May Ask the Expert
05 New Trends and Implications
Ask the Expert:
Markus Heilig, M.D., Ph.D. is a clinical psychiatrist and neuroscientist who is currently working at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as Chief of the Laboratory of Clinical and Translational Studies and as a Clinical Director. He also serves as a Foreign Adjunct Professor in the Department of Clinical Neuroscience at Karolinska Institute in Stockholm, Sweden. Prior to joining the NIAAA, Dr. Heilig was Chief of Research and Development in the Division of Psychiatry at the Huddinge University Hospital of the Karolinska Institute and a Director at the Addiction Centre South in Stockholm, Sweden. Dr. Heilig has co-authored over 100 published original articles related to addiction and he served as chair of a taskforce established by the Swedish National Board of Health and Welfare to create national guidelines for the pharmacological treatment of heroin dependence. In addition, he has served in editorial positions for Addiction Biology (co-editor in chief), Biological Psychiatry (editorial board member), Addiction (assistant editor) and Neuropeptides (editorial board member), and he is a member or fellow of the American College of Neuropsychopharmacology, the International Society on Biomedical Research on Alcoholism, the International Behavioral Neuroscience Society and the Society for Neuroscience.
1) Question: I am a new counselor taking my Certified Alcohol and Drug Counselor state exam for the second time. I am also 53 and have been in a Mental Health and Human Services B.S. program at UMA for 5 years. I work at a harm reduction Intensive Outpatient Program in Portland, Maine. My question is: Why is the CADC exam out of date with current knowledge? When or how are doctors going to get it?
Answer: Best of luck to you with your important work. The NIAAA is funding investigators to obtain the best possible understanding of alcohol addiction, and develop the best science based interventions. As you allude to, the field has made considerable advances, rendering many previously held beliefs obsolete. The NIAAA is making the advances available to the public in several ways - e.g. in its Clinician’s Guide, on its website, and by making its own experts available. Why there is sometimes little if any uptake of up to date knowledge by other organizations is, unfortunately, not a question that is easy for us to answer.
2) Question: I have read several articles about cognitive impairment as a consequence of stimulant use (meth, crack, etc.). Witnessing a close friend, who goes in and out of treatment following alcohol-then-crack binges, the articles make sense. He's not "in denial," when he says he doesn't recall what happened in similar circumstances 2 weeks ago--he actually DOESN'T REMEMBER. Unfortunately I have not read about any specific techniques for restoring those cognitive problems. Do you know of any?
Answer: Although greatest in young age, the human brain retains a tremendous plasticity up into the years – think of stroke victims who can partially regain function with hard practice, and you have the answer. The first part of it is to prevent the insult that caused the damage from happening again; the other is to practice the functions, and there are behavioral treatment techniques that do that. Some of us are also experimenting with medications that might facilitate this practice, but none of those have reached a stage when they would be approved for clinical use.
3) Question: Is suboxone intended to be a lifelong medication, or is it intended to be used to help get a person off of opiates, with a reduction of dependence on suboxone over time?
Answer: It depends. For people who are in the early stages of opioid use, Suboxone can be used as a taper to reduce the distress from withdrawal, and get the person into a good behavioral treatment. In these cases, a taper over the course of approximately a week is usually enough, although in some cases the patient can benefit from the taper being slower. For patients in later stages of opioid addiction, chances of successfully staying off opioids after such a taper are abysmal or approximately 10%. In these cases, long term maintenance over many years, or life-long is needed. It is appropriate in these cases to ultimately try to taper the treatment if the patient has been stable for several years, and so desires, but even in these cases, many patients relapse, and need to resume maintenance treatment.
4) Question: What are your thoughts on the heroin vaccine that's currently going through clinical trials?
Answer: It is a very interesting concept. There is a theoretical debate how likely this kind of approach is to succeed, but in the end, our theories don’t mean much – how useful the vaccine turns out to be will be answered by the clinical trials. It is certainly important to obtain that answer.
5) Question: I am clean and sober since 2007 from alcohol and benzodiazepenes. I had total knee replacement on 4/27/13. I am on 10 mg oxycontin every 8 hours and (2) 5/325 percocet every 4-6 hrs. I am having a real challenge keeping the pain level below 5, which is what the doctor suggests. I am wondering if people like me, ex-addicts, have a higher tolerance for medications and lower tolerance for pain than most people, and I wonder what can be done to help me avoid the terrible spiral into pain. I drank and used for 30 + years often to help me not feel chronic herniated disc pain which has now resolved itself. Now with osteoarthritis in both knees and this new knee, I am fearful that I will pick up again because they'll take me off the pain meds prematurely and I'll be in pain-hell again. I log every pill I take, time, date, and the pain level I am at to be accountable. I don't see a real progression in the easing of the pain. It's a constant relentless pain even with the meds. Icing helps some but only temporarily (30 mins max). Any research out there that could help me?
Answer: Yes, prolonged use of opioids is likely to result in what is called “hyperalgesia”, a higher sensitivity to pain, and possibly also a higher tolerance for pain medications. It is unfortunately not possible to provide medical advice in an individual case, and you will need to discuss this with the treatment providers who are involved. There are non-drug based strategies for chronic pain that can help at least as adjunct treatments, such as transcutaneous electrical nerve stimulation (TENS).
6) Question: When drugs don't seem to be helping that much, who do you turn to? Mine is a hard to solve case. What do you do when your loved one obviously has tremors but says she doesn't have a problem with tremors? Should I ignore it and go along with her assessment? What else can I do in addition to bringing it to the attention of a doctor?
Answer: Please see answers to questions 2, 3 and 5, above.
7) Question: Far too often professionals who work in the addiction field are too client focused and miss valuable opportunities to educate the addicts family (particularly young adults and teens who are still living in the family unit) about addiction, coexisting mental health issues, and they totally fail to provide support for the entire family which is usually suffering and falling apart. When are dollars for family support and education going to be a part of this necessary equation? The stigma of mental health issues and addiction keep many families in the closet which in turn prevents early intervention that could save lives, families, whole communities. By the way, treatment providers are not safe places for families who need to know that their information is confidential so that they have the freedom to get truly honest. Al-Anon is the only resource offered but it is not a place to seek resources and education.
Answer: You are absolutely right that getting family and members of the patient’s network involved is very helpful in the treatment of addiction, as shown by stringent scientific studies of the intervention called “Network Therapy” (see e.g. an elegant study by Marc Galanter, Galanter M et al. J Subst Abuse Treat. 2004; 26(4):313–318).