Brain Function And New Avenues Affecting Treatment, Relapse Prevention, And Recovery In Reward Deficiency Syndrome (RDS): Are We Betting On The Wrong Horse?
Why should we be concerned about brain function and new avenues affecting treatment, relapse prevention and recovery in Reward Deficiency Syndrome (RDS)?
It is no surprise that America is faced with an enormous public health problem labeled the “Opioid Epidemic” and the millions of people becoming victims of addiction liability induced by our American Pain Management society. The death rate of white Americans has risen due to deaths from opioids/opiates involving overdose to heroin, suicide, and terrifying withdrawal symptomatology. Recently Dr. Lewis Nelson, New York University School of Medicine, and colleagues commented in JAMA, “The chronic, relapsing nature of opioid addiction means most patients are never ‘cured,’ and the best outcome is long-term recovery. The lifelong implications of this disease far outweigh the limited benefits of opioids in the treatment of chronic pain, and in many cases the risks inherent in the treatment of acute pain with opioids.”
There are very disturbing facts to support this outcry in the American healthcare system. Dr. Beth Han, PhD, of the Substance Abuse and Mental Health Services Administration (SAMHSA) in Rockville, MD, and associates recently reported in JAMA the following facts:
• From 2003-2013, prescription opioid dependence rose from 0.4% to 0.6% in people aged over 12.
• Associated Emergency Department visits rose from 82.5 to 184.1 per 100,000 from 2004–2011.
• Prescription opioid related-deaths rose from 1.4 to 5.1 per 100,000 from 1999–2013.
• Drug overdose death rates involving prescription opioids increased from 4.5 per 100,000 in 2003 to 7.8 per 100,000 in 2013.
Moreover Han et al. also found that in 2013, the 16,200 deaths resulting from prescription opioid disorders exceeded the 14,774 deaths from use of all illicit drugs combined. Interestingly, disorders were more common among non-Hispanic white users, although the most frequent users of prescription opioids were non-Hispanic black people. Substance use disorders (SUD) were more common among people without a high school diploma, those who were disabled for work, people with major depressive episodes, those without health insurance and those with Medicaid coverage rather than private health insurance.
To better understand this major public health issue, consider these upsetting facts:
• Every day, 44 people in the United States die from overdose of prescription painkillers.
• Heroin is a highly addictive opioid drug with a high risk of overdose and death.
• People addicted to prescription opioid painkillers are 40 times more likely than others to become addicted to heroin.
• From 1999–2002, 57.6% of opioid users took an opioid stronger than morphine or morphine-equivalent; by 2011–12, this figure had increased to 80%.
• Use of higher amounts of prescription opioids is a significant risk factor for overdose death.
• In 2013, over 75% of adults aged 18–64 with SUD received no treatment
In spite of general agreement that FDA approved medication assisted treatment (MAT) drugs, including combinations of buprenorphine/naloxone and extended release of Naltrexone, for opioid and alcohol addicted individuals may be useful in the short term treatment, the vast majority of rehabilitation facilities in the U.S. do not offer such care and it has been estimated that nearly 75% of addicted people in America do not get any neurochemical therapy.
While we embrace the short-term use we do not believe that there is good evidence to support MAT long-term treatment approaches. There are studies supporting the fact that long-term utilization can lead to severe withdrawal when the buprenorphine/naloxone combination is abruptly ceased. Moreover, sophisticated lie detection devices by phone has revealed significant lack of emotional affect in patients treated with this combination compared with the general population and even with members of self-healing programs such as Alcohol Anonymous. Over many decades my associates, and even Nora D. Volkow (director of NIDA), have argued in favor of the enhancement not blockade of dopamine function in the long term with the goal of what we call “dopamine homeostasis.” It is our goal to achieve this regulation of brain dopamine, which is the cornerstone for a happy and healthy life.
It should come as no surprise that we are faced with an opioid epidemic, knowing that at least one addiction risk gene variant (allele) of the dopamine D2 receptor (A1 variant) is prevalent in approximately 100 million Americans. This being the case it seems intelligent to ask the many brilliant minds that are dedicated to the scientific advancement of addiction medicine to seek ways to enhance the quality of life for Reward Deficiency Syndrome (RDS) victims in recovery by improving “dopamine homeostasis.” One possibility is to consider natural assisted treatment (NAT). This more novel holistic approach could include exercise, hyperbaric chambers, cognitive behavioral therapy, brain spotting, and not least a natural highly research complex mixture known as KB220 z and variants thereof.
Just think if an individual having a cardiovascular problem went to a cardiologist for treatment and the cardiologist instead of prescribing digoxin or a beta blocker for the heart said, “Just go home and pray and you will be alright.” This is similar to most of the treatment facilities being allowed to practice treatment by not providing real treatment to help support brain function. If we continue to allow this in America, we are doomed to fail and we will not only lose the war on drugs (as well other non-drug related behavioral addictions) but lose our next generation (see Michel Deleon’s film Kids Are Dying).
Our work related to drug testing of urine as published in PLoS ONE (Blum et al. 2014) showed clearly that there was significant drug abuse even under therapeutic treatment by at least 10,000 patients across six East Coast states. The take home message here is two-fold: (1) The MAT approach may not be optimal, and (2) drug testing of urine must continue to confirm both prescribed opioids (like fentanyl) and non-prescribed drugs of abuse (like amphetamines, Spice, and even bath salts).
Finally, we should be aware that the chronic, relapsing nature of opioid addiction means most patients are never “cured,” and the best outcome is long-term recovery. Thus, it is my opinion the lifelong implications of this ASAM defined “Brain Disorder” far outweigh the limited benefits of opioids in the treatment of chronic pain. In many cases the genetic risks for inherent predisposition (possible genetic diagnosis in the near future) in the treatment of acute pain with opioids should be standard practice to avoid future addiction to legal opioids leading to death by overdose (due to cheaper heroin).
Han, B., Compton, W. N., Jones, C. M., & Cai, R. (2015, October). “Nonmedical Prescription Opioid Use Disorders, Frequency of Use and Deaths Increase in the U.S.” JAMA, 314(14), 1453–1454.
Nelson, L. S., Juurlink, D.N., &Perrone, J. (2015, October). “Addressing the Opioid Epidemic.” JAMA, 314(14), 1468–1478.