Like many of us, I have been dealing with a member of the family who has an addiction. Alcohol addiction has long been recognized as a major medical problem, and treatment for alcoholism has been in use for decades. However, drug addiction, an equally important medical problem, has not been addressed nearly so well. Unlike alcoholism, the medical profession has directly or indirectly instigated drug abuse. Excess alcohol use is viewed skeptically as an addictive condition – too many of us imbibe and consider drinking a safe outlet for stress and pent-up emotions. Where does one draw the line between heavy drinking and alcoholism? Drug addiction, on the other hand, generally started with a prescription from the doctor for a legitimate concern, but its usage became habitual and excessive. Of course, not all drug addiction starts in the doctor's office; too many younger individuals have used drugs "recreationally" and found that their illicit drug use became insatiable and beyond their control. Although marijuana has been blamed for being a gateway drug for further drug use, it has been less self-abusive.
Since the 1960s, drug experimentation and heavy alcohol use have been a rite of passage for college students. In the 1970s and 1980s, cocaine frequently turned users into addicts; more recently, opioids and methamphetamines have become the drugs of choice. When opioids became difficult to obtain in the past several years, heroin, a cheaper drug, has exploded in use. Heroin addiction is now overtaking our young in cities, suburbs, and rural areas. The addiction is so difficult to break that treatment for the poor is limited to medicating the craving with a drug substitute – necessitating daily early-morning lineups waiting to be seen at a methadone clinic.
PBS recently showed a documentary focusing on several individuals in the Seattle area who are addicted to heroin, and the Seattle Police Department's program to facilitate rather than incarcerate addicts. Heroin addiction is not just a problem for drug courts and methadone clinics – addicted patients are coming to our offices and looking for answers from integrative physicians.
Perhaps we should all take a closer look at addiction and the addicted individual. After all, this is not merely a patient in the office – it's also a family member or a friend. When addiction involves a close one, we are personally impacted. In the book Broken, by William Cope Moyers, the son of TV journalist Bill Moyers, the author tells his story of addiction and recovery. The younger Moyers' memoir details how he became addicted to alcohol and crack cocaine while in college. Moyers' binging with alcohol is typical college-age drinking, becoming drunk, and occasionally driving under the influence. He follows in his father's footsteps and becomes a journalist, performing brilliantly, despite his jealousy that he can never match his dad. However, the stress is too great, and William uses the drug that he is introduced to in the 1980s, cocaine. When snorting powder is not enough of a high, he upgrades to smoking "crack" cocaine. Moyers describes the exponential increase in pleasure that he experiences that first time on crack, and with that one use, he was hooked on smoking it, gradually abandoning his wife, his kid, and his job.
At one point he drops out and disappears. His parents hire a detective to locate him; when William's car is spotted parked on a Harlem street, Moyers' mom canvasses the neighborhood before finding him crashed in his dealer's apartment. Moyers spends a few weeks in the psych ward in NYC detoxing and then is flown to Minnesota to the renowned Hazelden center for drug recovery. He details the recovery process, including counseling and the Alcoholics Anonymous Twelve Steps. Despite being sober for 6 months, Moyers returns to his home turf in New York and promptly relapses. He returns to Hazelden for another stint at addiction treatment and counseling. After he recovers, he is offered a plum journalist position in Atlanta. Despite a commitment to remain clean and continue AA meetings, after only a few months, he finds himself in a crack house. Moyers is given, yet again, another round of detox and drug counseling – and this time, his recovery work appears to achieve some spiritual epiphany that sinks in. He opts to give up the esteemed journalist position and returns to Hazelden, not as a patient, but as an employee. Moyers becomes a public relations advocate for drug treatment and rehabilitation, statewide and federally. He chooses to devote his life to advocacy work, lobbying for insurance company coverage for recovery treatment.
Perhaps the most important part of Broken is the discussion that Moyers provides of how his alcoholism and addiction affected his wife, his parents, his friends, and others. Addiction remains a very difficult problem, one that is heartbreaking for the addict and the family.
New CDC Guidelines Issued on Physician Prescription of Opioids
The medical prescribing of opioids is not exactly broken, but it isn't in good shape either. Over the past 3 years, the incidence of death from opioid overdose has mushroomed, as have resuscitations for such overdoses. Fortunately, efforts by public authorities to put injectable naloxone (Narcan) into the hands of police officers, EMTs, and related parties have dramatically prevented the death of unconscious, overdosed individuals. Still, the use of opioids by American is staggering: we are 5% of the world's population, yet use 80% of the world's opioid supply. Opioid use is now so rampant that it has become a major political issue in the 2016 election. While Moyers' story talks about the struggle of the addict using illicit drugs, patients experiencing pain are being prescribed opioids by their physicians, yet people in both situations are equally addicted. The difference begins to blur when the street addict is using Oxycontin or morphine. But how does a prescription drug make it onto the street? It had to start with the doctor writing a prescription for it and the "patient" selling the pills.
Of course, there is a black market supply for prescription painkillers that sidesteps the doctor's office, and is replenished directly from the corrupt pharmacist, drug company middleman, and pharmaceutical house. Still, the vast majority of the 10 to 15 million Americans who use opioids get their prescriptions legitimately in office visits with their primary doctors. The political answer is, as it always has been, to knock off the drug dealer. In this case, the physician is the drug dealer, and in mid-March the CDC issued a series of guidelines limiting opioid prescribing by the physician. Depending on one's viewpoint, the guidelines create red tape for the physician and endless grief dealing with the patient.
As before, the guidelines are not meant to stop the use of opioids in the terminally ill, particularly the cancer patient. The bugaboo is the patient with musculoskeletal pain. Many of these patients were given an initial prescription by the emergency room doctor following an acute injury. Others were given oxycodone prescriptions following surgery or a dental procedure. Even though severe pain is only present for several days, many patients have taken home 30 to 40 pills, sometimes even 60 to 100. Oddly, oxycodone and hydrocodone are inexpensive drugs (when bought at the drugstore, not on the street). Typically, a patient who sustained an acute injury will use a handful of pills and then put the rest in the bathroom cabinet. But more than a few individuals "like" the feeling that they experience on the drug, and continue to use it a week, 2 weeks, 3 weeks. By that point, they are hooked. In that short period, they have become opioid dependent. For others, the acute pain has never resolved. The pain stubbornly remains moderately severe and the opioid lessens the pain, dulls the interminable time of experiencing the pain, and enables one to persevere in doing chores and work. It's in these patients who have stubborn pain that the opioid is now a dependency – and the patient insists that the physician prescribe more. In the 1990s when doctors were encouraged to conquer the patient's pain, opioids were handed out like lollipops; now the pendulum has swung and physicians are shirking from any opioid prescriptions.
The CDC guidelines are outlined in a March 15 JAMA article.1 Opioid prescriptions are initiated for pain only after determination that aspirin, acetaminophen, or a NSAID is not indicated or effective. Opioids should be prescribed for 2 to 3 days, certainly less than 1 week. Patients requiring refills of pain medication need to be reevaluated and only short prescriptions should be provided. Patients requiring lengthier prescriptions should be asked to do physical therapy, acupuncture, chiropractic (not part of guidelines), and other modalities supporting pain without medication. In addition to NSAIDs, patients needing long-term pain medication should be prescribed antidepressants, but not antianxiety medication (which should be avoided). Patients already using high-dose opioids should be required to taper their daily medication with the goal of lowering their dose to 50 mg/day of morphine equivalent. (Hydrocodone 5 mg is comparable to morphine 5 mg; oxycodone 10 mg is comparable to 15 mg morphine.) Patients requiring more than 50 mg morphine equivalent of opioids should be considered for an addiction detoxification/recovery program using methadone maintenance or buprenorphine/naltrexone. Of course, patients should be screened with random urine drug analyses. Opioid prescriptions should be reevaluated every month to justify ongoing use and assess for drug dependency.
None of the above makes the business of prescribing pain medication easier, more straightforward, or less unpleasant. Furthermore, it is unclear how these guidelines will stem the flow of patients who have been denied opioids from seeking heroin. Integrative and naturopathic medicine should be implemented concomitantly with patients requiring ongoing drug prescriptions or detoxification programs.
ALS: An Infection of the Gut?
Although ALS (amyotrophic lateral sclerosis, or Lou Gehrig's disease) is relatively uncommon, it still affects nearly 20,000 individuals in the US and perhaps 10 times as many internationally. A progressive disease of the motor neurons of the brain and spinal cord, it has no effective therapy and most patients die in 2 years. While there is a familial variant of the disease, most patients develop ALS with no genetic predisposition. The disease is not only famous for taking Lou Gehrig's life at age 37 – it also claimed the lives of actor David Niven (73), historian Tony Judt (62), and soccer star Patrick Grange (29). Stephen Hawking, the astrophysicist, has a rare slow-progressing variation of ALS. The symptomatology of ALS dramatically weakening one's musculature is a grim way to die. If one could alter the course of this disease, it would be a boon for the patient and the patient's family and friends.
David Steenblock, DO, is a physician and medical researcher who is well known in the integrative medical community. David and I have had a collegial friendship for many years, first sharing our medical experiences at ACAM meetings focused on chelation therapy in the early 1980s. David has been very active in researching the medical literature, seeking information not limited to pharmacology but addressing biochemistry and physiology. In the late 1990s he became intrigued with the breakout of stem cell research and the early exploration of stem cell therapies. Steenblock's work had been focused on understanding the role of infection and inflammation in chronic, degenerative disease. His research in the 2000s examined the role that stem cell treatments would play in treating patient with neurologic disease, including ALS. Steenblock conjectured that while stem cells would be critical to repair of degenerative tissue, addressing inflammation, infection, and detoxification were all necessary to ensure stem cell efficacy. While treating patients with ALS, Steenblock uncovered a surprising pathophysiology for the disease.
In this issue, Bob Frost interviews Dr. Steenblock, who discusses the role that trauma to the neck plays in setting up the ALS process. Steenblock bases his hypothesis on his study of 54 ALS patients; he will submit his study to a journal later this year. Steenblock conjectures that it is the entry into the spinal cord of biofilms and other infections, monocytes, and toxins that sets in motion the death of motor neurons leading to the ALS process. Steenblock's clinical cases treated with stem cells and anti-infection, anti-inflammatory, and detoxification protocols have resulted in a number of individuals whose disease was "reversed."
Given that medicine's only treatment for ALS is life quality palliative care, Steenblock's work deserves close attention.
The Bureaucratic Mind and Your Health
Kenneth Smith is the communications director of Beech Tree Labs, an early-stage biopharmaceutical company. He is also the executive director of Beech Tree's sister company, the Institute for Therapeutic Discovery, a nonprofit focused on bridging biochemistry and biophysics. In May 2014 his writing appeared in the Townsend Letter hypothesizing that we might need a "periodic table of allergens." His paper suggested that due to "molecular cross-reactivity," many allergies and hypersensitivities might be due one or more common denominator allergens. It would be very interesting indeed to have a periodic table of allergens.
In this issue, Smith examines the philosophic concept of "the bureaucratic mind," particularly its influence on our health. He states that the bureaucratic mind is a mindset that is quite "rigidly organized" so that "thinking is compartmentalized and passed on to others with minimal examination of value." The bureaucratic mind is not limited to organizations and governments. Our day-to-day personal mindset depends on our own bureaucratic mind to make decisions efficiently with little thought and evaluation. We want to come to a stop when we see a red light – we don't want this to be a decision open to interpretation or alternatives. But what about when we come to a fork in the road and there are no signs to direct us? Our first thought would be to confirm that there really is no sign; after all, why take a chance with a wrong decision? The problem in health is that the health bureaucracy wants to streamline medical diagnosis and treatment into a simple, codified process. What if the diagnosis and the treatment are open to different pathways, different options?
Hence the collision course that one faces opting for alternative medicine in a conventional medical setting.
Smith considers how the bureaucratic mind does not function well with genomics. How could chronic infection or toxicity contribute to a disease process? The bureaucratic mind falters when we approach health as a process of homeostasis or, as he terms it, homeodynamics. Smith is particular interested in psychologic homeodynamics, when the psychological state directly affects our physiological and immuno-logical response.
Smith argues that we will always deal with the bureaucratic mind – the question is how we manage it.
Jonathan Collin, MD
1. Dowell D et al. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA. 2016:March 15.