Dr. Thomas Simpatico doesn't think it's news to anybody that “the war on drugs hasn't gone well.”
The chief medical officer for the Department of Vermont Health Access, Simpatico calls the current environment a “supply-and-demand market.”
And he names the solutions, “from a simple business sense”: the new controlled delivery system that “simply outmaneuvers” the criminal element by making opiate replacement therapy (ORT), or medically assisted therapy (MAT), cheaper to access.
ORT, as delivered through this Hub and Spoke Initiative, is cheaper for everyone, says Simpatico. By providing a cheaper alternative to addicts and a controlled delivery system, the criminal element is eliminated. The system also provides for better safety and health for the addict, as well as a chance for one to return to a stable lifestyle.
Confirming “an uptick in drug overdoses secondary to opiates,” and substance abuse-related cases within the criminal-justice system, Simpatico says that for the addict, “if your access to opiates is curtailed, you may be very motivated to find access through illegal means.
“To the extent we build and provide an alternative to criminal activity, we can progressively understand and cope with the scale of the problem, while eradicating the criminal activity,” he adds.
Claiming no magic bullet, or any real sense of the scope of the problem, Simpatico explains the nature of addiction, focusing on providing a safe alternative for addicts, eliminating the criminal element in the process. This new approach is likely to be the most successful one to address both addiction and the increasing criminal element present via heroin trafficking in Vermont.
Pain medication connection
Simpatico explained that “for at least 15 years, if not more,” health-care providers nationally were monitored for health-care delivery, in part, with the expectation that pain management was to be front and center on providers' minds.
But Simpatico pointed out the unintended consequences of the medical establishment emphasizing that patients be pain-free.
Surveys by the Joint Commission, the nonprofit that accredits and certifies U.S. health-care programs and organizations, started finding a number of people had become dependent on a class of very highly addictive drugs prescribed for relief of severe pain.
These opioids achieve their pain-relief effects from opium or from chemicals that stimulate the same brain receptors. These drugs include hydrocodone, codeine, and oxycodone, as well as their variants, including oxycontin (oxycodone and acetaminophen) and Vicodin (hydrocodone and acetaminophen).That's when health-care providers realized they had a problem.
With increased attention to this aspect of pain management, doctors started paying more attention to prescribing pain medications, and they became harder to come by.
As the supply started drying up, Simpatico says, addicts discovered that “heroin is pretty available.”
“So it is true that prescription pain control is one of the entrees to illicit drug abuse,” he says.
Simpatico adds that the medical community now knows that all psychological ills stem from the brain, from post-traumatic stress disorder to addiction.
“The mental experience is a different kind of physicality,” Simpatico explained. “It happens as a result of an alteration of the neurological subsystem. Our subjective experience is mediated by the body.”
He said it is an outmoded distinction to differentiate between the psychological and the physical.
“Things that have traditionally come under the heading of physical or mental illnesses are now seen differently. We now have the technological means to understand that at the cellular and the sub-cellular level, at its base, it's all physical,” Simpatico says.
“The brain, like the pancreas, is an organ,” he explains. “The product of the brain is consciousness, thought and subjective experience.”
Thus, he says, treating addiction successfully means a coordinated approach to all systems.
The endogenous system in the body produces chemicals on its own that Simpatico describes as “the body's own opiate.”
The phrase “runner's high” describes what the body does quite naturally, and how a person subjectively feels when those dopamine and endorphins are produced by the endogenous system in the body.
“Part of the way the human and mammarian (physiology) functions is they have substances that are internally generated that are used for control of pain that are linked to pleasure centers that reinforce certain kinds of behavior,” Simpatico explains.
“Runner's high is one example of our endogenous opiate systems,” he said, adding that this system is in the brain and in human tissue.
So humans already have opiate receptors in place in our brains.
“When people use opiates, whether they are prescribed or obtained illicitly on the street, they are essentially overriding the natural system that uses these substances,” Simpatico says.
And, he continues, “the way that the body works, the body wants to be responsive to things that it encounters. So if a substance like an opiate is available in large amounts, the body will habituate to its presence.”
Tolerance and dependence
Asked if it is a psychological or physiological need that develops, Simpatico replies, “it's all of the above.”
“When somebody takes prescription opiates or uses heroin, they are binding those related chemicals to the receptors that the body naturally has to its internal opiate system,” he explains. “When that happens, the body reacts to the abundance of these chemicals.”
It's all about the body's response. Someone who is newly introduced to external opiates “develops what is called tolerance,” he says.
The body begins needing higher doses of the drug to achieve the initial response.
Simpatico adds that the other response that the body has to opiates occurs during withdrawal, as the user tries to reduce intake of the drug.
He says that within 24 to 48 hours, withdrawal symptoms generally peak, but he adds that some people can have ongoing symptoms for months.
These symptoms are very uncomfortable, and include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes, and goose bumps.
The phrase “cold turkey” comes from “what the skin looks like for somebody who is in midst of acute opiate withdrawal,” Simpatico says.
He notes that between tolerance and dependence, both “contribute to the behavior of seeking more opiates and making it difficult to stop taking opiates once the body has habituated to taking opiates.”
Simpatico says it is an important point to understand that taking opiates “directly affects the pleasure centers in the brain, resulting in the release of dopamine.
“All of those things together make it very difficult to stop taking opiates once the body has become used to taking opiates, and the longer you take them, the harder it is to stop,” he says.
“The longer one is taking doses of external opiates, the more likely they will develop tolerance and physical dependence and have a difficult time stopping opiates,” Simpatico adds. “And this is true whether they are taking prescription or street opiates.”
This is why heroin is such a difficult drug to kick.
These external opiates end up replacing the natural system at the same receptor locations in the brain, and after a while, the body develops a dependence on the new opiate that has been artificially introduced.
And trying to kick an opiate once the body has developed a tolerance is cruelly uncomfortable.
Also, he says, these same receptors in the brain reinforce behavior that produces pleasure, such as the natural high from running or from an external opiate source. An addict will do anything to obtain the drug that produced the high.
The danger of additives
Simpatico says that in addition to the physiological dependence that can lead to illegal activity to obtain the opiate to maintain the high, heroin is rarely pure. The “adulterant” added to the drug causes addicts to risk incurring secondary health dangers.
“With prescription opiates, you know what you are getting in pure, dose-able, standard amounts,” Simpatico says. “There is often a large benefit, if you are dealing in an illicit substance, to stretch the product by adding all sorts of adulterants that are not opiates and not an active ingredient.”
“With street opiates, like heroin, it can range from reasonably pure to highly adulterated, so an addict can never know what exactly the substance is,” he continues.
Conversely, Simpatico says, the purer that the heroin is, “the greater commonality it has with pure prescription opiates,” in terms of known physiologic response to the substances. Thus, it is easier to treat, with its lesser degree of complications.
But “if one is dealing with illicit opiates, there is a great danger in not knowing what dose one is taking, as well as what one is actually introducing to the body. The more adulterants introduced into the body, the greater the likelihood of a variety of healthy problems arising, not just from the opiate.”
Simpatico says dealers mix adulterants such as talcum powder with the heroin to stretch it for purely business purposes. These foreign substances end up “clogging up” the body systems, he says. An addict could eventually develop respiratory problems, rheumatoid arthritis, a compromised immune system, and sores - complications that can eventually lead to death.
Adulterants are the biggest reason behind illicit opiate mortality, he says, and they can also be the source of infection or death of tissues that are downstream to the profusion of blood vessels.
Adulterants can trigger an autoimmune response “where the body is tricked into attacking itself,” Simpatico says.
Why opiate replacement therapy works
Simpatico notes that “there is no question that beginning with the needle-exchange programs - programs such as the state is doing with opiate replacement therapy - precisely get rid of the problems we are talking about.”
They “basically eliminate” the illicit drug trade, Simpatico says. “Therefore, it can dramatically eliminate the crime involved in supporting drug traffic, and that is a benefit to society at large, of course.”
And ORT, he adds, “eliminates the danger of someone's introducing unknown substances into their body and creating any number of medical conditions as a result of the adulterant.”
“So if someone is going to use opiates, it is much safer for them to use pure opiates in a controlled setting as they would in an opiate replacement therapy setting. Much safer.”
Ultimately Simpatico says, these programs “cut way down on the kinds of general medical conditions that are caused by illicit opiates, and cut way down and can eliminate criminality associated with supporting illicit drug trafficking.”
The whole point of ORT, he says, “is it takes the legs out from the illicit drug trade. It provides a predictable supply to a safe substance that is used to control withdrawal from opiates.”
Simpatico notes the goal: that “once a person enters into ORT, they can hopefully become much more functional because they are less concerned about getting money for the next fix. And, once in a stable place, they are in a better place to hold jobs and have a lifestyle to approximate a drug-free and productive lifestyle.”
“As they move towards abstinence in a controlled or ongoing program with predictable access to relatively safe, pure, and dose-specific access to opiates,” he says, that is the point of ORT.
How do ORT drugs work?
An agonist is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain, fully resulting in the full opioid effect. Examples of full agonists are heroin, oxycodone, methadone, hydrocodone, morphine, and opium.
Simpatico notes that although methadone clinics have long been used, “Methadone is an opiate. Methadone is what heroin turns into in the brain to be active. So one way of doing ORT is using methadone, which engages with the receptors in the brains opiate receptors.”
What that means is that “you have these [opiate] receptors, and you can either engage those receptors and cause them to produce the response that they normally produce, and you can do that with methadone.”
“Or, you can partially engage with drugs like buprenorphine, which are wonderful,” he says.
The chemical in buprenorphine and similar drugs bonds to those receptors only partially: while they give “the response that a pure trigger like methadone would do,” Simpatico says, they do not generally produce the high, unlike methadone or the original illegal opiates.
Another common drug is Suboxone, which combines buprenorphine with naloxone, an antagonist.
An antagonist is a drug that blocks opioids by attaching to the opioid receptors without activating them. Antagonists cause no opioid effect and block full agonist opioids.
“So it can stabilize someone without giving them the high,” Simpatico explains. “It's a pretty good way of keeping someone in a stable state to help move toward abstinence.”
Strategies for treatment success
Simpatico says an addict can begin a treatment with drug therapy, “but as far as strategies for treatment, for many or most people, it is most effective coupling the pharmacological approach with counseling.”
He noted that either approach can work well but, “as a general rule we aspire to couple pharm- and non-pharm ORT therapy to help stabilize someone ongoing with help moving towards abstinence.”
And “it depends on the circumstances” as to what plan is adopted, Simpatico explains.
“Some people will aspire to abstinence” and a treatment plan will be constructed to support that goal, he says.
“For other people, the goal is to stabilize, to eliminate, withdrawal symptoms, and move toward a productive lifestyle,” he adds.
But the overall plan is to move an addict away from illicit drug use to a “controlled legal program of opiate replacement that eliminates the criminal element,” he says - one that “gives them a safer reliable way of eliminating the withdrawal, and not be distracted, to reach a reasonable stability.”
“And we can do that best in an ongoing program maintaining ORT provided through the [Hub and Spoke] programs,” Simpatico asserts.