Heroin Dependence Implant

The October issue of the Archives of General Psychiatry contained a report about the potential usefulness of an implant containing sustained release naltrexone for the treatment of heroin dependence. Heroin dependence is very difficult to treat with relatively few users who are able to maintain abstinence. The standard treatments now include both methadone and buprenorphine which are heroin substitution therapies that greatly reduce the risk of complications such as HIV, hepatitis C, unemployment, criminality and prostitution. There are limitations to both of these treatments however and many patients continue to use heroin despite taking these medications so anything new that shows promise is very encouraging.

Since 1984 an oral form of naltrexone has been available to treat heroin dependence but has essentially been useless. Naltrexone is an opioid antagonist. It sits on the opioid receptors and blocks the ability of heroin and other opioids to bind to these receptors. As a result, using heroin has no effect. The problem is though that all one has to do is stop taking the naltrexone and the ability to get high returns quickly. So oral naltrexone has been of very limited usefulness. What has been developed is a sustained release version of naltrexone which can be implanted under the skin and which can have an effect for up to 6 months providing a long period in which the user can move away from the heroin lifestyle.

The study included 70 adult patients who were randomly assigned to receive oral naltrexone plus a placebo implant or daily placebo tablets with a naltrexone implant. During the 6 month period 63% of patients receiving the implant reported complete abstinence with 17% returning to daily heroin use and the rest reporting heroin use a few times per month. In contrast the patients taking only oral naltrexone had 62% returning to regular heroin use, 26% reporting abstinence and the others heroin use several times per week. Although not looked at in this study about 20% of heroin addicts remain abstinent in this time period with psychosocial treatments only.

63% 6 month abstinence is amazing in heroin addiction and I hope that these findings can be replicated by others in follow-up studies.

Thought for the day

Most heroin users hate their lifestyle. They just feel trapped.

Neuroenhancement American Academy of Neurology 2

Yesterday I talked about the guidance document for physicians that came from the American Academy of Neurology dealing with the issue of neuroenhancement, which is the prescription of psychotropic medication to healthy individuals who want to enhance their cognitive performance. They concluded that it is ethical for physicians to prescribe medication for these purposes. It is interesting to see their argument and justification for their conclusion.

The argument that they make is that they divide the practice of medicine into three domains, a core domain, a middle domain, and an outer domain. The core domain are those actions consistent with the traditional goals of medicine: to prevent, diagnose, and treat disease or injury, reduce suffering and to help patients die in peace. The outer domain are those actions that are ethically prohibited such as participating in the torture of prisoners and the like. They describe the middle domain as those actions that are not prohibited but fall outside the traditional role of physicians. They use cosmetic surgery as an example of a middle domain action and liken this to cognitive enhancement.


Right now we have three types of medications used for cognitive enhancement; stimulants, the wakefulness agent modafanil, and the anticholinesterase inhibitors used to slow down memory loss in dementia. There will be more to come in the near future so this is an issue that will stay with us.


I do not think that I will participate in the use of medications for cognitive enhancement in healthy individuals. Medications can result in great benefits but have side effects and risks as well. The physician must always balance potential benefit vs. potential risk. For example I would find it hard to justify myself prescribing Adderall to healthy individuals and putting them at risk of addiction or cardiac difficulties.


I would love to get comments or questions on this issue.


Thought for the day


This is the day that the Lord has made. Let us rejoice and be glad in it.

Neuroenhancement American Academy of Neurology

I have not been posting for awhile. I did go on vacation for a week which was quite nice and then surprisingly (for me) I had very little to say for awhile but my mind is back and I will resume posting.

It is amazing how much we forget and distort the past. I indicated in my last post that we had no student loan debt to pay off after medical school. My wife reminded me that we did have some debt (she had to work hard to pay it off!) but it was a small amount compared to what graduating medical students face today.

I want to talk a little bit about the topic of "neuroenhancement". Neuroenhancement refers to the use of psychotropic drugs in mentally healthy individuals to improve cognition to enhance performance. The three main medications that are considered are the stimulants used to treat Attention Deficit Hyperactivity Disorder, modafanil which is a wakefulness agent used to treat narcoplepsy and the cholinesterase inhibitors which are used to slow down the progression of Alzheimer's disease. Stimulants are already widely used on college campuses by students to improve their ability to stay up and study for long hours without losing focus. They work. Modafanil is now starting to be used for the same purpose. It has been clearly shown that these agents enhance cognitive performance. Caffeine has been known for a long time to do this. It is not yet clear whether the cholinesterase inhibitors will improve memory in healthy people but patients are asking their doctors for them. The question is, what are the ethical issues involved in prescribing psychotropic medications to healthy people?

I haven't seen a lot of discussion of this issue but the American Academy of Neurology has recently issued a guidance document for physicians. This is the only organized medical group that has tried to tackle this one. They acknowledge that there is no professional or societal consensus on this issue. Their statement though indicates that they believe the prescription of cognitive performance enhancing medications is ethical for physicians "provided that they adhere to the well known bioethical principles of respect for autonomy, beneficence, and nonmalficience".

I will talk some tomorrow on their reasoning regarding this issue and provide my own ideas.

Thought for the day

We are definitely in the era of better living through modern chemistry.

Psychiatry Availability Tucson

I have noticed that it is very hard to schedule a psychiatric evaluation appointment in Tucson these days. I have had the repeated experience of trying to find a psychiatrist who can see a patient from Cottonwood after discharge to continue treatment and what I run into is that most of the psychiatrists here are either not taking new patients or have no appointment availability for several months. I don't know exactly how many psychiatrists we have here but I note there are 37 in the phone book not counting the University of Arizona or community mental health centers. If my math is right that makes about one psychiatrist for approximately every 27,000 people.

Now not everyone with mental health difficulties needs to see a psychiatrist but there a number of people who do and we are under served here in Tucson. This is not just a local problem but one that is experienced in many parts of the country. It is even worse for child and adolescent psychiatrist availability. Another problem is that many psychiatrists are no longer taking insurance payments due to low rates of reimbursement. Medicare is the worst and as I have mentioned before Medicare rates are not enough to support a psychiatric practice so a number of psychiatrists are not taking patients covered under Medicare.

The situation is likely to get worse as psychiatric residency training programs are having a hard time filling their spots. One reason is that for many medical students the debt burden upon completing school is enormous. This was not the case when I went to medical school. The costs were reasonable enough that with my wife working we did not have to take out any student loans. That could not happen now. The costs of medical school are way too high for that. For many newly graduated medical students it is not feasible to go into the lowest paying specialty of psychiatry. High paying specialties are those that have many procedures as reimbursement is very high for procedures but very low for cognitive services or time spent with patients. Some people may attribute the low rate of students going into psychiatry as "greedy doctors" but for many it simply would not be possible to repay their student loans in a medical specialty like psychiatry which has such low reimbursement rates.

I am not whining. I love psychiatry, am glad that I chose it, and probably would not be happy doing anything else. But I did not have any debt upon completion of medical school and I wonder if I would be able to make the same choice today that I did back in 1983.

Thought for the day

Lack of available psychiatrists is likely to be a problem for a long time.

Nicotine Alcohol Marijuana Part 2

I have received some negative comments about my last post where I indicated that a recent study showed that those alcoholics in early recovery who continue to use tobacco have the same relapse risk as those alcoholics who smoke marijuana after completion of treatment for alcoholism. I may have been unclear about one point.

I did not in any mean to imply that those alcoholics in recovery who use tobacco are not truly in recovery. That is not what I meant. If you are abstinent from alcohol you are in recovery. There are many recovering alcoholics who continue to smoke. The issue is that there is a high rate of relapse in the first six months following treatment. Every thing that can be done to reduce that relapse risk is very important. What I want to emphasize is that the effect of continued nicotine use is as great as an effect of continued marijuana use for the alcoholic in early recovery. No one would think it would be a good idea for a recovering alcoholic to use marijuana. The evidence suggests that we should be thinking about nicotine in the same way.

I apologize for any confusion I may have caused.

Thought for the day

"Guard your heart for it is the wellspring of life"

The Psalmist

Nicotine Alcohol Marijuana

We have known for some time that continued use of Nicotine in patients recovering from alcohol dependence significantly affects risk of relapse but a recent study in The Journal of Addictive Medicine empasized how great the effect is. The information came from a study that was actually looking at another issue and that is the effect of use of acamprosate (Campral) in alcoholism. Acamprosate is designed to reduce alcohol cravings and the evidence so far is unclear about how much it really helps. This study of 601 patients over a six month period in those alcoholics who smoked showed about 14% of good response rate vs. 7% for placebo.

For alcoholic smokers there were several factors that predicted a poor outcome regarding alcohol relapse rates over the six month period. Those factors were smoking while sick in bed, difficulty refraining from smoking in public areas and smoking more than 20 cigarettes per day. The ionteresting thing is that for those who had any of these factors the relapse rate was the same as those who continued to smoke marijuana in this early recovery period. Those of us in the field of addiction are well aware of the phenomenon of cross tolerance in which the use of one drug increase the possibilty of abuse of any other drug. What is suprising here is that the cross tolerance effects of nicotine are the same as marijuana. We would not consider any alcoholic who smoked marijuana to truly be in recovery and this evidence suggests that the same is true for nicotine. I want to repeat this. The cross tolerence effects increasing alcohol relapse rates are the same whether one is smoking tobacco or marijuana! To me that is striking.

Thought for the day

If you smoke in early alcohol recovery it doesn't matter whether it is tobacco or marijuana that you smoke.

Opioid Overdose Triples

The Centers for Disease Conntrol and Prevention (CDC) issued a very disturbing report yesterday in regard to deaths from opioid use. Opioids are the narcotic pain medications that include Vicodin, Lortabs, morphine, oxycodone, OxyContin, and methadone. They are used for pain relief and are all highly addicting. As I have said before the abuse of these drugs is growing faster than any other drugs of abuse. I have talked about the high risk of fatal overdoses in these medications which many people see as "safer" than cocaine and other drugs but I did not realize how bad the problem had gotten until this CDC report was relesaed.

The number of fatal overdoses from opioid medications has tripled sine 1999. Tripled. That's amazingly disturbing. Drug overdoses are now the second leading cause of injury death and in the 35-54 year age group the leading cause surpassing motor vehicle deaths! I did not know this.
It turns out that in half of those overdoses were accompanied by other drug use, particularly the benzodiazepines.

Thought for the day.

Used properly the opiods are wonderful to have for pain treatment. Used improperly they are poisons.