For the first time, pain is becoming visible to researchers through the use of functional Magnetic Resonance Scanning Technology (fMRI.) This can be critical in our getting a better perspective on how to address the chronic pain issues that many people have. Also a discussion of the Addiction Equity and Affordable Care Acts, in the context of addiction treatment options. The Federal drug policy chief has come out with another statement of intention to pursue drug use regardless of contravening state laws. Also we revisit the issues of the illusion of safety of drug use depending on the current times, and in the context of public service announcements and educational efforts. And one company has a monopoly on the life-saving drug Naloxone, used for heroin (and opioids) overdoses. PODCAST.
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Transcript (edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. Darryl you just returned from a conference in Nevada and mentioned there was a display of E-cigarettes. The jury is still out on E-cigarettes. I continue to mess around with them myself and the jury is still out. Other interesting things in the news..the federal drug kingpin, Gil Kerlikowske, announced recently that the feds are going to crack down on the growers and sellers of medical marijuana and marijuana in general. This in the wake of laws passed in Washington and Colorado. There was also news of brain imaging that reveals how pain works and the mechanisms involved. The Addiction Equity and Affordable Care act was also in the news and how that might lead to better treatment. Apparently one of the drug companies now has a monopoly on the drug, Naloxone, which is the immediate, first aid for a heroin overdose. So, Darryl, there are many topics this week but the most intriguing one is the brain imaging…can you fill us in on that one a little bit?
DARRYL: Howard, actually, you know, all of the stories you mentioned were very interesting …its one of those strange weeks where there’s a plethora…. that is a great word….of with interesting stories about addiction and the brain and treatment and policy. So this is a week we probably need a couple of hours just to go through all of them.
HOWARD: when it rains it pours.
DARRYL: So, we’ll just cover as many of these as we can. The brain scan story is just fascinating to me because for the first time ever, scientists at Columbia University teamed up with scientists from the University of Colorado, using functional MRI to actually see pain, to actually see the phenomenon of pain actually occurring. There were four procedures – first watching pain happen, then measuring the intensity of the pain and then a third part evaluated the kind of pain – physical pain like putting something hot on someone’s skin and watching how the pain was transmitted and processed in the brain and how intense it was. Then they measured emotional pain – people who had suffered romantic breakups and other situations of loss and the scans showed emotional pain is very different from the physical pain or what we call nosusceptic pain. Imaging showed morphine relieving the pain – the article didn’t say whether it was emotional versus physical pain, but I’m convinced from all the people Ive worked with throughout these years, Howard, that morphine works for both. It relieves and sedates both kinds of pain. It’s amazing that for the first time we could see pain – image pain. Of course, MRI scans are still pretty pricey, several thousand dollars per scan, but that we are able to actually see you can see pain opens a window in terms of pain treatment. Things we’ve been wrestling with, hyperalgesia and alodenia – opiates are used chronically and they produce worse pain. Now – if we can see pain then we can find different ways of effectively treating it. We can also determine how much of a person’s pain is what they call subjective because basically pain is the most subjective symptom in all of medicine right now. We have no real way of measuring how much pain somebody is really in and how aggressively we should treat it based on their complaints so this will enable us to better quantify pain objectively and interact with it, treat it, and develop more effective medications without creating addiction. So this is new and major. Wagner at Colorado is the head author or lead author on this new science thats evolving as well as others at Columbia University, which did this research, but its exciting to me and its again, a furthering of the use of functional MRIs which are still admittedly controversial. because people interpret the findings differently but it is just exciting that this is still happening and growing in the field that is sorely in need of more objective measurements and more ways of seeing addiction and validating that addiction is a biological process and now looking at pain and maybe more effectively being able to treat pain. So its great for me.
HOWARD: Yes, and pain in particular is one of those things that has always been elusive. What about Addiction Equity and the Affordable Care act – what are we looking at in terms of increased access to treatment ?
DARRYL: That is another refreshing development – there is some movement on the Addiction Equity act of 2008 – everything seems to be folding into Obamas Affordable Care act. Tom McClellan is reporting that under the Affordable Care act, addiction is going to be considered a medical entity and must be treated as such by insurance companies..which means 3 to 5 million people who would otherwise not gain treatment for addiction because its still looked at by insurance companies and other providers as criminal behavior – will now be eligible because it is considered a medical condition that must be covered by health insurance. This will mean a huge increase in the number of people in treatment. The estimate by the Associated Press is 10% of 23 million Americans with current drug and alcohol problems are in treatment and that will increase once the Affordable Care act and the exchange provisions go into effect in 2014.
HOWARD: How do those numbers stack up to our traditional understanding or perception of the number of people in need of addiction treatment?
DARRYL: Well, there are the people who meet the medical diagnosis for addiction but are not aware that they have addiction and that covers 75% of people who are evaluated. So if we assume that 30% of our U.S. population will meet the medical criteria at some point for addiction then were looking at 30% of 300 million people which is much higher than the number theyre reporting. Ive always believed that only 1 of 20 to 1 of 26 people who need and want treatment for addiction have immediate access so, the numbers are much greater. But regardless of the number the positive thing here is the realization by those who have this condition and an acceptance by the general public that it is a medical condition so insurance companies will pay and mental health systems will pay that that will greatly increase the ability of people to get into treatment. There has been a fear that this will increase costs in tremendously when this occurs. And were already seeing results from some states that have implemented parts of this and – yes, there was a great increase in the number of people utilizing addiction treatment and the costs therefore went up, but when compared to the overall cost of healthcare in their states particularly emergency room and other major other medical systems that addiction affects, there was a decrease. So there the offset resulted in a break even situation.
HOWARD: Well thats good. And you know whats important, I guess here, is not the actual numbers and the specifics at this point but the fact that were actually seeing some movement where for so long we’ve seen no movement at all.
There was another story I wanted to talk about – from the New York Times about the definition of treatment and treatment providers. And its a discussion that I thought we ought to have because, although we talk about treatment a lot, we dont talk about the specifics like the credentialing for instance.
DARRYL: Yes, there is a very important aspect of that so Im glad you brought it up. It was announced today that addiction is now considered a medical primary care issue and less as a criminal issue and the goal is to get people in to treatment – but where are the providers?
HOWARD: Right.
DARRYL: Where are the people who can do these services?
HOWARD: Who’s going to be the first person?
DARRYL: They need infrastructure. They need to fund the schools. They need to fund the industry. You know, many programs have closed across the country because they have been providing services that are costly and have not been reimbursed. The Affordable Care act will provide funding for the treatment in an appropriate way and an incentive and motivation for the medical industry to do this as well as the training. There are 10 universities now offering addiction medicine, but still were woefully lacking in medical resources to cover this huge increase of addicts who are finally going to be able to get into treatment should they choose to do so.
HOWARD: Yes and along those lines is this interesting little story you came up with about the company that produces Naloxone and the fact that however they did it, they’ve managed to take the market into a monopoly situation and raise the price by a huge percentage. How they managed to do that is still a mystery but this drug is becoming increasingly important and a lot of people.just regular folk – mom and pop – want it on hand in the event that their son or daughter has an overdose experience, not to mention the hospitals and the treatment providers and other agencies you might expect. I don’t know how they pulled it off, but its kind of scary when this kind of thing happens.
DARRYL: Absolutely, Howard. Its more like follow the market, I think in this case, and the money will follow. This is similar to what happened during the AIDS crisis – there was a lot of passion and compassion to deal with it. At first nobody talked about it and then when everybody recognized the major health consequences of AIDS all of a sudden condoms became tremendously affordable, dirt cheap. Health departments and treatment centers had barrels of them and provided them for free – grab as many as you want. It is interesting to me that if you provide things in unlimited quantities people seem to take fewer – but if you ask them to take only 5, they will always take 20… as if they’re going to have 20 encounters in an evening. But the opposite thing has happened here and although the company denies that they had any intentions of creating a monopoly. Opiates, unlike other drugs of abuse, kill a lot of its users – more so than alcohol, or other things, although the actual numbers are far lower than those killed by alcohol – because there are more alcoholics – but percentage-wise, its a very dangerous drug. Naloxone is an antidote that immediately reverses the drug’s action when injected within only 5 to 8 seconds. When I was in San Francisco years ago wed just hand it out to people, train them how to administer it, and explain the dangers. There are several states that now do just that. There is an effort before the government to make it an over-the-counter product – take it off prescription and make it available for every parent to have it in their medicine cabinet at home. If they find their daughter or son overdosing and turning blue on the floor and bubbling up, they can hit them up and save their lives. Research shows that the availability of Naloxone has already saved 10,000 lives – people who would have died otherwise. Two of the labs that produced this medication discontinued the product in the early 2000’s and that left only one producer, Hospira and they cannot keep up with the demand. Every doctors office has to have it, every emergency room and every ambulance has to have it. Everybody has to have it and that is the reason for the push to make it over-the-counter. As a result of this demand and lack of competition the cost has increased dramatically over what it was before 2000. The drug has a very short shelf life so even though the it might last longer than the expiration date, at some point youre going to throw that one away and buy another one. So, its an amazing thing. The company’s not even embarrassed or apologizing for the price increase. The article included an interview with officials at the Hospira Laboratory, who said that they needed to increase their profits for their company and for their stockholders by 3 to 4% back then and they considered increasing the price on all their pharmaceuticals by 3 or 4% but they decided increase the price of just one of their products by 1,100% – injectable Naltrexone – to gain the 3 to 4% overall profit they were targeting. Their justification probably is that there are other important medicines that patients find more difficult to afford so we have protected them by raising the price on this one particular medication since it was so cheap to begin with. But again, that is kind of iffy. Was it Teddy Roosevelt who said he was going to go to a war in Cuba and somebody said, what war? And he says, don’t worry, Ill make one or something like that.
HOWARD: He liked his Cuban cigars, I believe.
DARRYL: Oh, is that what it was?
HOWARD: I think so. Its all about the cigars. Is there anything else that you want to focus in on today? Do we know anything else about Kerlikowske and the government’s increased enforcement?
DARRYL: There were many articles both on line and in print where he announced more activity.
HOWARD: They go back and forth on this so often. Its so frustrating.
DARRYL: Well people are assuming that the president is going to be soft on this because he admitted he tried marijuana and therefore will be more lenient and was not going to mess with Colorado and Washington at all. Gill, who is a pretty good guy, he is from Seattle, Washington and was chief of police – has been a fairly good person in the office of National Drug Control Policy. Lets see if I can find the exact quote in today’s paper because it was interesting to me. He said, no executive can nullify a statute that can be passed by Congress, which is an interesting statement in terms of state rights versus federal rights and something that harkens back to the time when we wanted to use Darvon to treat heroin addiction as an alternative to methadone and the federal government said they just ratified an international treaty identifying Darvon as a heavy narcotic drug with restrictions agreed on internationally and they didn’t care how we regulated it in the United States or what the voters said or even what the constitution said – They told me this: international agreements trump our constitution. So you get these weird legal positions and wonder where are they coming from. The current drug czar maintains states cannot violate federal law. There is a federal supremacy act and he will prosecute if you violate a federal statute, so – they can still come into Colorado, or Washington. They can bust someone for smoking and using marijuana because it is against federal law even though the state passed a law saying it is okay. Many people believe Obama will avoid messing with this – if a state wants it, let them have it. But, Gill is worried – and rightfully so – about whats happening with marijuana and other illicit drugs because when states pass such laws it creates the perception that drugs are less dangerous and that results in an increase in illicit drug abuse, not just marijuana, across the United States. And he is concerned about that and he says we need to stay the course here and deal with these situations in ways we know work, so that’s what hes doing.
HOWARD: That goes back and forth constantly and we know that the war on drugs has been an absolute failure. So, why are we going to pound this horse over the head again?
DARRYL: Well, that’s the problem. How do you deal with it? How can you decriminalize when there is an increase in drug abuse and therefore put more people in jail.
HOWARD: Right and back again to the earlier conversation about treatment. We don’t offer adequate treatment and so were just left with intervention, with trying to stop it at the borders and we know that doesn’t work and that just creates more violence.
DARRYL: I believe in where Gill is coming from. Research shows that public service announcements and all these, you know, scare stories about drugs causing this and smoking causing that do nothing but increase curiosity in our young and actually increase drug abuse. You know, we saw drug abuse on the decline for a decade for the first time in America and with some major changes and drops in illicit drug abuse. And when we overlap that with a perception of drugs being harmful, there was an identical match. So when people see drugs as harmful – especially adolescents, there is a corresponding decrease in drug abuse. When we see drugs as less harmful – as we saw in the late 2000s, then we see a great increase in drug abuse. At that junction, you look at marijuana and in Colorado and Washington where the people voted to legalize use the perception decreases that they’re harmful and causes an increase in marijuana use as well as methamphetamine, cocaine, and heroin and that’s probably scaring the heck out of everybody, including Gill.
HOWARD: These are events that impact our society.
DARRYL: Its a statement of our times. I wonder if we know how to make advertisements to effectively show the dangers of drugs. Either were not truthful enough or we try and scare people. So we shouldn’t over-glamorize or over-dangerize these things but rather present plain simple facts to people – highlighting the reality of use. Maybe that’s the approach we have to take because if it changes perceptions and attitudes, it will decrease use. I think Gill has a valid concern that we are headed toward major, major drug problems. Of course, as you said, we lost the war on drugs. The 1990s, saw a fairly significant, decrease in illicit drug abuse across the board and now were seeing a return to higher usage and the return seems to be related, he thinks, to this liberalization or this de-demonizing or more casual attitudes toward marijuana in states like Colorado and Washington. So there are both sides to this debate – there should be some middle ground.
HOWARD: The magical, mythical middle path. Okay, that’s all the time we have today. Well be back in the next week or so. Darryl, thank you very much.
DARRYL: Thank you, Howard.
HOWARD: That wraps our pod for today. If you have comments, suggestions, or questions send us at note at www.cnsproductions.com. Thanks for listening and check back soon for the next in the series.