Opiate addiction and prescription drug abuse: a pragmatic approach.

During this second decade of the 21st century, the United States is

in the midst of a major public health problem. At near epidemic

proportions, the abuse of prescription drugs and especially opiates

significantly contributes to escalating care costs, increasing patient

hospitalizations, and growing numbers of untimely deaths.

Although tobacco, alcohol, and marijuana traditionally have

represented the drugs of choice for adolescents, recreational use of

pharmaceuticals has the potential to become as prevalent. This is due to

prescription medications' relative low cost, ready availability,

and accepted medical usage. In addition, the problem is exasperated by a

small percentage of unscrupulous providers who for financial gain play a

major role in this epidemic.

Some may question the usage of the term epidemic; however,

statistics bear the appropriateness of this appellation. Approximately

14% of American adults are estimated to be using pain medications for

nonmedical purposes, and the recreational usage of opioids has steadily

risen during the past decade. From 2002 to 2006, the percentage of young

adults aged 18 to 25 abusing prescription opioids increased from 4.1% to

4.6%. These figures suggest that approximately 1.5 million young adults

are regularly abusing these medications.

Additionally, opioid-related emergency room visits increased 126%

from 2004 to 2008. Treatment admissions for non-heroin opioid abuse and

dependence are also on the rise. From 1996 to 2006, the numbers of these

treatments nearly quadrupled nationally from 16,605 to 74,750. In West

Virginia, this trend especially has been severe. During the same

ten-year period, non-heroin opioid treatments soared in the Mountain

State from two treatments per Treatment every 100 thousand to 78 in every 100

thousand. Currently, West Virginia has the third highest non-heroin

opioid treatment rate in the nation.

While we believe that the majority of physicians are treating

patient pain appropriately, a number indiscriminately prescribe opiates.

This is done without a proper treatment plan of when and how to use the

medications, without assessing the illness for the need of such

medications, and a lack of use of standardized pain assessment

instruments. Some physicians routinely neglect alternatives to narcotics

for treatment such as psychosocial and behavioral techniques as well as

non-addictive adjunctive medicines to reduce dependencies on opioids.

The result has created a culture of iatrogenic drug addiction, and the

offending providers are ascribed as being "legalized drug

pushers." It is our intention to propose pragmatic changes to

physician practices to address this ever growing problem.

Pain Management: Prescription of narcotics for non-cancer pain

should be a treatment that is time-limited and of a last resort. It

should only be used when non-narcotic and psychosocial interventions

have failed. Even when legitimately used, the prescriptions should

include a dosage, quantity, and treatment duration that is adequate to

treat the pain. Monitoring the usage of these medications reduces the

risk of patient abuse and dependence, and it decreases the likelihood of

diversion through the drug's sale or theft. Since diverted

prescription pain medications are the leading source of opioid access

for adolescents, the importance of limiting quantities of prescribed

narcotics cannot be overstated.

Opioid Treatment Dependence: Although methadone and

leva-acetylmethadol (LAAM) have been used as agonist replacement

treatments for opioid dependence, the Substance Abuse and Mental Health

Services Administration are now recommending buprenorphine (Subutex[R])

and Suboxone[R], a combination of buprenorphine and naloxone, as

office-based treatment alternatives for opioid addictions. Physicians

can be licensed to prescribe buprenorphine with minimal training and are

only required to be able to refer patients for adjunctive psychosocial

treatments. Unfortunately, buprenorphine has developed a street value.

The duration of treatment dosage of Suboxone[R] has been debated, but

the medication has been successful in the treatment of opioid addicts.

We believe, however, that unless these medications are properly

controlled, they will meet the same fate and notoriety of methadone.

Motivation: Another factor that plays an important role in the

prognosis and treatment of drug addiction is motivation. Detoxification is not a cure. When utilized without adequate support measures and

proper follow-up, detoxification has proven to be ineffective. While

continually problematic, assessing an individual's motivation is

subjective. Although psychological tools exist, consequences or losses

associated with drug use and abuse is a more accurate predictor of a

patient's motivation. These consequences may include being

ostracized socially and religiously and may be indicated by the losses

of income, jobs, professional licensures, and intimate relationships. As

society becomes more tolerant to these issues, drug addiction and abuse

becomes more pronounced. Often the patient's family and friends

ignore or enable the addiction.

Recommended Treatment Guidelines: While general guidelines for drug

abuse treatment should be observed, we recommend the following:

a. Restricting the patient to use one pharmacy of his or her choice

throughout the treatment.

b. Requiring the patient to attend regular Narcotics Anonymous,

Alcoholic Anonymous, or other treatment support group meetings. The

patient should attend at least three sessions per week Opioid Addiction during the first

three to four months of treatment. These meetings can be gradually

lessened after this time period.

c. Obligating the patient to pay co-payments in advance. Third

parties can assist by keeping co-pays as low as possible ($10 to $20 per

session). In addition, we recommended requiring Medicaid patients to pay

a nominal fee of $5 to $10 to demonstrate responsibility towards the

treatment process. If patients fail to attend designated treatment

and/or counseling sessions, prescriptions should be withheld until such

time as the patient returns to compliance.

d. Reporting excessive charges by physicians and counselors to the

appropriate state agencies.

e. Using standardized tests, such as pain assessment tools, as

absolutely necessary. Documenting the use of adjunctive treatment

modalities remains important.

f. Administering a goal-directed therapy with gradual tapering of

medication as the patient progresses through treatment.

g. Constructing a patient agreement that includes random pill

counts and monitored drug screening that is strictly adhered to by the

physician or therapist.

h. Monitoring and documenting the patient's weaning process of

the medication. This is especially critical when dosages have been

increased or have been at a high level for long periods.

i. Requiring physicians to complete periodic training and

continuing education when dispensing narcotics on a long-term basis.

Licensure renewal may be tied to the successful completion of this


j. Collaborating between physicians and addiction specialists is


k. Limiting the Suboxone[R] treatment, in most cases, to not exceed

16 mg per day.

l. Documenting objective factors in detoxification including blood

pressure, pulse, respiration, diarrhea, rhinorrhea, and lacrimation.

These should be combined with subjective symptoms to individualized


While the above mentioned treatment recommendations represent a

practical approach employed by physicians, these are only part of the

equation. We believe that these steps alone are insufficient and

additional action at the public policy level is needed. These include

the following:

First, the DEA's regulations for Schedule II drugs with a high

likelihood for abuse need to be seriously evaluated. Such drug

dispensing should be restricted and time-limited. Medicaid in West

Virginia presently limits this to one month's duration. In

addition, triple prescription copies are warranted. One copy would be

kept on file with the prescribing physician, one with the dispensing

pharmacist, and one submitted to the Drug Enforcement Agency in order to

review and verify that the drugs are being dispensed properly.

Second, the Board of Medicine should conduct periodic audits of

patients' charts and other physician records for compliance with

good clinical practice guidelines. This is especially critical in regard

to cases where physicians are prescribing large numbers of narcotics.

Third, an increased level of public education regarding opiates and

their inherent dangers needs to be promoted via the media at the

national and local levels. Patients must be educated on the proper

disposal of leftover portions of opioid prescriptions. This will

contribute to a decrease in the number of diverted pain medications sold

on the street.

Fourth, there should be greater enforcement of providers accepting

private or government insurance (Medicaid and Medicare). Physicians

engaged in abusive charges in exchange for prescribing Methadone Drug narcotics need to

be reported to the Board of Medicine. Conversely, patients guilty of

doctor or pharmacy shopping should be investigated by the proper

authorities and the appropriate charges be filed against the patient.

Finally, controlled prospective studies need to be conducted to

determine treatment effectiveness of Suboxone[R] across multiple social

and economic domains. Post treatment follow up needs to be conducted by

interviews and random drug testing for an additional year. Success would

be determined upon the patient's ability to resume, maintain, and

fulfill social and personal role obligations. Results would be

triangulated through the comparison with other studies.

While prescription drug abuse exists in epidemic proportions, it

has the potential to spiral out of control to conditions not yet seen in

modern society. The implementation of more stringent guidelines and

broad-reaching educational programs are imperative to stop this

continually developing trend.

by Khalid M. Hasan, MD and Omar K. Hasan, MD


Chumlee, of 'Pawn Stars' fame, had 12 handguns and vault with narcotics

An arrest report for "Pawn Stars'" Chumlee, obtained by KTNV, reveals the reality star had multiple guns, marijuana, Xanax and methamphetamines in his home.

Chumlee, whose real name is Austin Lee Russell was arrested March 9 after police say officers serving a search warrant in a sexual assault investigation found the illegal items in his southwest Las Vegas home. FOX411 has learned "Pawn Stars" was not filming at the time of his arrest. 

According to the police documents, Russell was reluctant to open a vault they discovered. He told detectives that he kept marijuana and guns in the vault and while he smoked "a lot of weed," he insisted to the officers was not a Methadone Withdrawal dealer.

At Russell's residence, police found many items including digital scales, a .45 caliber handgun and magazine, rolling papers, marijuana in various size bags, multiple Xanax "Zanie" bars, and a rolled up $1 bill with white residue on it. 

Police also found narcotics and narcotic paraphernalia throughout his home.

Russell's lawyers told TMZ Tuesday, "We will be analyzing what was allegedly found and whether the alleged seizure was lawful in a courtroom, not in the media. Austin has great faith in the judicial system, as do we, and looks forward to a just resolution of this matter."

Russell posted $62,000 bail and was released from jail pending a May 23 court date.

The 33-year-old was booked on 19 drug-possession charges and one weapon charge.

Russell wasn't booked on a sex-crime allegation. Police said that investigation Methadone Side stems from a recent complaint by a woman and is continuing.

The Associated Press contributed Dependence to this report.


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Dein Leben. Dein Business. 

Die Idee

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Wir lieben, was wir tun. Diese Passion leben wir jeden Tag.