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11/24/2014 12:00 AM

Adolescents with opioid use disorders, in most places, do not get buprenorphine — they get detoxification, and then drug-free treatment. But experts tell ADAW that just as with adults, and perhaps even more so, maintenance treatment with an agonist such as buprenorphine is less likely to lead to relapse. The problem is that in many parts of the country, there are no pediatricians who are familiar with buprenorphine, much less licensed to dispense it. And while buprenorphine is commonly used as a detoxification adjunct, it should be used for maintenance, to help the adolescent get stable, according to John R. Knight, M.D., director of the Center for Adolescent Substance Abuse Research at Children’s Hospital Boston.

Adolescents with opioid use disorders, in most places, do not get buprenorphine — they get detoxification, and then drug-free treatment. But experts tell ADAW that just as with adults, and perhaps even more so, maintenance treatment with an agonist such as buprenorphine is less likely to lead to relapse. The problem is that in many parts of the country, there are no pediatricians who are familiar with buprenorphine, much less licensed to dispense it. And while buprenorphine is commonly used as a detoxification adjunct, it should be used for maintenance, to help the adolescent get stable, according to John R. Knight, M.D., director of the Center for Adolescent Substance Abuse Research at Boston Children’s Hospital.

“I work with someone who is a bereaved mom, whose daughter detoxed on buprenorphine, went to a halfway house and had a fatal overdose her first night there,” Knight told ADAW. Indeed, newspaper article after newspaper article details the tragedies of young people who cycle in and out of rehabs, their parents taking out second mortgages to pay for them, only to relapse and, in many cases, to die from an overdose. Oddly missing from these stories is any indication that the families had ever been offered, much less tried, buprenorphine.

“For adults, maintenance is the standard of care, and it should be for adolescents,” Knight said. “People need to get on maintenance, and not be tapered down.” Knight, one of the first pediatricians to have a buprenorphine license, said that adolescents can be maintained on very low doses of buprenorphine. A taper isn’t even considered at Children’s until the adolescent has been stable — defined by having no positive drug tests — for at least a year, said Knight. There are about 40 adolescents in the buprenorphine program, which is outpatient, at a time. Their parents attend groups, as do the teens, and there is regular drug testing.

Public health

“We need more research on what long-term effect there may be on the adolescent’s still-developing brain,” said Knight, noting that critical growth in both structure and function occur until the mid-20s. “But there’s one thing for sure,” he said. “Whatever buprenorphine’s effects are on the developing brain, they’re far less than the effects of continuing use of heroin.”

As the rates of dependence on prescription opioids and heroin among youth remain high and alarming, expanding effective treatment models for opioid-dependent youth is a public health priority, said Lisa A. Marsch, Ph.D., director of the Center for Technology and Behavioral Health at Dartmouth Psychiatric Research Center, author of one of the only two clinical trials of buprenorphine on adolescents. “A growing research base and clinical experience underscores the important role that buprenorphine can play as part of treatment for opioid dependence among adolescents and young adults.” Marsch’s research, funded by the National Institute on Drug Abuse (NIDA), “has shown that this medication is safe and effective to use with youth as part of a multicomponent treatment model,” she told ADAW. “Although the optimal length of medication administration for youth is not yet known, our work is increasingly showing better outcomes with a period of maintenance on the medication as opposed to brief detoxifications, after which time relapse rates to opioid use are high.”

Teens at Hazelden

Hazelden was one of the first treatment programs to break away from the drug-free dogma and offer buprenorphine, mainly because patients who were discharged from drug-free treatment were overdosing when they got home (see ADAW, Nov. 12, 2012).

Now, under the direction of Joseph Lee, M.D., youth continuum medical director at the Hazelden Betty Ford Foundation, adolescents are getting buprenorphine as part of comprehensive treatment.

“A lot of families are forced to choose between buprenorphine-naloxone office treatment with very little else in the way of psychotherapy and community support, or they go to the other extreme and use a psychotherapy community approach without any medication,” Lee told ADAW. “Those of us on the front lines don’t have the luxury of using rigid ideologies, so we decided to change our protocol.”

When Hazelden started using buprenorphine, recalled Lee, “people said, ‘Finally Hazelden is coming on board’ — we wanted to offer the best of both worlds.”

To be on buprenorphine, adolescents have to be at least 16, and their opioid addiction “has to be a real deal,” based on either severity or duration, said Lee. The family is educated about different options; Hazelden also has a Vivitrol track. “Sometimes, for clinical reasons, we may ask that they consider one track over another,” said Lee. “If they go the buprenorphine route, we ask that they stay in our system.”

Some parents initially are resistant to buprenorphine, but “when they understand the stakes,” they accept that it is science-based and safe, he said. Ironically, some of the adolescents themselves have a stigma about buprenorphine, said Lee. “I make a point to let them know that my job is to keep these teens alive — I don’t sugarcoat the realities,” said Lee.

Maintenance “means different things to different people,” said Lee. “My philosophy is that as long as they need to take it, they take it.” Many teens don’t want to stay on it, he said. “You can imagine if you’re 17 years old, looking down the barrel of how long am I going to take this — they have the feeling of invincibility,” he said. “So we just let them know that for now, they need it.”

Maintenance at Children’s

In many parts of the country, pediatricians and other primary care doctors may assume that detoxification in the local hospital followed by drug-free rehab is the best treatment for teens. But once the teen has been through detoxification, that basically rules out any treatment with buprenorphine, because it has to be given while the patient is in withdrawal, said Knight. At Children’s, all buprenorphine inductions are done on Mondays, so patients are instructed “to stop using no later than Sunday morning,” said Knight.

Unfortunately, the way Children’s uses buprenorphine — as a maintenance, not a detoxification, medication — makes it an “outlier” among adolescent providers, said Knight.

Ultimately, however, most adolescents are highly motivated to get off of buprenorphine, he said, echoing Lee’s experience. “We do a very slow taper, and if cravings return, we stop the taper,” said Knight. For some patients, the taper stops at a very low dose — as low as 2 milligrams a day. “Until they get older and can learn through cognitive behavioral therapy how to handle cravings, buprenorphine is a valuable asset in the tool kit,” he said.

Knight noted that the clinical trial conducted by George Woody, M.D. and colleagues, which was a “remarkable service” to the field, lasted only six months, after which the participants were tapered. He cautioned that only six months of buprenorphine with a taper would most likely be followed by “a lot of relapses, some of which will manifest as fatal overdoses.” In fact, the NIDA POATs trial with adults found relapse rates of greater than 90 percent (see ADAW, Nov. 14, 2011).

More research needed

There is a reluctance on the part of family members to start an adolescent on a controlled substance, said Bob Lubran, director of the Division of Pharmacologic Therapies in the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), which administers the licensing program for physicians who prescribe and dispense buprenorphine. In addition, there’s a shortage of physicians who can prescribe buprenorphine, Lubran said, noting that there’s a shortage in general of physicians who are interested in treating addiction. “We don’t have the numbers on how many pediatricians” can prescribe it, he said, “but we know there are relatively few.”

“There’s an urgent need for further trials comparing maintenance treatment with psychosocial treatment,” said Lubran. “These studies should have a long follow-up period — and that’s a matter for NIDA.”

It’s unclear whether NIDA is planning to do anything more with buprenorphine and adolescents. NIDA was one of the first places we contacted, but they were unable to provide anyone to be interviewed, instead referring us to David Fiellin, M.D., at Yale, who conducted the initial trials on buprenorphine for adults. He referred us to Knight. NIDA funded the only two studies on buprenorphine among adolescents, but they are both old: one by Woody in 2008 (see ADAW, Nov. 10, 2008), and the other by Marsch in 2005 (see ADAW, Oct. 10, 2005). Both showed buprenorphine was effective. Woody told us it was very difficult to recruit subjects, as those under 18 had to get parental consent; most didn’t want to tell their parents.

Still, more studies are essential, said Lubran. “I think there’s the reluctance of a clinician to start a young adolescent on a maintenance therapy, because you’re exposing somebody to a drug for which there are no long-term studies for adolescents,” he told ADAW. “I heard this years ago with methadone — there’s a tendency to be concerned about the consequences of long-term therapy for an adolescent,” he said. “I would venture that the same is true of buprenorphine.” However, he stressed that untreated opioid addiction leads to a high risk for overdose, hepatitis and HIV.

Lubran’s agency has been aggressively promoting buprenorphine, to the extent of lifting the 100-patient cap. But when it comes to adolescents, “the current state of the art is detox to drug-free,” he said. “We would argue for more research to help guide clinical practice.”

Knight knows that a study will have to be done on adolescents showing the effects of buprenorphine. “My sense is we’re not going to find much, once that study gets done,” he said. In the meantime, “buprenorphine can save young lives,” he said.

Other resources include http://pcssmat.org/wp-content/uploads/2014/03/PCSS-MATGuidanceTreatmentofOpioidDependantAdolescent-buprenorphine.SubramaniamLevy1.pdf.

Bottom Line…

Buprenorphine maintenance treatment has not been studied in adolescents, but whatever the risks, they are not as great as those from untreated opioid addiction, experts say.

11/3/2014 12:00 AM

Early next year, nationally prominent addiction interventionist Brad Lamm will introduce to Detroit a treatment alternative for substance use disorders (SUDs) that integrates day treatment with “spiritual healing” and that appears more insurance-friendly than standard residential care. The Breathe Life Healing Centers program in Detroit will resemble a pioneering program that Lamm founded under the same name in Los Angeles.

Early next year, nationally prominent addiction interventionist Brad Lamm will introduce to Detroit a treatment alternative for substance use disorders (SUDs) that integrates day treatment with “spiritual healing” and that appears more insurance-friendly than standard residential care. The Breathe Life Healing Centers program in Detroit will resemble a pioneering program that Lamm founded under the same name in Los Angeles.

Under the anticipated payment model, around 80 percent of clients will have their outpatient treatment services covered by insurance, billed under a partial hospitalization/intensive outpatient level of care. They will receive these services off-site from the “spiritual retreat” that will serve as their home for around 90 days, with a base cost of $1,500 a month charged according to their ability to pay.

The retreat center will be housed in a 15-bedroom mansion that Lamm purchased last summer for $1.6 million in the historic Palmer Woods section of Detroit; Lamm plans to make the home his own primary residence and to house around 20 men and women there.

“The days of reliance on residential treatment centers are over,” Lamm told ADAW. “And 30 days [of treatment] isn’t enough.”

He emphasized that the businesses in Los Angeles and Detroit (and one in New York City that has not yet fulfilled his vision because of a bogged-down licensing process) are not directly linked to the intervention work for which he is best known. Lamm says he has not referred any of his intervention clients this year to Breathe Life because those individuals generally need a more intensive level of care than what the Breathe Life concept is geared to provide.

Typical schedule

Clients living at a Breathe Life retreat generally are off the property by 7 a.m. each day to attend 12-Step meetings followed by their day treatment. Lamm says the most prominent techniques used in the daily treatment include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), eye movement desensitization and reprocessing (EMDR), and psychodrama. Equine therapy is offered up to two times a week, and clients regularly visit a gym before returning home at day’s end for dinner and for evening groups in spiritual development.

Each Breathe Life center is structured to have a campus pastor; in the Detroit program, that role will be filled by Lamm’s brother, who is a minister. Lamm, the son of a minister, who also has another brother in the ministry, says his personal background shaped his vision for a program that would seek to “reignite the flame” spiritually for persons with substance or process addictions.

“The campus is ministerial, as individuals connect with their inner life and issues of faith and spirituality,” Lamm said. “For some, all of that is a concrete notion, while for others it’s a real conflict,” particularly if their past experience with religion has not been a welcoming one.

“The work we do is very ‘out, loud and proud’ spiritual development,” he said. On the clinical side, Tian Dayton, Ph.D., serves as Breathe Life’s director of clinical programming.

Lamm’s vision involves having clients stay for around 90 days before moving to a sober living environment. The 26,000-square-foot mansion where the Detroit program’s clients will live will offer the kind of serenity Lamm believes all treatment clients deserve.

“If you’re in middle-class treatment that’s insurance-driven, it’s often not in the nicest place,” he said. “If you have the creature comforts — a nice bed, good hygiene, good lighting — it’s easier to stay if you’re in a place where you feel safe.”

Because Breathe Life is not seeking a residential treatment use for the house and essentially will be operating as a spiritual center, it will not have to clear any regulatory hurdles before opening in the first quarter of next year. Winning over local neighbors may take longer.

“They’re not thrilled that I’m there,” said Lamm, who added, “We’ll be fine there — we hope time will help some people identify us as a good neighbor.”

Dual roles

It is not uncommon for an interventionist also to have a role in a primary treatment program or in some other segment of the continuum of care. Phil Scherer, who chairs the board of the Association of Intervention Specialists (AIS), offers an example of this: He conducts interventions and is also administrative director of the Illinois Institute for Addiction Recovery. He says while there are still a number of completely independent interventionists practicing, around half of AIS members serve some other role in the treatment field.

Like Lamm, who is also an AIS board member, Scherer has avoided referring his intervention clients to the treatment programs where he has worked. “There has been a movement in AIS that if you work in a center and also do interventions, there is an inherent conflict of interest,” he told ADAW. “The perception is there. One guy said to me once, ‘You can’t tell me that if on Monday morning your program’s census is low, you’re not getting pressured to refer.’ I said to him, ‘I don't look at the census when I do an intervention.’”

Scherer added that in his intervention work with individuals and families, he always fully discloses his philosophy about intervention and all of his professional affiliations.

Lamm believes the Detroit program will serve an important need in a state where residential centers are operating above capacity and many individuals’ insurance coverage will not allow an out-of-state placement. As he sees with his intervention clients, about eight of ten people needing treatment face payment barriers that he believes Breathe Life can avoid.

Bottom Line…

Brad Lamm’s Breathe Life Healing Centers concept combines an intensive outpatient level of treatment with an extended period residing in a “spiritual healing” center, thereby skirting the problem of seeking insurance reimbursement for a residential level of care.

11/3/2014 12:00 AM

This summer, Seabrook House quietly sued Elements Behavioral Health and Recovery Brands, which operates Rehabs.com, for trademark infringement and unfair competition. In the complaint, filed August 26 in the U.S. District Court for the District of New Jersey, Seabrook House asks for a full accounting from both Recovery Brands and Elements of the money they received as a result of people searching for Seabrook or Seabrook House and any subsequent call center on any of the Recovery Brands websites. In addition, Seabrook asks for an award of damages in an amount to be determined at trial of an amount greater than three times the profits of Elements and Recovery Brands or three times the damages sustained by Seabrook. Seabrook also asks for attorney’s costs and lost profits.

This summer, Seabrook House quietly sued Elements Behavioral Health and Recovery Brands, which operates Rehabs.com, for trademark infringement and unfair competition. In the complaint, filed August 26 in the U.S. District Court for the District of New Jersey, Seabrook House asks for a full accounting from both Recovery Brands and Elements of the money they received as a result of people searching for Seabrook or Seabrook House and any subsequent call center on any of the Recovery Brands websites. In addition, Seabrook asks for an award of damages in an amount to be determined at trial of an amount greater than three times the profits of Elements and Recovery Brands or three times the damages sustained by Seabrook. Seabrook also asks for attorney’s costs and lost profits.

The complaint is remarkable in that it brings out in the open what is very common practice, as the complaint itself notes: that the program’s name is used in marketing and promotion, with other programs — and the website — getting the benefit of the prospective patient. Here’s what happens: a desperate person looks for a treatment program online, probably Googling “addiction” or “rehab.” The person lands on a website featuring a searchable directory, finds treatment programs that may be of interest and calls the website’s 800 number. This is actually a call center that determines whether the patient has good insurance (out-of-network is the best), and then funnels the caller to a treatment program that may or may not have paid for the privilege of getting patients. Recovery Brands claims on its website that programs on Rehabs.com do not pay for patients.

In fact, Rehabs.com does use the trademarks and website links for many treatment programs, but the links are, at least in some cases, to the programs’ actual websites and to those programs’ actual phone numbers, based on research we conducted last week. Seabrook House is no longer listed on Rehabs.com.

Elements’ alleged role

In the case of Seabrook House, however, the complaint goes farther, saying that Elements worked with Rehabs.com to pay for advertisements on the website, and to match search results to a call center that leads directly to an Elements call center, which diverts the prospective patient to an Elements facility — even if the patient wanted Seabrook House.

“Defendants’ rendering of this web of deceptive and misleading advertisements using the valuable ‘SEABROOK HOUSE’ and ‘SEABROOK’ trademarks (and many other third-party competitor trademarks) for their own related and/or identical services has, and is likely to continue to cause confusion and to deceive consumers and the public regarding their source,” the complaint said.

Along with the complaint, Seabrook filed a 34-page list of exhibits — screen shots and more — detailing the Elements connections.

Matthew Wolf, vice president for business operations of Seabrook House; David Sack, M.D., president and CEO of Elements; and Abhilash Patel, co-founder of Recovery Brands, all responded to our request for comments by saying they had been advised by counsel not to discuss the pending litigation. In addition, Sack and Patel declared that their companies had committed no wrongdoing.

“My client denies the complaint, and we will defend it if necessary,” said Jessie Beeber, Esq., from Venable in New York City, who represents Recovery Brands. Seabrook is represented by Christopher D. Olszyk Jr. of Fox Rothschild in Philadelphia; Olszyk did not respond to a request for an interview.

We talked to David Lisonbee, president and CEO of Twin Town Treatment Centers in California, and Beth Ann Middlebrook, Esq., lawyer for The Watershed Treatment Programs in Florida, about the case.

Settlement likely

“It’s infringement because they’re competing by using Seabrook’s own name,” said Middlebrook. “This is just one example of how the proliferation of treatment providers throughout the country is leading to this type of marketing,” she said. “If I go online and find a number and I think I’m calling a particular program, but instead I’m calling a referral center, they’re going to refer me to a treatment provider based upon whatever private contractual arrangement they have, unbeknownst to me,” she said. “This is a consumer problem.”

When treatment providers become aware of this, they can take action, at least with a cease and desist letter on behalf of themselves, she said. “If Seabrook has instituted this lawsuit, I’m sure there’s a good deal of damages at stake,” she said. Seabrook, like Twin Town, is just one program. It doesn’t have a network of programs throughout the country that people can be referred to. So those geographically isolated programs are likely to suffer the most in an Internet-call-center-type marketing scheme.

“Any defendant in a lawsuit like this is going to deny wrongdoing,” said Middlebrook. “They may settle this, because Elements and Recovery Brands can’t afford to go to trial — they may lose, and it would cost them and tarnish their reputations.” Any settlement agreement would likely include a statement by both defendants denying any wrongdoing, she added. “That’s just par for the course,” she said.

Internet marketing not bad per se

This makes treatment marketing look terrible, we said. “You’re right,” said Middlebrook. But she added that just because treatment providers participate in such referral schemes doesn’t necessarily mean that they are bad treatment providers, clinically. And she doesn’t think the practice is so prevalent that treatment providers feel pressured to participate. She added that The Watershed does not participate in such schemes. Based on her reading of the Seabrook complaint, in which only Elements advertisements popped up when people specifically searched for Seabrook, she said that situation is “egregious.” But, she said, “there’s nothing wrong per se to effectively market yourself via the Internet.”

Lisonbee could not comment on the specifics of the Seabrook complaint. But he is known as an icon of ethics in the treatment field, and said that “it’s pretty clear that patients are being purchased as collateral” on the Internet and through call centers. “Unfortunately, the treatment field is not able to self-regulate and we’re begging the authorities to step in and parent us,” he said.

‘Payola’ and call centers

“They’re all looking for patients who have out-of-network coverage,” said Lisonbee of treatment programs participating in call centers. If a provider is in network, the patient’s HMO or PPO will decide what kind of treatment you can provide. “So it’s popular to go for the out-of-network PPOP patient,” he said. Out-of-network PPOs can also bill for the medically unnecessary and exorbitant drug testing, he said.

Twin Town does not work with call centers, said Lisonbee. “Most of the call centers are working on a payola basis,” he said. “It’s like dealing with a cattle auction. These people aren’t in it to help; they’re in it for the money.”

Lisonbee pointed out that many treatment center websites give no indication of where the program is located. He found his own program listed on his mobile phone. He called the number, and it went to a call center in Florida. It wasn’t just a coexisting ad that popped up. He threatened them and they stopped doing it. “But first I called them 20 times to run up their bill, because every time you do that they have to pay for the click,” he said.

Middlebrook said that treatment programs, when they find their trademarks are being misappropriated by call centers, “just want it to stop; they want the injunctive relief, they don’t want the whole hassle of a lawsuit.” What Seabrook is doing in filing this suit may help other treatment providers to contact websites asking them to stop.

Recovery Brands, which owns the website Substance.com and has ventured into providing content to news outlets, is one of the more respected websites in the field. ADAW learned of the complaint when a reader forwarded it, after we ran a positive article about Recovery Brands (see ADAW, October 6). Elements is also highly respected as a treatment provider. Stay tuned: all parties have agreed to comment when the case is resolved.

This article was revised November 3.

From the Field
10/27/2014 12:00 AM

Last week, the Harm Reduction Coalition held its conference in Baltimore. Marijuana legalization is not one of its issues, which are mainly access to clean needles and syringes, overdose prevention with naloxone, HIV and hepatitis C, and the rights of drug users. Keynote speaker Michael Botticelli, acting director of the Office of National Drug Control Policy (ONDCP), supports naloxone and medication-assisted treatment. He is a clear harm reduction advocate, but not an advocate of marijuana legalization.

But harm reduction sometimes gets confused with marijuana legalization. I had the privilege of speaking to the “Politics” class at American University in nearby Washington, D.C. on October 20, a few days before the conference was to begin. I was invited to discuss the movement toward drug legalization. I also covered some “harm reduction” assertions as well.

Unfortunately, because the legalization movement is sweeping across America, my counterpoints were very well-received — I say “unfortunately” because we are being overcome by the tidal wave of the movement. Here is some of what I said to Assistant Professor Rick Semiatin’s “Washington Semester” class of juniors and seniors from 200 colleges and universities across the United States.

I’m a “liberal” on most things, but on the drug issue, I know the harm that is done by car crashes, DUIs, date rape and the impact of flooding already overcrowded emergency rooms — and that includes from marijuana, which most “legalizers” claim they want to separate from “harder” drugs. I was the one who wrote then-Congressman Ed Koch’s testimony on his bill in the 1970s to legalize marijuana, and sat with him at the table as he told Congress that drugs are personal and harmless, and that we should stop crowding our prisons. But both Ed and I learned and changed our positions, he as mayor of New York City and me as I learned more and more as spokesman for the House Narcotics Committee and then the White House ONDCP.

I told the students that the election is being overwhelmed by the issue because my own party, the Democrats, don’t want to touch it. They are afraid their candidates will lose a big chunk of the youth and liberal base who support legalization/decriminalization in the legislatures and state referenda. Like laetrile in the 1970s (which was legalized in more than 20 states and was supposed to cure cancer but turned out to be useless apricot pits that simply deferred real and needed treatment), “medical” marijuana is backed up only anecdotally and never is compared to an “n” of other treatment modalities that would be prescribed by doctors. There is truth to former drug czar Barry McCaffrey’s joke that a shot of gin also takes away your pain. Having said that, no one wants to deny a truly sick or dying patient who wants to get high the opportunity to feel better, even if it’s a placebo effect. It’s not the truly “medical” cases anyone wants to stop; it’s what law enforcement tells us are the 90-percent-plus (and as many as 99 percent) nonsick people who also come in to the clinics feigning illness with a makeshift letter just to get drugs.

Harms of marijuana

The evidence on harm in the legalizing states is rolling in. You have to scrounge for the reports, but they say, “youth marijuana use increased by nearly 11 percent since medical marijuana became legal in 2009,” “traffic fatalities involving drivers testing positive for marijuana have increased by 100 percent between 2007 and 2012” and “toxicology reports with positive marijuana results for driving under the influence have increased 16 percent from 2011 to 2013.” In addition, Colorado Public Radio reported, “Denver Emergency Room Doctor Seeing More Patients for Marijuana Edibles.” The United Nations reported, “Marijuana-related Health Problems on Rise in US,” with a 12 percent rise last year in marijuana usage by teens.

But for the most part, the legalization referenda are speeding ahead. The most-cited ones, in Oregon and D.C., show legalization 11 and 20 points up, respectively, with just days before the election, and the legalization advocates say they are counting on “young voter turnout.” Since Democrats count on that demographic as well, you can understand the silence.

Even though Maryland Governor Martin O’Malley told me personally two weeks ago that “I’m concerned about legalization” because of car crashes, emergency room upticks, the horrible message to kids (how legalization disarms parents from the moral high ground on the message), and the like, politicians in the state are silent on the issue.

Of course, the legalizers say the drug war is a “failure.” But the students I addressed did open their eyes when I said that because of the efforts of parents, teachers, coaches and religious and business leaders, and a strong foreign policy (Plan Colombia) and domestic enforcement efforts, drug use has declined almost 50 percent in the last three decades, and cocaine use — the disproportionate driver of crime — is down 70 percent. If any other social problem, such as literacy, hunger or poverty, or health problem, such as cancer, diabetes and heart attacks, improved 50–70 percent, would we call it a failure?

To these quite smart college juniors and seniors, I pointed out that medically assisted treatment — including methadone, buprenorphine and Vivitrol — is in fact harm reduction. It’s valid because people can function, work and pay taxes. But if we’re talking about heroin, cocaine and methamphetamine to addicts, that’s pure nonsense that destroys their lives. If we are talking about marijuana, I still oppose it because it jams hospital emergency rooms with car crashes and treatment centers with patients. Legalization or decriminalization would simply increase availability and use. When I debate the Ethan Nadelmanns of the world on radio or Bill Maher or Crossfire, they invariably say, “That’s true but…” I cut in and say, “You can’t say ‘but’ to more availability and use — that’s the point. Aside from that, Mrs. Lincoln, how was the play?”

I do concede we need to stop prison overcrowding but point out that’s why Attorney General Janet Reno and ONDCP Director McCaffrey supported creating drug courts, for treatment instead of prison for nonviolent drug offenders. There were eight drug courts when we started in 1996. Drug courts rose to 1,000 under Clinton-Reno-McCaffrey, and now are near 3,000.

Science, not politics, should guide U.S. drug policy.

From the Field
8/25/2014 12:00 AM

One of the greatest NFL players of all time, if not the greatest, is Lawrence Taylor. Known as LT, his struggles with cocaine are as well known as his quarterback sacks.

Thurman Thomas was one of the most versatile players of his era, a strong, tough, speedy back who was elected to the Hall of Fame. His battles with alcohol are well documented.

Max McGee scored the first touchdown in Super Bowl history. However, he is better known for playing that famous game with a hangover.

Substance abuse, in any form, is nothing new to the NFL — not even the abuse of painkillers, as one of the best quarterbacks in history, Brett Favre, has publicly struggled with addiction to Vicodin. Jason Peter, a lesser-known player but a highly touted defensive prospect when at school in Nebraska, became addicted to painkillers while in the NFL, which in turn led to a heroin addiction.

There is a criminal aspect to substance abuse as well. In this regard, entire teams have been investigated in the past. The New Orleans Saints — no strangers to team-wide discipline from the league — had its entire franchise under suspicion. Team officials were accused in a 2010 lawsuit of covering up the theft of the prescription narcotic Vicodin from team headquarters, an allegation that triggered an investigation by the U.S. Drug Enforcement Administration. Kyle Turley, an offensive lineman for eight years who retired after the 2007 season, said it was common for members of the Saints’ medical staff to routinely hand out the prescription painkiller Vicodin on the flights home — regardless of whether a player had a prescription for it.

“The trainers and the doctors used to go down the aisle and say, ‘Who needs what?’” Turley said. “If you had something hurting and needed a painkiller to take the edge off so you could sleep that night, they made sure you had it,” he said in a piece first published by ESPN.

Entire league under investigation

Yet now, it is not an individual being investigated, or even just one franchise. It’s the entire league. Agents from the Drug Enforcement Administration’s New York division are reaching out to former players to learn how NFL doctors and trainers get access to potent narcotics such as Percodan and Vicodin, according to the New York Daily News. The investigation was prompted after more than 1,300 former players joined in a lawsuit against the league, alleging that the league illegally used painkillers to mask injuries and that the NFL obtained and administered the drugs illegally without prescriptions. The lawsuit also claimed that the league failed to warn players about potential side effects. The reasons for this abuse, according to the players, were to expedite the return of injured players to the field and generate the highest possible profits.

The nine named plaintiffs include Chicago Bears quarterback and Super Bowl champion Jim McMahon, and his Bears teammate, Hall of Fame defensive end Richard Dent. The lawsuit alleges that the NFL has violated state and federal drug laws. The drugs numbed pain, allowing hurt players to return to the field, but they also led to aggravated injuries and created long-term health problems — both in terms of the underlying physical injuries being aggravated and in the form of addiction.

Complaints by players

Also, NFL retirees have long complained that the disability program the league operates jointly with the Players Association seems designed to reject claims by players physically debilitated by football-related injuries. Not only do these claims need to be accepted, but the insurance carriers must recognize that substance abuse and addiction must be treated as well, especially if a player’s team, or the entire league, was negligent in distributing controlled substances to those without a prescription, or even to those with a prescription if the player was not properly monitored while on the drug.

There’s a reason a medication requiring a prescription is a “controlled substance.” Without the “control” aspect, it can indeed lead to abuse and dangerous implications for the user. In many cases, even with tight controls, addiction is still a risk. If the allegations are true, not only were teams promoting substance abuse, but they were adding one more health problem to a player’s already existing injuries, without thought or consideration to the player’s welfare. Just reimagine Turley’s story for a minute, with one wrinkle: imagine team officials walking down the aisle of the plane with baggies of heroin, passing them out indiscriminately. Sounds pretty insane, doesn’t it? That’s how reckless these team officials were.

Painkiller misuse

A scientific study conducted by researchers at Washington University in St. Louis found that retired NFL players misuse opioid pain medications at a rate more than four times that of the general population. The study, co-funded by ESPN and the National Institute on Drug Abuse, provides new evidence to suggest the roots of that misuse can be traced to the misuse of painkillers during players’ NFL careers. Linda Cottler, a professor of epidemiology in Washington University’s Department of Psychiatry, who directed the research, said, “That’s a problem, I think, that only 37 percent got [prescription pain medications] exclusively from a doctor…. It tells me that there has to be more evaluation, more monitoring.”

Between the drug policy violations and the concussion issue, we are forced to recognize that football is a gladiatorial sport. Pain is inflicted, often and in large amounts. This author, for one, accepts that and, to be candid, enjoys the sport to a level of fanaticism. While the league looks for new ways to prevent concussions, via equipment and rule changes, one has to wonder if they can ever be truly done away with based on how the game is played. Concussions might be down in recent years, but they are far from being eliminated. Can rules be implemented to cut down on painkiller abuse? The answer in a perfect world is “yes,” but in reality, any player who is injured wants to get back to playing as fast as possible — not only because of their competitive nature and drive to win, but for fear if they do not, they will lose their job and their livelihood.

Much of the news about the NFL lately has been about their drug policy. Numerous players have been suspended anywhere from one game to an entire season, based on the number of times the policy was violated. In many of the cases, the violations were for marijuana use, which has caused a debate as to whether marijuana use should be the harbinger of such stiff penalties. Maybe, instead, we should be looking at the hypocrisy of the league, as some players are suspended while others become addicts and the league turns a blind eye.

From the Field
6/30/2014 12:00 AM

Marijuana is a potent drug. My personal experiences with marijuana — occasional recreational use during graduate school — were relatively benign. A few times I had experiences I found distinctly unpleasant. Usually I found that marijuana made me feel slow, heavy, dull and sedate. And because I am a person who is predisposed to the seduction of altered states, I generally enjoyed those feelings. But I found that mixing alcohol and marijuana tended to make those unpleasant experiences more likely. And because I greatly preferred the effects produced by alcohol to those produced by marijuana — and because I was uncomfortable with the illegality of marijuana — I almost always forsook smoking for drinking.

In sobriety, I have had the opportunity to see a very different side of marijuana from the privileged, private-university world I inhabited when I indulged. In the rooms of Alcoholics Anonymous, it is very common that the stories I hear involve both drugs and alcohol. While I consider myself to be fairly exclusively an alcoholic and not a drug addict, I have no illusions about the nature of my disease: I enjoy treating discomfort with mind-altering substances. Though alcohol is my preference, I have also used marijuana and benzodiazepines. That’s not uncommon at all, nor is using cocaine, heroin, methamphetamine, or any number of prescription drugs.

The effects of chronic marijuana use that I have seen are not particularly dissimilar in their manifestations from the effects of chronic alcohol use. Not in terms of how they affect a person’s body, perhaps, but in terms of how they affect a person’s life — increasing isolation from mainstream society, ruptures in relationships and families, unemployment, legal consequences, despair, suffering and misery — problems that are routinely relieved when the abuser commits to abstinence and a program of recovery.

I also see what we in AA call “The Marijuana Maintenance Program.” Many of us come to realize that we have a problem with alcohol and need to stop imbibing. But we are unwilling or unable to face the things in ourselves that are necessary to face in order to recover. And so we turn to a drug that we believe is less harmful, or more manageable. This is no different from deciding that liquor is too dangerous so we try to switch to beer. There is occasionally a brief period of respite, but our addiction will not remit until we abandon all of our artificial anesthesias and examine the underlying causes of our affliction.

As a member of Alcoholics Anonymous — I do not, of course, speak for that organization — I take no position on the legalization of marijuana for recreational use. As a scientist, I do believe that the medical value of the cannabis plant should be studied as we study any other plant and given appropriate opportunities to relieve human morbidity and suffering as is possible. Simply because some people abuse it, we should not discard it as a source of medicines. And there is significant evidence that medicines derived from marijuana, or marijuana itself, may be beneficial for a variety of conditions. A recent article in the British Medical Journal (Farrell M et al., Should doctors prescribe cannabinoids? BMJ 2014;348:g2737) neatly capsulizes the evidence and counter-evidence for marijuana as a medical intervention for a variety of conditions.

Medical marijuana is, of course, also obviously a capillary-action attempt to open the door to recreational marijuana, and it has been successful in Washington and Colorado. The joke I’ve heard over and over again from such advocates is “I need medical marijuana because I get depressed when I run out of pot.” From the pragmatic perspective of someone who is primarily interested in addicts and alcoholics having a path to recovery, and the opportunity to reclaim lost lives, I am not certain that whether marijuana, or even alcohol, is legal or not matters much to me. Humans will use and abuse mind-altering substances. Some will become dependent. Of those, a few will seek recovery.

There are enormous societal investments and consequences associated with the control and enforcement of marijuana as a banned substance, and it may be worth investigating whether legalization would have a net positive or net negative impact on things like crime, poverty and social disparities. I don’t pretend to know the answer. What I know is that marijuana abuse and dependence are real and troublesome problems, but recovery from them is entirely feasible. I have seen it countless times.

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  • Meet the Editor

    Alison Knopf
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    Alison Knopf is a professional journalist who began covering the addiction field in 1984 as founding editor of Substance Abuse Report. She has been the editor of Alcoholism & Drug Abuse Weekly since 2005.
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