Addiction Treatment Horizons discussion with leading national researcher

The following is a transcript of a radio interview Dr Schiesser performed in the summer of 2007 with Dr Frank Vocci from the National Institute of Drug Abuse.

Dr. Michael Schiesser:  Good morning and this is Health Dimensions. This is Dr. Michael Schiesser on AM KPTK in Seattle. This morning we're talking about addiction and opiate dependence. And I have my guest here today, Dr. Frank Vocci from the National Institute on Drug Abuse. I want to remind people to visit TurnToHelp.com. That is a site to get more information on some of the things that we're discussing this morning.

Dr. Vocci's identifying some profiles of mental health problems that sometimes can predispose a person or set them up to self medicate with either prescription drugs or street drugs and make a person more vulnerable. Sometimes people are struggling with uncomfortable symptoms that are really an underlying mental health problem and they find that some of these prescription drugs that are obtainable either through doctors or through other sources work well to control some of the symptoms. However, they have the downside of creating a dependence. Is that accurate?

Dr. Frank Vocci:  Yeah but it's a possibly a predisposing condition to a person who then has to take opiates for a legitimate reason possibly becoming dependent.

Dr. Schiesser:  I see. So maybe they're getting treated for pain by their physician but they're at a higher risk for developing a dependence on those drugs.

Dr. Vocci:  That's right. That's correct.

Dr. Schiesser:  What kind of signs might a person be experiencing if they are going to the doctor to get treated for pain? What are some of the warning signs that their treatment for pain is not going as planned and they're on the road to having an addiction problem?

Dr. Vocci:  Well I think that one of the things that does seem to occur is dosage escalation. So that if people start to increase their dose and again if they start to run out of their prescription medication and start to doctor shop, those are the kinds of things that you start to see with these folks. That's a tell tale sign and again the misuse can be to take a medication and to alter its form so that you get a more rapid effect.

Dr. Schiesser:  You mean like crushing it up?

Dr. Vocci:  Crushing or injecting. Yeah.

Dr. Schiesser:  Yeah. Do you see that this problem as increasing in our culture? How big of a problem is this and is it getting bigger?

Dr. Vocci:  Yes, it is a problem. It is getting bigger. We think that about 2% of the people who are prescribed opiates will develop some sort of a problem with it. You have a much greater likelihood if you have a concurrent mental disorder or you have a history of a drug dependence. Those are the two populations that are most likely to run into trouble with it, with an opiate.

Dr. Schiesser:  So 2% of the people who are getting treated for pain run into [excuse me]run into problems? [cough]

Dr. Vocci:  Yes sir. That's right.

Dr. Schiesser:  Then how many people are not prescribed opiates by their physician are also dependent who are sourcing it on the street? Is the larger proportion of people who end up being treated for these problems people who have never been treated in the doctor's office, rather they started out recreationally?

Dr. Vocci:  I don't think that that's a large proportion of the folks although that could be a pattern that is emerging. What we are seeing is generally people who are prescribed the opiates. The other thing that we are seeing is that when abuse is occurring among young people who are adolescents, the primary way that they get the drug is from family members. The family members may even give them the drug or they may steal them, so where the kids are well aware of what's in the medicine cabinet and they can take the drugs without the parents being aware of it. They can also sometimes be given drugs by the parents because the parents don't really understand the risk of the prescription opiate.

One of the biggest problems that we have is trying to educate people about prescription opiates is that they are not benign. The FDA says that prescription opiates are safe and effective, but that's with an asterisk. The asterisk says, "When prescribed by a physician and taken in the recommended quantity." If you take them outside of a medical context and outside of a physician deciding that you need to have them, then you're abusing the drug and you're at risk for developing a problem.

Dr. Schiesser:  If a parent is sourcing these drugs from their doctor and their family member is abusing these drugs, what kind of signs might someone see if they are abusing Oxycontin, Percocet, Vicodin, this sort of thing?

Dr. Vocci:  What you'll see is someone who is going to be less responsive to the daily activities of life. So you might see someone who's sleeping a little more, seems to not to care, not cooking dinner. There are certain things that they'll do where you will start to get a tip off that there's been a change in their behavior.

Dr. Schiesser:  So less engaged in their activities that otherwise were important to them,

Dr. Vocci:  That's right.

Dr. Schiesser:  and they become more focused on sourcing this drug.

Dr. Vocci:  That's right.

Dr. Schiesser:  Is it for the sake of getting high. My experience, some of these people can't get out of bed if they were using it for six months, because of the withdrawal symptoms.

Dr. Vocci:  That can create a very viscous cycle where you're right, the negative effects get to the point where someone really needs to be treated. So at that point they maybe using the opiates to stave off the withdrawal problems also. One of the biggest problems that we have with the prescription opiates is a perception problem. There was a study done by the Partnership For a Drug‑Free America where they asked parents of teenagers, "If your teenager were using heroin would you be concerned?" About 90% of them said, "Oh very, very concerned about that." Where they asked them, "If your teenager was using oxycontin or Vicodin would you be concerned?" and there were only one out of six were concerned about that. So there's a perception obviously from that sort of a survey that the prescription opiates do not have the addictive quality or the safety issues that heroin does. So people, essentially, are either overestimating the hazards of heroin or underestimating the potential hazards of prescription opiates or both.

Dr. Schiesser:  I'm speaking with Dr. Frank Vocci from the National Institute on Drug Abuse and we're talking about dependence on prescription drugs today as well as heroin, which all fall under the category of opiates.

Dr. Vocci, can you tell me about some of the other treatments that you're working on for other types of addiction?

Dr. Vocci:  Sure! We have a program where we're trying to develop medications and vaccines for stimulant drugs. We've tested over 60 different drugs for the treatment of cocaine dependence and they have found some that worked in some individuals and we're continuing to evaluate them. Disulfiram or Antabuse is one drug that seems to have an effect in some people who have cocaine dependence. Topiramate or Topamax is another drug. We did a study and found Ondansitron also had an effect in the treatment of individuals who were cocaine and alcohol dependent. Naltrexone has some effects. Propranolol or Inderal has also been shown to have some efficacy. So we're looking at those drugs.

We've got several large studies ongoing right now with a drug called modafinil or Provigil. Those will all be done in about a year or so, so we'll be able to determine whether or not we've got an effect there.

Dr. Schiesser:  So you're looking at therapies for alcohol and cocaine. Are these also therapies for methamphetamine?

Dr. Vocci:  Sometimes individuals who were dependent on both, yes, because we do see dual dependence in some individuals. So we look sometimes to people who are cocaine‑dependent, sometimes people who are cocaine and alcohol dependent, both.

Dr. Schiesser:  What about, it seems like methamphetamine is a big problem without a lot of solutions. Are you working on that?

Dr. Vocci:  Yes. We fund both behavioral and pharmacological research for that. One of the misconceptions with methamphetamine is that there's a poor treatment response and that's really exaggerated. What we see is that about half the people who go into treatment actually get a benefit going to treatment. So we're looking at the best ways to treat people.

From the behavioral standpoint, we also have a medications program that is looking at potential medications. We just found that there's a drug Wellbutrin (bupropion) which actually reduces methamphetamine use. We studied this in five different sites in United States and there'll be a publication coming out this year on that. So we have a first drug which seems to work for that. We're going to be doing a confirmatory clinical trial in the next year with the bupropion in methamphetamine‑dependent patients.

Dr. Schiesser:  That drug, interestingly, is also used to help people who have trouble with smoking.

Dr. Vocci:  That's right.

Dr. Schiesser:  And what you're saying is that can help people with methamphetamine dependence.

Dr. Vocci:  It did, and it did in people who were low or what we call low to moderate users. Those are people who use less than 18 days a month.

Dr. Schiesser:  It sounds like there's a lot of promising therapies out there for people who have difficult addiction problems. Is there a stigma related to addiction that seems to get in the way of treatment?

Dr. Vocci:  Clearly. It works at a lot of different levels. For example, a lot of emergency rooms do not test patients for alcohol if someone comes in in a motor vehicle accident. The reason they don't test them for that is because the insurance companies will sometimes fail to pay a bill. They're saying, "Well, no, that person was intoxicated. We're not paying." So you have people that are not dealing with things because of the fact that they do not want a medical history. Because if they are, then on job applications and other kinds of things and security checks and so forth, they would have to admit that they had been treated for a dependence disorder. And so oftentimes they would rather not be treated than to have that in their medical history. That is stigma.

Dr. Schiesser:  What about the ability for people to self‑identify or families to identify? Do you think that presents a barrier to treatment as far as just sort of brushing it under the carpet?

Dr. Vocci:  It does. It does. That's clearly another one of the issues. That is another thing where people don't realize that the amount of drug that they're using, the amount of alcohol they're taking in really meets a criteria for dependence disorder. But they think that they're doing fine. Oftentimes they feel that they're functioning well and other people may not agree with them but their explanation is that they're doing quite well. Thank you very much.

Dr. Schiesser:  Well I'm speaking with Dr. Frank Vocci this morning. We're talking about dependence on prescription drugs, heroin, methamphetamine, alcohol. And I want to remind people to look at the web site TurnToHelp.com where there are a lot of novel resources. This is a brand new web site to help patients and families who are struggling with prescription drug dependence and other forms of opiates like heroin.

I appreciate Dr. Vocci coming on the program this morning. Dr. Vocci has been speaking to us from the East Coast and he is at the director level at the National Institute on Drug Abuse.

Dr. Vocci, do you have any closing comments this morning?

Dr. Vocci:  If someone has a problem, I think there's help out there. One of the things that we're aware of is that addiction is probably the most under treated illness in the United States and that it's up to both the individuals and their physician to have an honest conversation.

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Dr. Schiesser:  This is Dr. Michael Schiesser from Creekside Center in Bellevue. For treatment of opiate dependence and other addictions, call 425‑644‑6048 or visit TurnToHelp.com. That's TurnToHelp.com. For more information at Creekside Center, visit creeksidemedicine.com.

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