Ketamine is a dissociative anesthetic that acts on the central nervous system by antagonizing the n-methyl-d-aspartate (NMDA) receptors. It is a rapid acting anti-depressant, but there is a lot more attention being paid to it’s efficacy in alcohol and drug abuse treatment.
Ketamine has been shown in some studies to prolong abstinence from alcohol and drug use disorders. It also has been found to reduce cocaine craving and self-administration in untreated patients.
The mechanisms by which this works has been through the disruption of relevant neural networks which blocks reconciliation of drug-related memories, neuroplasticity and neurogenesis, and enhancing psychological therapy.
We know that addiction is a chronic relapsing disorder with cravings, drug seeking, and unpleasant withdrawal symptoms upon cessation of the drug. Relapse rates with current therapies are between 40-80%.
Pre-clinical research on Ketamine has shown effectiveness in alcohol intake in a rat model:
Alcohol-preferring rats could self-administer 0.08% weight/volume saccharin, 10% weight/volume ethanol or water. After intraperitoneal administration of either ketamine or memantine, operant responding and motor activity were assessed. A dose of 20 mg/kg of ketamine reduced ethanol administration significantly (33.3% less than vehicle-treated rats) without affecting motor activity and water consumption. Importantly, coadministration of rapamycin blocked ketamine-mediated reduction of alcohol intake, but not that of memantine (Sabino et al., 2013). Similarly, ketamine’s antidepressant effects are suppressed by rapamycin. mTOR activation is required for the anti-alcohol effect of ketamine, but not memantine, in alcohol-preferring rats
The devastating consequences of alcohol-use disorder (AUD) on the individual and the society are well established. Current treatments of AUD encompass various strategies, all of which have only modest effectiveness. Hence, there is a critical need to develop more efficacious therapies. Recently, specific glutamatergic receptors have been identified as potential novel targets for intervention in AUD. Thus, the current study was designed to evaluate the effects of acute administration of sub-anesthetic doses of ketamine, an NMDA receptor antagonist, as well as NBQX, an AMPA/kainate receptor antagonist on alcohol intake and its possible behavioural consequences. Adult male Wistar rats were trained in drinking in dark paradigm (3 weeks), and following stable alcohol intake, ketamine, NBQX as well as their combination were injected prior to a 90 min drinking session. In addition to alcohol intake, sucrose preference (overnight), and locomotor activity and forced swim test (FST) were also evaluated before and following alcohol intake. Both doses of ketamine (5 and 10 mg/kg) and NBQX (5 and 10 mg/kg) significantly attenuated percent alcohol intake. The combination of the higher dose of ketamine and NBQX, however, did not significantly affect percent alcohol intake. Moreover, animals exposed to alcohol showed decreased sucrose intake (reflective of anhedonia), decreased locomotor activity and swimming in the FST (reflective of helplessness), that were not affected by ketamine and/or NBQX. These results suggest that selective antagonism of the NMDA or AMPA/kainate receptors may be of therapeutic potential in AUD.
Addiction is characterised by disruptions in learning and memory. Addicts develop cue-specific responses to drug-related
cues. One preclinical study examined the effects of ketamine administration on reconsolidation
where memories are rendered more labile following reactivation. After morphine CPP ( conditioned place preference) was induced, rats were intraperitoneally administered 60 mg/kg of ketamine after being reexposed to the conditioned context or while they were in their home cages. After ketamine administration, preference for morphine decreased significantly in the first retest. This has been interpreted as evidence that ketamine successfully disrupted reconsolidation of the environment-drug memory.
Persistent memory associated with addictive drugs contributes to the relapse of drug abuse. The current study was conducted to examine the effects of scopolamine and ketamine on reconsolidation of morphine-induced conditioned place preference (CPP). In experiment 1, after morphine CPP was acquired, rats were injected with ketamine (60 mg/kg, intraperitoneally) and scopolamine (2 mg/kg, intraperitoneally), respectively, after reexposure to an earlier morphine-paired context or in their home cages. The CPP was reassessed 24 and 48 h after reexposure. An additional group of rats received saline following reexposure to the earlier morphine-paired context. In experiment 2, two groups of rats were only given saline during the CPP training and subsequent administration of ketamine or scopolamine during the reexposure. In experiment 1, rats failed to exhibit morphine CPP when ketamine and scopolamine were administered only after reexposure to a morphine-paired context. CPP was not abolished by ketamine or scopolamine administration in the animals’ home cages. Also, the animals receiving only saline injections showed strong morphine CPP 24 h after a short exposure to the morphine-paired context. In experiment 2, ketamine or scopolamine treatment alone did not induce CPP or aversion. Administration of scopolamine and ketamine, after reexposure to a drug-paired context, resulted in the disruption of morphine CPP, suggesting the potential effects of scopolamine and ketamine in disrupting memory associated with environmental cues and addictive drugs.
The capacity of ketamine to treat addiction was not investigated scientifically until decades later when Krupitsky and
Grinenko (1997), published work that reported the use of ketamineto reduce relapse in recently detoxified alcoholics. These
published results were a review of 10 years of previous research.The procedure that was investigated was referred to as Ketamine Psychedelic Therapy (KPT) and had been applied since the mid-80sin the former Soviet Union, until ketamine was banned in Russia 1998. Ten Year Study of Ketamine Psychedelic Therapy (KPT) of Alcohol Dependence [
KPT consisted of three stages. The first step was the preparation,during which patients underwent a preliminary psychotherapy session where a psychotherapist discussed with them the content of the psychedelic experience. They were told that under the influence of ketamine, they would view the world symbolically, realise about the negative aspects of alcohol dependence and see the positive sides of sobriety. They were also told that they would become aware of unconscious mental concepts about the negative aspects of their addiction, such as their personal problems and their self-identity. These insights would help them to accept new life values, purposes and meaning of life and in turn e to overcome
their alcoholism. The second stage was the ketamine session in which ketamine was intramuscularly injected and the psychotherapist interacted with the patient. The psychotherapist verbally guided the patient, with the aim of creating new meaning and purpose in life. At moments of highly intense psychedelic experience, the smell of alcohol was introduced to the individuals. The idea was to enhance the negative emotional valence of the thoughts related to alcohol during the session. Finally, group psychotherapy was performed after the session. The aim of this session was to help patients integrate
insights of psychedelic experience into their lives. It is reported that this procedure was used in
over 1000 alcoholics with no reported complications.In Krupitsky and Grinenko, 1997 report, relapse rates in a group
of recently detoxified alcohol dependent patients undergoing KPT (n ¼ 111) were compared with another group of alcohol dependent patients who were treated with treatment as usual (n ¼ 100). Both groups underwent alcohol detoxification before treatment. After these sessions, the KPT group received an intramuscular injection of ketamine (2.5 mg/kg) along with the corresponding preparation. The control group received ‘conventional, standard methods of treatment’ in the same hospital. Only 24% of the control group remained abstinent after a year, whereas 66% of the KPT group did not relapse during the same period (p < .01).
In a further study, 70 detoxified heroin-dependent patients were randomised into two KPT groups, who were injected different doses of ketamine, in a double-blind manner (Krupitsky et al., 2002). One group (n ¼ 35) received 0.2 mg/kg i.m. of ketamine, which was considered an active placebo, whereas the experimental group (n ¼ 35) received 2.0 mg/kg i.m. After two years, the higher dose of ketamine resulted in a greater rate of abstinence (17% vs 2% abstinent subjects, p < .05). Additionally, the experimental group had a larger positive change in nonverbal unconscious emotional attitudes and a greater and longer-lasting reduction in craving for heroin. The authors therefore concluded that effectiveness of ketamine
was dose dependent. Ketamine psychotherapy for heroin addiction: immediate effects and two-year follow-up
In 2007, Krupitsky’s lab compared the impact of a single vs three KPT sessions (dose: 2.0 mg/kg, i.m.) (Krupitsky et al., 2007). Fifty nine detoxified heroin dependent patients first received a KPT session. After this, 6 participants relapsed and abandoned the treatment. The remaining participants were randomised into two groups: one received a further two KPT sessions (n ¼ 26) in monthly intervals, whereas the other underwent two counseling sessions (n ¼ 27) also in monthly intervals. After a year, 50% in the 3-session KPT group remained abstinent compared to 22% in the single KPT (p < .05) (Krupitsky et al., 2007). This clearly demonstrates the superior efficacy of three KPT sessions in comparison to
one KPT session, which indicates that the KPT sessions are beneficial. Single Versus Repeated Sessions of Ketamine-Assisted Psychotherapy for People with Heroin Dependence
In a private psychiatric practice in the US, another psychiatrist has successfully conducted KPT since 1994. He has not only treated patients with drug addiction, but also individuals with other types of addictions (e.g. food addiction) and other psychological disorders. His reported anecdotal, clinical findings are positive, having adhered strictly to the original protocol. Ketamine Enhanced Psychotherapy: Preliminary Clinical Observations on Its Effectiveness in Treating Alcoholism. Kolp, Eli,Friedman, Harris L.,Young, M. Scott,Krupitsky, Evgeny The Humanistic Psychologist, Vol 34(4), 2006, 399-422
Ketamine is a dissociative anesthetic widely used by physicians in the United States and also a psychedelic drug that physicians can legally prescribe off-label within the United States for other therapeutic purposes. It has been used in Russia and elsewhere to successfully treat alcoholism and other psychological or psychiatric problems, but has not been researched for this purpose in the United States. Results of a series of clinical trials using ketamine for treating alcoholism in the United States are retrospectively reported, along with 2 case studies of how psychotherapy facilitated by this substance helped two individuals achieve abstinence through ketamine’s transpersonal effects. Considering the massive problems caused by alcoholism, the need to begin formal research studies on ketamine psychotherapy for alcoholism is emphasized.
In 2014, 8 cocaine dependent males disinterested in treatment received 3 infusions in a double-blind, cross-over design: 0.41 mg/ kg ketamine, 0.71 mg/kg ketamine, and 2 mg lorazepam (an active benzodiazepine control, which induces mild subjective and anxiolytic effects) (Dakwar et al., 2014b). Infusions lasted 52 min and were separated by 48 h. Before and after each infusion, motivation to quit cocaine and cue-induced craving were assessed. Relative to the lorazepam, motivation to quit cocaine was enhanced and cueinduced craving for cocaine was reduced by the 0.4 mg/kg ketamine (both ps ¼ 0.012), and this latter effect was augmented by the 0.71 mg/kg ketamine dose. During the psychedelic experience,
dissociation and mystical-type effects were assessed. As predicted, the higher dose of ketamine led to greater mystical experiences. Strikingly, these mystical-type experiences, but not the dissociative effects, were found to mediate motivation to quit. However, the small non-treatment-seeking sample, the absence of an inactive placebo and the cross-over design, limit the results.Having said that, the participants showed a significant reduction in the frequency and amount of cocaine
consumed in normal life in the 4 weeks following the experiment, compared to baseline. Dakwar, E., Levin, F., Foltin, R.W., Nunes, E.V., Hart, C.L., 2014b. The effects of subanesthetic ketamine infusions on motivation to quit and cue-induced craving in cocaine-dependent research volunteers. Biol. Psychiatry 76, 40e46. https://doi. org/10.1016/j.biopsych.2013.08.009.
Also, more cocaine research from the same group is here:
Cocaine self-administration disrupted by the N-methyl-D-aspartate receptor antagonist ketamine: a randomized, crossover trial E DakwarMolecular Psychiatryvolume22, pages76–81 (2017) |
Repeated drug consumption may progress to problematic use by triggering neuroplastic adaptations that attenuate sensitivity to natural rewards while increasing reactivity to craving and drug cues. Converging evidence suggests a single sub-anesthetic dose of the N-methyl-D-aspartate receptor antagonist ketamine may work to correct these neuroadaptations and restore motivation for non-drug rewards. Using an established laboratory model aimed at evaluating behavioral shifts in the salience of cocaine now vs money later, we found that ketamine, as compared to the control, significantly decreased cocaine self-administration by 67% relative to baseline at greater than 24 h post-infusion, the most robust reduction observed to date in human cocaine users and the first to involve mechanisms other than stimulant or dopamine agonist effects. These findings signal new directions in medication development for substance use disorders.
Neural plasticity is defined as the cellular and structural reorganisation
of the brain. Synaptogenesis is a crucial mechanism for
plasticity, since for change to happen within brain circuitry new
synapses between neurons must be formed. Surface expression of
AMPARs and upregulation of other synaptic proteins are involved in
the process of synaptogenesis. Diminished glutamatergic synaptic transmission and reduced plasticity are thought to be associated with addiction. Existing models suggest that ketamine’s blockade of NMDA receptors
increases synaptogenesis by stimulating protein synthesis
and the insertion of AMPA receptors. Hence, ketamine’s
effects help to reverse the glutamatergic changes associated
with depression and addiction.
Animal models of addiction, depression and other psychiatric disorders
have been linked to a reduction in adult neurogenesis . It has been suggested that in addiction
the loss of neurogenesis, especially in cortical and hippocampal
regions, may contribute to levels of self-administration and the
vulnerability of relapsing. The reduction of neurogenesis in addiction is supported in
humans by the reduction in BDNF serum levels. In a study, 37
subjects with diagnosis of alcohol dependence showed significantly
reduced BDNF serum levels compared to healthy individuals
. Similarly, cocaine- and heroin-dependentpatients have significantly lower serum BDNF levels and these
seem to recover during withdrawal. Rapid and transient up-regulation of the neuroplasticity marker
BDNF is implicated as a critical component of the antidepressant
mechanism of ketamine . BDNF knock-out mice do not show anti-depressant response to
ketamine in animal models of depression.
Recent research has
demonstrated that ketamine increases peripheral plasma BDNF in
depressed people who respond to treatment but not in treatment
non-responders or patients receiving an active placebo. These BDNF increases in depressed people given ketamine
are robustly correlated with the drug’s antidepressant effects.
It has been found there is a dispersion in normal brain connectivity and the disruption of the usual pattern of communication in depression and addictions. . The integrity of functional networks decreased, being the
change maximal in functional hubs such as the thalamus, putamen
and high-level association cortices. In particular, connectivity
within the Default Mode Network was reduced between the posterior
cingulate cortex and the mPFC .
The connectivity between the parahippocampal and the retrosplenial
cortex also decreased as well as the segregation between
other major functional networks such as the salience, attention and
different visual networks Infusions of ketamine have shown to decrease connectivity
between and within resting-state consciousness networks.
Connectivity between the mPFC and the rest of the Default
Mode Network (via the posterior cingulate cortex) has been found
to be reduced, along with the integrity and activity of the salience
and visual networks are also affected. Since it is known
that connectivity with the mPFC is elevated in depression , the reduction of connectivity in the Default Mode
Network observed during the psychedelic experience might be a
mechanism that helps treat depressive states, which are very
common in addicts and predictive of relapse.
Given addiction is highly co-morbid with depression and ketamine’s role within psychiatry changed
dramatically when it was discovered to be an anti-depressant, we
now briefly describe the research concerning ketamine and
depression. In 2000, the first clinical trial hinted at the potential of
ketamine as a treatment for depression. Four subjects diagnosed
with depression were intravenously administered 0.5 mg/kg of
ketamine in a randomised, double-blind design. The results were
compared to the injection of saline solutions in 3 subjects with an
equivalent diagnosis. Comparison on the Hamilton Rating Scale for
Depression (HAM-D) showed moderate evidence for a greater
reduction in scores after ketamine infusion compared to saline
(Berman et al., 2000). The reduction was rapid and outlasted the
subjective effects of ketamine, lasting for 3 days after infusion.
Despite the small sample size and the limited follow-up, this result
and anti-depressant effects observed in animal models of depression
encouraged researchers in the field to perform more studies in humans . Since then, over 30 studies have
examined the antidepressants effects of ketamine in patients with
treatment-resistant major depressive and bipolar disorders.
Ketamine has shown a 65-70% response rate in treating
depression within 24 h, which contrasts with the ~47% response
rate of conventional monoaminergic antidepressants after weeks
or months . Furthermore,
ketamine’s antidepressant actions are almost immediate and last
for approximately a week ,
whereas conventional antidepressive medications take weeks to
have an effect, are given daily and most of them fail to exert long lasting
effects . Furthermore, studies
have consistently shown that after a ketamine infusion there is a
significant reduction in suicidal ideation which also lasts for several
days.Depression and addiction’s co-expression is almost ubiquitous
People with alcohol, opioids, cannabis and
cocaine use disorders show notably higher rates of depression than
the average of the general population. Furthermore, high levels of depression and anxiety
may predispose relapse to: heroin, alcohol, cannabis and cocaine.
Memories and their creation and alteration is felt to be at the heart of cues and triggers and relapse in addiction. Once consolidated, memories are thought to be stored in a
stabilised state after initial acquisition. Shortly after reactivation
(i.e. remembered) of consolidated memories, these are rendered
transiently unstable and labile, before they then re-stabilise. This
process has been named reconsolidation . After reconsolidation,
the memories are stored again, but they may have been slightly
altered or updated. Each time memories are reactivated the latest
version is retrieved and they are again susceptible to change. During reconsolidation memories may be vulnerable to
manipulation and disruption. This was first demonstrated in animals
using fear conditioning. Rodents were trained to associate a
neutral stimulus with a shock such that the neutral stimulus elicited
a fear response. Researchers eliminated this fear response by
pharmacologically disrupting the reconsolidation process . Reward memories can also be disrupted such that a
neutral stimulus that once elicited appetitive behaviour no longer
does so. Therefore, non-pharmacological and drug therapies that
aim at weakening drug-cue memories via manipulation of reconsolidation
are of interest. Preclinical studies have shown that ketamine affects reconsolidation of drug memories. . A recent review has suggested that ketamine (along with other psychedelics) may be able to disrupt maladaptive appetitive memories
(Fattore et al., 2017). Psychedelics and reconsolidation of traumatic and appetitive maladaptive memories: focus on cannabinoids and ketamine
Clinical data with 3,4-methylenedioxymethamphetamine (MDMA) in post-traumatic stress disorder (PTSD) patients recently stimulated interest on the potential therapeutic use of psychedelics in disorders characterized by maladaptive memories, including substance use disorders (SUD). The rationale for the use of MDMA in PTSD and SUD is being extended to a broader beneficial “psychedelic effect,” which is supporting further clinical investigations, in spite of the lack of mechanistic hypothesis. Considering that the retrieval of emotional memories reactivates specific brain mechanisms vulnerable to inhibition, interference, or strengthening (i.e., the reconsolidation process), it was proposed that the ability to retrieve and change these maladaptive memories might be a novel intervention for PTSD and SUD. The mechanisms underlying MDMA effects indicate memory reconsolidation modulation as a hypothetical process underlying its efficacy.
Mechanistic and clinical studies with other two classes of psychedelic substances, namely cannabinoids and ketamine, are providing data in support of a potential use in PTSD and SUD based on the modulation of traumatic and appetitive memory reconsolidation, respectively. Here, we review preclinical and clinical data on cannabinoids and ketamine effects on biobehavioral processes related to the reconsolidation of maladaptive memories.
We report the findings supporting (or not) the working hypothesis linking the potential therapeutic effect of these substances to the underlying reconsolidation process. We also proposed possible approaches for testing the use of these two classes of drugs within the current paradigm of reconsolidation memory inhibition.
Furthermore, a meta-analysis of pre-clinical
studies found evidence suggesting that NMDAR antagonists can
be used to target reward memory reconsolidation, and more successfully
than adrenergic antagonists such as propranolol (Das
et al., 2013) Das, R.K., Freeman, T.P., Kamboj, S.K., 2013. The effects of N-methyl d-aspartate and B-adrenergic receptor antagonists on the reconsolidation of reward memory: a meta-analysis. Neurosci. Biobehav. Rev. 37, 240-255.:
Pharmacological memory reconsolidation blockade provides a potential mechanism for ameliorating the maladaptive reward memories underlying relapse in addiction. Two of the most promising classes of drug that interfere with reconsolidation and have translational potential for human use are N-methyl-d-aspartate receptor (NMDAR) and B-Adrenergic receptor (B-AR) antagonists. We used meta-analysis and meta-regression to assess the effects of these drugs on the reconsolidation of reward memory in preclinical models of addiction. Pharmacokinetic, mnemonic and methodological factors were assessed for their moderating impact on effect sizes. An analysis of 52 independent effect sizes (NMDAR = 30, B-AR = 22) found robust effects of both classes of drug on memory reconsolidation, but a far greater overall effect of NMDAR antagonism than B-AR antagonism. Significant moderating effects of drug dose, relapse process and primary reinforcer were found. The findings suggest that reward memory reconsolidation can be robustly targeted by NMDAR antagonists and to a lesser extent, by B-AR antagonists. Implications for future clinical work are discussed.
► Meta-analysis of NMDAR and B-adrenergic antagonists in preclinical reward reconsolidation. ► Larger effects of NMDAR (r = .613) than B-adrenergic (r = .24) antagonists were found. ► ‘Relapse process’, trace type, reinforcer and drug dose moderated effect sizes. ► NMDAR antagonists particularly might be of clinical use in treating addiction.
Mystical experiences and psychedelic effects
Mystical experiences and psychedelic effects provoked by
classic psychedelic drugs have been shown to be psychologically
beneficial in long-term studies.They have not only been linked with positive
outcomes in various treatments, but also to ‘life-changing’,
‘spiritually meaningful’ and ‘eye opening’ events.In the ketamine studies described
above, anecdotal and qualitative reports suggest that the subjective
psychedelic experience seemed to help patients. For example, to
help them: undergo a cathartic process, improve relationships with
the world and other people, maintain positive psychological
changes and enhance self-awareness and personal growth.During KPT, patients reported a feeling of ‘resolution’ and
‘catharsis’ of some psychological problems, mainly those related to
alcohol. Furthermore, the degree of mystical experience was also
linked to the insight and impact of KPT reported by patients
. Interestingly, the intensity of the negative experiences (experiences associated
with negative emotions, fear and horror) during the
ketamine session was associated with longer remission. This was
blindly and quantitatively assessed by analysing patient’s selfreports.
Moreover, spirituality, self-concept, emotional attitudes
to other people and positive changes in life values and purposes
were improved after the ketamine experience.
Notably, ketamine’s mystical experiences, but not dissociative
effects, were found to mediate ketamine’s increase motivation to
quit 24 h after the infusion in cocaine addicts .
Moreover, consistent with previous studies, it was also observed
that mystical experiences were positively dose-dependent. This
study therefore provides evidence that the mystical experience
induced by ketamine is important in its therapeutic mechanism
. Speculatively, mystical experiences may help
to rapidly shift patients’ mindsets towards the integration and
acceptance of a sober lifestyle.
The acute disruptions of the functional networks, especially the
alterations to the default mode network, are related to the psychedelic
experience. In fact, the degree of network dissolution in
LSD and psilocybin is correlated with the intensity of the psychedelic
experience . The disruption to the default mode network may engender a reduction in rumination and maladaptive repetitive thoughts. Psychological
therapies for addiction often aim to help the patient consider
different ways of life, especially those without the drug, and a
pharmacological agent such as ketamine which expedites that
process may be useful in treating addiction.
Speculatively, ketamine can
provide a unique mental state during and after acute drug effects
that facilitates and enriches therapeutic experiences, which in turn
may improve efficacy and lengthen treatment effects. Furthermore, synaptogenesis
and neurogenesis are putatively critical in learning new
information . The uptake of psychological therapy may
therefore be facilitated after ketamine infusions due increases in
synaptogenesis and neurogenesis, and thus improved learning of
relapse-reducing strategies, such as those used in relapseprevention
based cognitive behavioural therapy (CBT). In fact, the
idea that neurogenesis and synaptogenesis work synergistically
with psychological therapies is becoming recognised as a new
approach in the treatment of mental disorders . Theoretically, the administration of ketamine (which can
produce a ‘psychedelic’ experience) may open people’s minds so
they are more able to embrace what is presented during therapy as
well as enhancing the uptake of new therapeutic content.
The promise of ketamine in the treatment of addiction is supported
by research with large treatment effect sizes, especially in
comparison to existing treatments. In recently detoxified alcoholics, ketamine treatment increased one-year abstinence rates in alcoholics from 24% in the control to 66% in the ketamine group
(Krupitsky and Grinenko, 1997) and reduced cocaine self administration
by 67% relative to baseline in non-treatment
seeking cocaine users (Dakwar et al., 2016). These results clearly demonstrate profound effects of ketamine administration (with and without therapy) on drug and alcohol use, of an order of magnitude which is 2 or 3 times more effective than existing pharmacotherapies.
Adulterants in drugs are commonly found, such as Levamisole in cocaine. Now, there are reported outbreaks of people bleeding to death from synthetic marijuana. The Virginia Department of Health released a flyer regarding this issue today:
Coagulopathy in Emergency Department Patients Reporting Synthetic Cannabinoid Use April 5, 2018 Dear Colleague: The Virginia Department of Health recently received a report of a case of elevated prothrombin time international normalized ratio (INR) in a patient who reported use of synthetic cannabinoids. Currently, the Illinois Department of Public Health (IDPH) is investigating an outbreak of Vitamin K-dependent coagulopathy among emergency department (ED) patients reporting synthetic cannabinoid use before suffering severe bleeding. As of April 4, 2018, IDPH has received reports of 81 cases, including two deaths. I am writing to alert you as there is a potential for additional cases in Virginia. Patients with Vitamin K-dependent coagulopathy may first present to the ED with bleeding from at least one site, before returning later with an extremely elevated INR and severe bleeding requiring hospital admission. As ED and urgent care providers are likely to be the first healthcare providers to encounter these patients, we encourage you to implement the following guidance for patients who present with bleeding not from an injury and not otherwise explained, including epistaxis, bleeding of the gums, bruising, hematemesis, hematuria, hematochezia, menorrhagia: 1. Ask patients if they have used synthetic cannabinoids within the last 3 months. Terms for these products include K2, spice, synthetic marijuana, fake weed/legal weed, and genie. 2. If the patient reports synthetic cannabinoid use or you suspect use, check the patient’s INR before releasing them. 3. If you encounter a patient with significant bleeding and an elevated INR without a definitive etiology (e.g. taking warfarin or overdose of rat poison), please promptly report the case to your poison center at 1 (800) 222-1222. 4. If you have previously encountered any similar cases since February 1, 2018, please also promptly report the case to your poison center at 1 (800) 222-1222. For questions regarding the treatment and management of these patients, please contact your poison center, 24/7 at 1 (800) 222-1222. For additional information on the public health response, please contact your local health department. Sincerely, Marissa J. Levine, MD, MPH, FAAFP State Health Commissioner A version of this letter is available on the VDH Resources for Health Care Professionals web page.
OUD is the diagnostic term used for a chronic neurobiological disease characterized by a problematic pattern of opioid use leading to significant impairment or distress and includes signs and symptoms that reflect compulsive, prolonged self-administration of opioid substances for no legitimate medical purpose or, if another medical condition is present that requires opioid treatment, the opioid is used in doses far greater than the amount needed for treatment of that medical condition.
MAT is a comprehensive approach that combines approved medications (currently, methadone, buprenorphine or naltrexone) with counseling and other behavioral therapies to treat patients with OUD. Regular adherence to MAT with buprenorphine reduces opioid withdrawal symptoms and the desire to use opioids, without causing the cycle of highs and lows associated with opioid misuse or abuse. At proper doses, buprenorphine also decreases the pleasurable effects of other opioids, making continued opioid abuse less attractive. According to the Substance Abuse and Mental Health Services Administration, patients receiving MAT for their OUD cut their risk of death from all causes in half.
Sublocade should be used as part of a complete treatment program that includes counseling and psychosocial support. Sublocade is a drug-device combination product that utilizes buprenorphine and the Atrigel Delivery System in a pre-filled syringe. It is injected by a health care professional (HCP) under the skin (subcutaneously) as a solution, and the delivery system forms a solid deposit, or depot, containing buprenorphine. After initial formation of the depot, buprenorphine is released by the breakdown (biodegradation) of the depot. In clinical trials, Sublocade provided sustained therapeutic plasma levels of buprenorphine over the one-month dosing interval.
The safety and efficacy of Sublocade were evaluated in two clinical studies (one randomized controlled clinical trial and one open-label clinical trial) of 848 adults with a diagnosis of moderate-to-severe OUD who began treatment with buprenorphine/naloxone sublingual film (absorbed under the tongue). Once the dose was determined stable, patients were given Sublocade by injection. A response to MAT was measured by urine drug screening and self-reporting of illicit opioid use during the six-month treatment period. Results indicated that Sublocade-treated patients had more weeks without positive urine tests or self-reports of opioid use, and a higher proportion of patients had no evidence of illicit opioid use throughout the treatment period, compared to the placebo group.
The most common side effects from treatment with Sublocade include constipation, nausea, vomiting, headache, drowsiness, injection site pain, itching (pruritus) at the injection site and abnormal liver function tests. The safety and efficacy of Sublocade have not been established in children or adolescents less than 17 years of age. Clinical studies of Sublocade did not include participants over the age of 65.
Sublocade has a boxed warning that provides important safety information, including the risks of intravenous self-administration. If the product were to be administered intravenously rather than subcutaneously, the solid mass could cause occlusion (blockage), tissue damage or embolus (solid material that is carried in the blood and can become lodged in a blood vessel, which can lead to death). Sublocade must be prescribed and dispensed as part of a Risk Evaluation and Mitigation Strategy (REMS) to ensure that the product is not distributed directly to patients. Sublocade will be provided to HCPs through a restricted program, administered only by HCPs in a health care setting, and will require health care settings and pharmacies that dispense Sublocade to complete an enrollment form attesting that they have procedures in place to ensure that Sublocade is dispensed only to HCPs and not directly to patients.
The Food and Drug Administration approved a monthly injection for treating opioid addiction last week, and drug-court professionals are saying it’ll be a boon for them. The new treatment is actually a novel form of an old drug, called buprenorphine. But it appears to resolve a long-standing problem for the courts, which aim to funnel people convicted of non-violent drug crimes into addiction treatment: It seems more difficult to sell on the black market than other, popular forms of buprenorphine. (If used improperly, buprenorphine can give the user a euphoric high.)
Because of the diversion issue, it’s been difficult to convince some judges to allow burenorphine treatment among their participants, Connie Payne, the former head of Kentucky’s drug courts, said during a conference this spring. But denying defendants medicines that help prevent relapse can be deadly, as Maia Szalavitz reported inPacific Standard‘s May/June 2015 issue. For her story, Szalavitz spoke to the parents of one man who overdosed and died at 28 after weaning himself off of methadone, a drug that works similarly to buprenorphine, at the direction of a drug-court judge who philosophically opposed medication-assisted addiction treatment.
The new FDA-approved injection gets around the issue of buprenorphine’s black-market value in a few ways: A health-care professional must administer the injection, which is brand-named Sublocade. There are no pills or little strips to be sent home with the user. Once injected, Sublocade turns into a solid mass under the skin that slowly dissolves over the course of a month. A black-box warning on the medicine says that, if people try to inject it into a vein, the way they might abuse heroin or prescription painkillers, it could create a fatal blockage. “From a court standpoint, you’re not having to worry about: Are they taking it every day? Are they abusing it? Are they selling it?” explains Mary Covington, program director for Houston’s drug courts. “It kind of takes away some of those barriers that we put out in our minds.”
The injection should also make life easier for drug-court participants, Covington argues, because it eliminates the need for early morning stops at a methadone clinic and regular blood-samplings taken by doctors to ensure a patient is indeed using his script. “It’s a win-win for everybody,” she says.
Could Sublocade diminish the number of courts that forbid their participants from using buprenorphine? “I would like to think it would,” Covington says. In a surveypublished in 2012, one in six drug courts didn’t allow defendants to take the drug because of worries people would sell their strips. Yet among addiction doctors, giving opioid-addicted patients buprenorphine or similar medicines, alongside counseling, is considered the standard of care. Folks who are funneled to abstinence-based treatment programs instead often fail, overdose, and die, as HuffPost found.
Medication-assisted opioid addiction treatment—which includes counseling plus buprenorphine, methadone, or a drug called naltrexone—is already more available through drug courts now than it was in 2012, says Christopher Deutsch, spokesman for the National Association of Drug Court Professionals. “The treatment court community has really embraced the use of M.A.T. [medication-assisted treatment].” But it’s not known how much more available it really is because nobody has done a survey since.
Outside of the criminal justice world, doctors are a little skeptical that many patients will want a buprenorphine injection if they’re not prodded by a judge. Folks tend to like buprenorphine strips, which dissolve under the tongue, doctors Pacific Standardconsulted say. Still, they’re happy to have an option for patients who seem to stumble in taking their buprenorphine every day, or whom they suspect are selling their strips.
“We’ll definitely use it,” says Joshua Lee, a doctor who studies addiction therapies at NYU Langone Health. “Those of us in the field are delighted that Indivior have gotten approval for this,” says Thomas Kosten, a psychiatrist who studies addiction at the Baylor College of Medicine, referring to the company that makes Sublocade. And there’s more to come: Another company, Braeburn, is currently seeking FDA approval for its long-term injectable buprenorphine, which may arrive in the coming months.
Hailed as the most compassionate way for the criminal justice system to deal with addicts, drug courts were designed to balance punishment with rehabilitation. But after 25 years, the verdict is in: Drug courts embolden judges to practice medicine without a license—and they put lives in danger.
When Ellen Sousares learned that her 22-year-old son, Darren, had been arrested in 2014 for felony possession of heroin and diverted into drug court, she wasn’t upset or ashamed. She was overjoyed. Darren had been addicted to heroin for six years. At the time of his arrest, he was living on the street in Colorado, far from her home in California. He’d already overdosed seriously enough to require emergency care at least six times. He had repeatedly tried rehab, but he’d never stayed long enough to get his mental health properly evaluated. Finally, Ellen thought, he’d be forced to get the help he really needed.
Drug courts celebrated their 25th anniversary last year. Designed for defendants who have committed non-violent felonies such as drug dealing or burglary while addicted, they have been touted as a perfect balance of treatment and punishment, and as a way for the most corrigible offenders to avoid the harsh sentences mandated by drug-war laws. The idea is appealingly simple. If defendants complete a program of drug testing and mandatory treatment—often including short jail terms, known as flash incarcerations, in the case of serious rule violations—they can avoid lengthy mandatory prison terms. Those who fail to “graduate” from the program, in the self- improvement-geared parlance of drug courts, face the mandated sentence, or sometimes an even harsher one. Coercion, the theory goes, is the key to rehabilitation. There’s even a sense nationally that drug courts produce better results than voluntary treatment. In 2008, when voters in California were considering a proposition designed to use less punishment and more treatment in handling drug offenders, Governor Jerry Brown recommended voting against it because, he claimed, less-punitive sentencing would hurt drug courts. “We know that the hammer of incarceration is often what is needed,” he said, “to assist an addict to get off his dependency.”
At first glance, the statistics suggest that drug courts deserve this unusual bipartisan enthusiasm. According to the website of the National Association of Drug Court Professionals, 75 percent of those who successfully complete drug court “remain arrest-free at least two years after leaving the program,” and for every dollar invested in drug court, “taxpayers save as much as $3.36 in avoided criminal justice costs alone.”
It’s not surprising, then, that Ellen Sousares felt that drug court was the perfect solution for Darren. (Their names have been changed for this story.) It would treat his addiction as a disease and match him to appropriate care, while using the threat of prison to motivate him to stick with it. As a mom, she felt relieved that her son would be safe, at the very least, and that he would finally be forced to stay in treatment long enough for the professionals to find out what would actually work for him.
But within a few weeks she began to worry that drug court might be doing Darren far more harm than good. And many others have started to feel the same way.
Darren’s problems started long before he ever tried heroin. A painfully shy child, he was diagnosed with attention deficit hyperactivity disorder in the third grade. “He was always really active, running around, climbing trees,” says Ellen. “I just couldn’t gather him up.”
Although Darren loved studying history, he suffered intense fears and anxieties, and had a hard time with schoolwork. He seemed to find solace only in playing the guitar. At times, Ellen wondered whether his fears and anxieties were signs of mental illness. With a family history of bipolar disorder, Ellen worried that her son might be genetically vulnerable. Research shows that such a history can increase risk for addictions.
Darren was first arrested, for marijuana use, at around age 14 or 15. A judge sentenced him to a rehab program, where he met people with more serious drug problems, including heroin users. His first overdose—stemming from a mixture of heroin and prescription pills—came at 17. “His respirations were down to six to seven a minute,” Ellen recalls. “He almost died that day.” Many more overdoses followed. Over the next few years, Ellen had to tell Darren to stop calling her from the ER after each one, because she couldn’t bear knowing how often he was close to death.
After the arrest that got him placed in drug court, Darren was jailed for several days, during which time he suffered through the initial nausea, insomnia, and shakes of heroin withdrawal, which typically last at least two weeks. As a former emergency-room nurse, Ellen understood this process. She wasn’t especially pleased that he was being left to go cold turkey and denied medical treatment for his symptoms; however, she knew that jails aren’t designed to be hospitals or rehab clinics. But then came her first inkling that drug court itself was not what she had thought it would be: After 10 days, the judge decreed that Darren would be set free, still in active withdrawal, with an order to return in several days to visit the probation office.
This shocked and infuriated Ellen. From a medical perspective, Darren was now in a highly vulnerable state. When people who are addicted refrain from using heroin for over a week, they lose their built-up tolerance to opioids. A dose that a week ago barely produced a high might now be fatal. When such people are freed from custody without the proper treatment, as Darren was, their odds of a fatal overdose increase exponentially.
Ellen knew heroin addiction to be one of the deadliest of all psychiatric disorders, with an annual risk of death of one to three percent. And she knew that Darren’s risk was now glaringly acute. Homeless and still in active withdrawal, Darren had nowhere to go and nothing to do.
Alarmed, Ellen argued with probation officers and anybody else she could think to call, but to no avail. They all told her the same thing: “Everybody has to go through this system.”
Predictably, Darren didn’t show up for his meeting at the probation office. A warrant was issued, and he was quickly arrested. As punishment, he was given a flash incarceration of around 10 days. Then the cycle repeated itself: Again he was released, still in withdrawal, and told to turn up days later for a probation appointment; again he failed to show; and again he was arrested, briefly imprisoned, and released. Not long afterward, Ellen got the call. “All I know,” she says, “is that within hours of getting out of jail he overdosed on heroin and ended up in the ER.”
By the time Darren was assigned to drug court, his addiction story carried almost every possible red flag for high-mortality risk: prior overdose, prior treatment failure, a childhood ADHD diagnosis, and a family history of mental illness. Any addiction doctor—or anybody who simply follows evidence-based treatment guidelines—would know exactly what to prescribe for him: opioid maintenance, by far the most effective treatment, known to lower the death rate of opioid addiction by between 66 and 75 percent. Maintenance is the indefinite use of an opioid medication such as methadone or buprenorphine, typically combined with counseling. The World Health Organization has called it “essential medicine,” and the National Institutes of Health, the Institute of Medicine, and the White House Office of National Drug Control Policy have all endorsed it in various consensus statements. Even the National Association of Drug Court Professionals describes it on its website as a “best practice.” In 2000, after a defendant in a California drug court died of overdose after being denied maintenance, the state passed a law requiring drug courts to allow it.
But many drug court judges vociferously oppose the practice and require patients to become completely abstinent as a condition of participation or graduation. They believe that maintenance simply amounts to swapping one drug addiction for another. This critique betrays a fundamental misunderstanding of opioid pharmacology and addictive behavior. Left to their own devices, most addicted people take escalating and irregular amounts of their drug, creating a roller coaster of highs and lows that often precludes normal functioning. They’re either in withdrawal, actively seeking drugs, or wasted.
By contrast, maintenance evens out the highs and lows. If you take the same dose of an opioid at the same time daily for long enough, you become completely tolerant to it and experience no high or impairment at all. This is a unique property of opioid use; alcohol, for instance, doesn’t work this way, which is why it makes no sense to say, as critics frequently do, that swapping heroin for methadone is like swapping vodka for gin. On opioid maintenance, patients can drive, attend school, work demanding jobs, and experience the ordinary emotions of family life. Methadone and buprenorphine each have unique pharmacological properties that make them particularly useful for maintenance, but heroin itself is prescribed in Canada, the United Kingdom, and Switzerland for people who do not benefit from the other drugs. If stable maintenance dosing is achieved, it does not leave people numbed out or stoned, and is no more impairing than Prozac.
According to a 2012 study, only about a third of all drug courts permit participants to start maintenance as the treatment component of their program, and many oppose it. For example, the handbook for the Manhattan Treatment Court, which serves the city that has America’s largest number of heroin users, tells those hoping to enter the program, “You must agree to move from methadone to abstinence in order to participate.” In a hopeful sign, the Office of National Drug Control Policy announced in February that it would refuse to fund drug courts that apply for grants if they have such policies. They cited a lengthy exposé by the Huffington Post, which examined widespread problems with drug treatment in Kentucky, including a drug court judge who refused to allow maintenance, dismissing it as a substitute addiction, even though he admitted he was not “an expert on what works and what doesn’t work.”
Unfortunately, the ONDCP’s move may not lead to as much widespread change as one might think, in part because most drug courts are primarily funded by states or other localities, not the federal government. An even bigger obstacle is logistics: In most jurisdictions, jails, too, ban maintenance—at a rate far higher than drug courts do. This means that any flash incarceration would become, in effect, court-ordered withdrawal. Although the National Association of Drug Court Professionals says that a judge’s decisions must be based on “treatment and medical evidence,” it nevertheless strongly believes that judges should retain the discretion both to use flash incarceration and to decide on a case-by-case basis what treatments are acceptable.
Overwhelmingly, however, experts agree that opioid addiction is a health problem and that maintenance is the standard of care. Hundreds of studies show that it cuts death, crime, and blood-borne disease rates better than any alternative. A 2004 WHO summary of the data noted that crimes committed by those in their first year of methadone maintenance treatment are “reduced by around one-half.”
If doctors were to deviate this far from the standard of care in treating patients, they would face malpractice judgments and, in extreme cases, criminal prosecution. But drug court judges face no such accountability, even though they generally acknowledge that addiction is a disease and make final decisions on which treatments are permitted. “A judge’s decisions cannot be mucked about with unless they’re illegal or a total abuse of discretion,” says Peggy Hora, a retired drug court judge from California who has long argued in favor of maintenance. Unfortunately, this judicial independence, otherwise so crucial to the balance of democratic power, means that drug court judges—who are not required to have special training—can disregard the medical consensus. They are granted great leeway in making life-and-death decisions about treatment. In effect, they are allowed to practice medicine without a license.
Rudolf and Judith Lepolszki know all too well what can happen when drug courts deny access to maintenance, because they witnessed the effects on their 28-year-old son, Robert.
Robert had been a much-wanted child. His parents had struggled for seven years to conceive him and then had emigrated from Romania to Long Island in 1996, when he was 11, in order to give him a chance at a better life. “He was such a smart kid,” Rudolf recalls. Unfortunately, Robert got involved with drugs during high school, moving from marijuana to cocaine, then to pain pills, and finally to heroin. A series of arrests and attempts at drug-free rehab didn’t stop his addiction, but he kept trying to recover and eventually entered a methadone program. After a 2012 arrest, he was allowed to continue his medical treatment in jail, while serving an 80-day sentence in Suffolk County. On the day of his release, Rudolf drove him to a community-based methadone clinic, because the drug did seem to help him. Finally, Robert seemed to be turning a corner. For the first time in years, as Judith puts it, he was “doing great,” dutifully submitting to drug tests and attending Narcotics Anonymous meetings three days a week. He had even returned to his work in sales, earning excellent commissions. Like many young-adult immigrants, he lived with his parents, but that was a choice, not a necessity.
One Friday night, however, the police showed up at the Lepolszkis’ home, a three- bedroom house on a quiet suburban street in Farmingdale, New York, with a warrant for Robert’s arrest. Before he’d started methadone treatment, he’d sold a small amount of the anti-anxiety drug Xanax, which he’d been legitimately prescribed, and the police had now tracked him down, about a year after the crime.
Robert’s case now fell under the jurisdiction of the Nassau County drug court, where a judge decreed that in order to avoid more prison time, he would have to stop taking methadone—the only treatment that had ever helped him. Although Suffolk County had allowed him to take methadone even in jail, and Robert had responded well to it, Nassau’s drug court judge was philosophically opposed. A county line—not the data—thus determined his medical care.
Robert decided to taper off methadone rapidly, a more painful detox than is medically necessary, because he faced sanctions in court every time he tested positive for it. “He was suffering,” Rudolf recalls. Describing Robert’s response to the chills that occur in withdrawal, Judith adds, “It was like 90 degrees outside, and he was bathing in the sun, sweating, then taking hot showers.
As he stopped the methadone, Robert cut ties with his drug-using friends, determined to avoid relapse. “He was frightened that he couldn’t stop,” Rudolf remembers. “He just had this addiction [and] he was fighting it.” He told his parents that he didn’t even want to make new friends at Narcotics Anonymous meetings, having seen how many of those attending were still using. But at one meeting, not long after he went cold turkey, he met a beautiful young woman, and the two soon became romantically involved. She wanted heroin. Soon, so did he.
Because of his recent abstinence, Robert was at extremely high risk for overdose—and, not surprisingly, it happened. One Saturday, after he had returned home from a Narcotics Anonymous meeting with his girlfriend, the two went up to his room and shot heroin. Rudolf had no idea what was happening until he heard the young woman come downstairs and call 911. Robert had stopped breathing.
The ambulance came quickly, and the EMTs were able to re-start Robert’s heart, but, sadly, the damage was done: Robert died four days later in the hospital. He was 28 years old. Because he’d signed an organ donor card, in dying he was at least able to save four lives.
Cases like Robert’s haunt Ellen Sousares, who knows of at least three other families who have lost children after drug courts denied access to maintenance or otherwise failed to take the risk of overdose into account. It’s impossible to know how pervasive a problem this is, however, because drug courts do not track mortality rates. “Nobody has that information,” says Herman Joseph, one of the world’s leading experts on maintenance and a member of the original team that developed methadone treatment. Joseph is convinced that the problem is widespread, and believes that what drug courts are doing is a travesty. “They are destroying lives,” he says, “and it’s horrible.”
The first drug court opened in Florida’s Miami-Dade County in 1989, near the height of the hysteria in this country over drugs, particularly crack cocaine. Both conservatives and liberals found something to love: Conservatives liked the potential for reduced prison spending, and liberals liked the emphasis on therapy. From the start, however, critics voiced concerns about “cherry picking,” because the courts only allowed into the program defendants who seemed likely to succeed whether or not they received help. This sort of selectivity was built into the system: The federal laws that determine eligibility for grants to create new drug courts (ongoing funding is primarily state and local) require that the courts exclude people with a history of violent crime. Many drug courts also bar people with long non-violent criminal histories. Predictably, this eliminates many of those who have the most serious addictions—the very people the courts, at least in spirit, are supposed to help.
Proponents of drug courts celebrate the fact that those who participate do better than similar defendants who are simply incarcerated or given standard probation. This is unquestionably true. “The average effect is to reduce new crimes by 10 to 15 percent,” says Douglas Marlowe, the chief of science, policy, and law for the National Association of Drug Court Professionals. (Those crimes include not only drug sales and possession but also crimes committed to pay for drugs, such as burglary and robbery.) “The vast majority of evaluations show that they work,” says Ojmarrh Mitchell, an associate professor of criminology at the University of South Florida, “and the effect size is larger than any other large-scale criminal justice intervention.”
These improvements are seen mainly in people who graduate, however, which is only roughly half of those who participate—a fact that the NADCP and other advocates tend to play down. Worse, defendants who start but do not complete drug court often serve longer sentences, meted out by judges as punishment, than they would have had they simply taken a plea and not tried to solve their drug problem. That strikes many critics as a manifest injustice. “This is intensifying the drug war on half of the people,” says Kerwin Kaye, an assistant professor of sociology at Wesleyan University. “It’s not stopping the drug war, it’s continuing it by other means.” Not only that, many people who fail to graduate drug court often go on to become worse offenders, compared to both graduates and to similar defendants who do not participate in drug courts. According to a 2013 study of New York’s drug courts conducted by the Urban Institute and the Center for Court Innovation, which included data on more than 15,000 defendants, 64 percent of non-graduates were rearrested within three years, whereas only 36 percent of graduates were. Among comparable defendants who did not participate in drug courts, just 44 percent were re-arrested in that period, suggesting that those who tried but flunked drug court did worse than those who served their time.
Simply put, in these cases drug court appears to exacerbate recidivism, not reduce it. Why? “I have a theory about this,” says John Roman, a senior fellow at the Justice Policy Center and one of the authors of the study. “Suppose you are a 35-year-old guy and have 15-plus years of chemical dependency. You have a limited education and limited job history, a really debilitating substance-abuse problem that you’re trying to deal with. Maybe you owe child support and you’re a convicted felon. The first thing you do in drug court is have someone sit down and state those facts to you.” For some people that would be a wake-up call, but for others it’s a slap in the face. “It’s such an overwhelming tale of failure,” Roman says, “that it can make them worse.”
This idea fits in with a great deal of data about the effect of confrontation in addiction treatment, no matter what the substance. Attempting to “wake people up” by shaming them—an approach to addiction that runs deep in American attitudes and folklore—in fact fails far more often than it succeeds.
The idea that confrontation is harmful also aligns with data on what makes a drug court maximally successful. The courts with the highest recovery rates have judges who are seen as caring, consistent, and fair—not pushovers, but not deliberately harsh, disrespectful, or derisive. Research shows that empathetic, kind, and empowering therapies are by far the most effective treatments—but these aren’t the kinds of therapies most judges look for when choosing alternatives to prison.
Worse, despite having been created as an alternative to incarceration, drug courts are not lowering the prison population. In part, that’s because so many defendants in drug cases are ineligible off the bat. But another reason is the paradoxical result of what the experts call “net widening,” which takes place when people with addiction are arrested for non-violent petty crimes, such as shoplifting or drug possession. People convicted of these crimes usually do little or no jail time. However, when people who commit petty crimes are diverted into drug court and relapse a few times, they may end up doing extra jail time via flash incarcerations—and even more if they fail to “graduate.” In extreme cases, some people have spent up to 10 years under drug court supervision, with years of that in prison, on charges that would otherwise have resulted in a few months in jail.
Drug courts may have their worst impact on the youngest, newest offenders in the system. Stories about youthful marijuana arrestees, like Darren Sousares, who get turned on to harder drugs through contacts made in jail or treatment, are common. And according to the New York study, drug court increased the risk of re-arrest by 10 percent for those without any prior arrest history.
As in other aspects of the criminal justice system, drug courts also show racial biases. “The 50 percent who fail,” says Wesleyan’s Kerwin Kaye, “are the most disadvantaged, most likely to be black, the least educated, and the most in need, so it’s a way of allowing more privileged white people off the hook. Great—they should be off the hook. But so should the other people.” Kaye’s doctoral work included spending 10 months observing New York City drug courts, and another 11 observing one of the residential programs where participants are sent. During his research, he became familiar with many of the rehab facilities utilized by the city’s drug courts, and found himself appalled at the punitive nature of their treatments. “By my standards,” he says, “many of the places are pretty much abusive.” He describes the use of demeaning and humiliating tactics: yelling at clients, and punishments such as wearing a dunce cap and hours of pointless custodial work.
A patient currently in one of these programs, overseen by Brooklyn’s drug court, provided me with his diary, in which he documented such practices. “They made one guy sit at the same spot from 7 a.m. to 9 p.m. every day for like two weeks,” he wrote. “That was pretty harsh. They really try to break you mentally from what I’ve seen.” Unfortunately, when this type of treatment backfires, the people who pay for it with prison terms are the defendants who drop out, not the providers. And, ironically, high dropout rates tend to produce calls for even harsher approaches, because refusing treatment is seen not as a rational avoidance of harm but as an irrational refusal of help.
Rebecca Tiger, a sociologist at Middlebury College, has studied the punitive tactics used by drug courts. One staffer she interviewed told her that “force is the best medicine,” an attitude common in the courts, which explains why punitive treatment, despite its known failures, continues to be common. It’s important to understand, Tiger says, that drug court advocates tend to see their methods as superior not only to traditional criminal justice approaches but also to voluntary treatment, even though the data does not support this belief.
Nowhere is the disconnect clearer than in the prevailing opposition to opioid maintenance among drug court judges and advocates. In a statement released to NBC News in response to Robert Lepolszki’s death, for example, the judge in his case, Frank Gulotta Jr., declared—disregarding medical opinion—that drugs like methadone are “crutches,” adding, “They are substitutes for drugs and drug cravings without enabling the participant to actually rid him or herself of the addiction. It must be remembered, the purpose of this program is to rid the participant of all addictions.”
Until Americans become more comfortable thinking of drug addiction as a public- health problem, rather than as a crime, drug courts are likely to continue to grow. But there are ways to improve their practices. Following California’s lead, for example, states could make it illegal for courts to ban maintenance treatment and could require that treatment plans be made by doctors—not judges, prosecutors, or less-qualified court personnel. To really solve the problem, however, laws will have to be put in place at the state and federal levels to allow maintenance access in jail and prison.
There’s a legal case to be made against drug courts, too, based on the Americans with Disabilities Act, which classifies addiction as a disability. According to legal experts, outright bans of a therapy that medicine considers a best practice or standard of care for treating a disabling condition should not be permitted under the ADA. Following the Huffington Post’s investigation in Kentucky, a lawsuit was filed in March on these grounds by Stephanie Watson, a nurse whose legal circumstances bar her from from using maintenance medication.
Ultimately, we have to recognize that if we really believe addiction is a disease, doctors should have the final word on treatment. That’s what happens in the “mental-health courts” that a few states, including New York, Florida, and California, have created to help get mentally ill defendants into treatment, with drug courts as their model. In these courts, judges defer to doctors: They don’t tell defendants with schizophrenia that, say, they are allowed to take Haloperidol but not Risperdal, or that they have to stop taking the only medication that has worked for them.
Instead, judges leave these decisions to psychiatrists, and everybody understands that this is how the process should work. Of course, when addicted people commit crimes (driving under the influence, fraud, burglary, robbery), regardless of the legal status of particular substances, drug courts could still play a role. What’s critical, though, says Peggy Hora, the retired drug court judge, is that in such situations medical professionals make a proper assessment of each person’s needs, and determine an individualized course of care. “The judge is there to enforce the treatment plan,” Hora stresses, “not to create it.”
Ellen Sousares, Darren’s mother, feels the same way. “You have to remember,” she says of people with addictions, “that that’s somebody’s daughter or son, and a human being who’s suffering. We cannot continue to call addiction a disease and not begin treating it as one.” She speaks from the heart. Having left drug court, her son Darren will be in jail until December, where he has no help in overcoming his addiction, and no access to medication.
The FDA noted that Sublocade’s approval followed two clinical studies — including a randomized controlled clinical trial and an open-label clinical trial — of 848 adults who had been diagnosed with moderate-to-severe opioid-use disorder and had started taking Suboxone first. The results of the studies found that patients who were treated with Sublocade had “more weeks without positive urine tests or self-reports of opioid use” than those who administered a placebo.
The findings also showed that a higher proportion of patients on Sublocade had “no evidence of illicit opioid use throughout the treatment period,” the FDA said in a statement. The agency noted the most common side effects of Sublocade included constipation, nausea, and vomiting.
Patients who get Sublocade will receive an abdominal injection administered by a health professional after starting a daily regimen of sublingual buprenorphine tablets for at least seven days. If approved, Braeburn’s long-acting product, CAM 2038, would be available as either a weekly or a monthly shot, and would not require these stabilizing doses of daily buprenorphine.
Both long-acting products differ from Alkermes’s Vivitrol, the leading brand of injectable extended-release naltrexone, because neither one requires a detox period before patients can receive their first injection.
The US Food and Drug Administration (FDA) has approved the first and only once-monthly injectable buprenorphine formulation for the treatment of adults with moderate to severe opioid use disorder.
Buprenorphine extended-release (Sublocade, Indivior PLC) is administered subcutaneously. It is intended for patients who have begun treatment with a transmucosal buprenorphine-containing product and whose dose of that drug was adjusted after initiation of treatment and who have been receiving that adjusted dose for a minimum of 7 days.
According to prescribing information, the recommended dose of Sublocade is two monthly initial doses of 300 mg followed by 100 mg monthly maintenance doses. Increasing the maintenance dose to 300 mg monthly may be considered for patients for whom the benefits outweigh the risks.
Sublocade is a Schedule III controlled substance and should only be administered by a healthcare provider in conjunction with a complete treatment program that includes counseling and psychosocial support.
The FDA’s Psychopharmacologic Drugs Advisory Committee recommended approval of Sublocade earlier this month, as reported by Medscape Medical News.
“In the Opioid Blockade Study, Sublocade achieved complete blockade of drug-liking effects for a full month in most patients. Sublocade is the first and only therapy that, at steady state, delivers buprenorphine at a sustained rate of at least 2 ng/mL over a 1-month period,” Indivior CEO Shaun Thaxter said in anews release.
In the clinical trials, the overall safety profile for Sublocade was consistent with the known safety profile of transmucosal buprenorphine, except for injection site reactions, which were reported in 16.5% of patients. The most common adverse reactions (≥5% patients) included constipation, nausea, vomiting, abnormal liver enzymes levels, headache, sedation, and somnolence.
The article below is from the Fairfax county Police site regarding overdoses: Treatment is available for all these people, so they are all preventable deaths. Unfortunately, seeking treatment is a choice that the disease of addiction just doesn’t always allow:
In just the past week, our detectives have investigated six deaths as overdoses, five of which are believed to be caused by opioids. The first overdose death occurred Friday, December 1 in Alexandria. The second death happened on Sunday in Fairfax Station. The third and fourth deaths were on Wednesday in McLean and Clifton. The fifth death occurred yesterday in Fairfax. The victims were between the ages of 22 and 34.
Our detectives believe there are batches of heroin currently on our streets which could be laced with fentanyl and carfentanil,synthetic opioids which can be lethal even in the smallest doses. Until lab results are received, we cannot confirm the five overdose victims died due to a result of these new batches appearing in the county.
“In my 20 years in Narcotics, I have never seen anything like this. Before this week, the highest number of opioid overdoses we had in a weekend was five, and fortunately, everyone lived,” said Second Lt. James Cox of the Organized Crime and Narcotics Division. “We don’t want to see anyone else die. Please have a plan in place. You may remain anonymous. Help is also available through the Community Services Board for anyone, including families suffering from addiction. Narcan is available and the Chris Atwood Foundation will give it out this evening between 6 and 8 p.m. at 11890 Sunrise Valley Drive in Reston.”
Since the start of 2017, there have been 102 fatal overdoses in Fairfax County.
Of those 102 overdose fatalities, about 70% have been confirmed to be opioid related.
Our detectives are still awaiting lab results for overdose cases reported within the last 90 days, but they expect the majority of them to also be opioid related.
Cases have involved people of varying ages, from their early 20s to mid-60s, with higher numbers seen between the ages of 25 and 35.
Since the rise of opioid use in late 2014, we have partnered with a number of local offices and organizations to educate members of our community on the dangers of opioid use and the resources available within our community to combat this growing concern. The outreach includes students, nurses, Parent Teacher Associations, Rotary Clubs, Citizen Advisory Committees and more.
In addition to general outreach and education on opioid use, some groups also offer free Narcan training. Narcan is a medicine that can reverse an overdose when used quickly and correctly. It is available without a prescription at local pharmacy stores in Virginia. Free training on how to use Narcan is available through the Fairfax-Falls Church Community Services Board (CSB). Please visit https://www.fairfaxcounty.gov/csb/revive/ for upcoming training dates and information. This training is open to everyone.
If you feel you may have overdosed or are concerned someone around you has, please call 9-1-1 immediately. Fairfax County Fire and Rescue personnel also carry Narcan and are trained in its use.
Symptoms of opioid overdose include some of the following:
Loss of consciousness
Snore-like gurgling sounds
Breathing is low, shallow or erratic
Bluish purple, or ashen skin color
Nausea or vomiting
Fingernails turn blue or close to black
Our officers and detectives are working diligently and around the clock to reduce the number of deaths caused by opioids. Please call 9-1-1 if you suspect an overdose. Help is available 24 hours a day. If you or someone you know needs help to overcome drug dependence, please call the Community Services Board at Merrifield Center at 703-573-5679 to help find appropriate treatment and recovery services. Walk-ins are also welcome Monday through Friday from 9 a.m. to 5 p.m.