medicalization of addiction and the developments of medical treatments to treat that unconscious part of the brain that can be affected through education and counseling and learning and with that we may close the gap even more. We may have another 25% who are able to achieve long term recovery. Perhaps we may also address the spiritual part and find a better way for those people who resist or who don’t accept the 12 step spiritual processes. There are other spiritual processes that might be more effective or effective for them, anyway, to help them embrace and maintain their long term sobriety.
Howard: Right, right. Looks like we’re out of time for this week. I hope you’ve enjoyed our discussion. We welcome comments, suggestions or questions – drip us a note at cnsproductions.com. Darryl, thank you.
Darryl: Thank you, Howard, for hosting this show. You do a great job. It’s always fun to do it.
Howard: That wraps our pod for today. Thanks for listening. Please check back soon for the next in the series and visit our website, www.cnsproductions.com