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Breaking the bonds of addiction - 07/29/2009

Stacey was 17 when her brother died of a heroin overdose. “After my brother died, I said I’d never do heroin,” she says. Stacey (not her real name) grew up in a solid, working-class family in the Central Connecticut suburbs. At around age 13 or 14, like many young people, she started “experimenting” with marijuana and alcohol. “Back then it was different,” says Stacey, now 29.“When I started, it was fun.” After awhile, she graduated to harder drugs, including crack cocaine and prescription medications like Percocet®, OxyContin® and “benzos” (a nickname for benzodiazepines, a group of anti-anxiety medications that includes Xanax® and Valium®).But she still stayed away from heroin. Amazingly, even with her drinking and drug use, Stacey had little trouble keeping up her grades and working, even through college. “I was able to function just fine,” she says. That soon changed. The prescription pills became too expensive, and Stacey, despite her vow, turned to heroin, a cheaper and easily obtained alternative. The first time she tried it, she was about 21, her brother’s age when he died.

The path Stacey took to addiction is increasingly well traveled, say staff at The Hospital of Central Connecticut’s (HCC) Substance Abuse Services program. The program treats people of all ages and from all walks of life — including students, business owners, the homeless and others. They may be addicted to alcohol, cocaine, heroin, prescription medications or other substances, often in combination. The one group whose numbers have grown steadily for the past 10 years is young people addicted to opiates, like heroin, and opioid prescription drugs (see box). An opiate is made from the opium poppy plant; while opioids are synthetic opiates made from chemicals. “Among 16- to 23-year-olds nationwide, opiate/opioid addiction is the fastest-growing addiction,” says David Borzellino, a licensed marriage and family therapist and administrative director of The Hospital of Central Connecticut’s Outpatient Psychiatry and Behavioral Health programs, which includes Substance Abuse Services. “They’re the drugs of choice.” And not just in urban areas. Like Stacey, “most of our Substance Abuse Services patients started using drugs in their teens, and most grew up in the suburbs,” Borzellino says.

‘Skyrocketing’ abuse
For patients with certain medical conditions that cause severe, chronic pain, the newer opioid pain medications, like oxycodone, have been a blessing. Taken as directed, these and other pain medications are usually safe and effective. But they must be used with care. “The opioid medications introduced 10 years ago are much stronger than the old medicines,” says psychiatrist Javier Salabarria, M.D., medical director of HCC’s Outpatient Psychiatry and Behavioral Health department. “The newer opioids are very pure, very potent and very addictive.” As a result, opioid abuse has “skyrocketed” in the past decade, he says. For many people, it begins with a legitimate prescription. When the pills — or the money for them — run out, some opioid addicts turn to heroin. “A lot of people don’t start because they’re looking for a high – they’ve been prescribed opioids and they become addicted,” Salabarria says. “In my heart of hearts, I don’t believe people go into this thinking they’ll become addicts.” Opiates and opioids work by attaching to opioid receptors in the brain. When the drugs attach to these receptors, they can block the transmission of pain messages to the brain. They can also induce euphoria, by stimulating the production of neurotransmitters (brain chemicals) called endorphins. “Heroin is a very quick-acting substance. You feel good immediately,” Borzellino says. “According to a lot of our clients, you really feel in control of your life.” Our brains naturally produce endorphins to help regulate mood and other functions, but when a person uses heroin or prescription opioids, two things happen: More endorphins than normal are released; and the body’s natural mechanism for releasing endorphins is suppressed. These are major aspects of addiction. After a short time using opiates/opioids, the user’s brain, accustomed to the higher endorphin levels, sends messages to the body — essentially, “we need more opiates.” “Now the person is left with a craving — a signal from the brain that they want more opiates so the body can produce those endorphins,” Salabarria says. The only way for drug users to get the endorphins at the level they’re accustomed to is by taking more opiates/opioids. If they don’t, they’ll soon experience withdrawal, which can include severe pain, vomiting, fever, chills and other symptoms. “Withdrawal from heroin use is nasty,” says Borzellino, who previously ran a detoxification facility. “It’s difficult to watch another human being go through that.” Stacey knows this well. She’s
experienced it many times. “It’s horrible,” she says.

New treatment, another chance
“When I was taking drugs, people would say, ‘Why can’t you just stop?’” Stacey recalls. “It’s not that simple.” By age 23, her addiction to heroin and prescription opioids was so bad, she had to leave graduate school. In the following years, “I cared more about the drugs and getting high than anything else,” she says. “I would sell things, pawn things, work as a prostitute. I stole from people, lied to people. I would do anything to get money for drugs. I lost jobs, apartments, my dogs … I lost everything.” Last Oct. 27 — she remembers the exact date — Stacey got kicked out of yet another apartment. That day was also her first in a 30-day drug treatment program, which led to transitional housing as she worked to get her life back. After relapsing a couple times, she came to HCC’s Substance Abuse Treatment program last December. There, Stacey got a medication called Suboxone®, which, along with another prescription medication, Subutex®, contains buprenorphine. The Hospital of Central Connecticut began offering buprenorphine last November for some opioid-addicted patients as an alternative to methadone, a drug used for decades to treat heroin addiction. Unlike methadone, which must be dispensed once daily and must be distributed via special clinics or centers, buprenorphine, although also taken daily, can be prescribed in an office setting on a weekly, or even monthly basis. Physicians must be certified to prescribe the drug, but patients can fill the prescription at their local pharmacy as they would any other medication. “It’s a more convenient option for many patients, because they can take it on their own vs. having to visit a clinic every day,” Borzellino says. “It also allows for a little more patient privacy.” Buprenorphine is given in three stages. In the immediate short-term, it reduces withdrawal symptoms. Over weeks or months, it also reduces cravings and thus the chance of relapse, allowing patients to undergo counseling. Patients then enter a maintenance phase that can last a few months or longer. Buprenorphine and methadone attach to the same opioid receptors as heroin and opioid drugs, but don’t produce euphoria. This lack of a high and other ingredients in Suboxone reduce the potential for patients to abuse Suboxone, Salabarria says. For many addicts, methadone works well, but Stacey found it didn’t completely eliminate the withdrawal and craving symptoms. It also caused severe lethargy and a sweets craving that triggered her to gain 70 pounds. The buprenorphine “helps a lot,” she says. “It helps you get back on your feet so you can function again.” Stacey’s only problem with the buprenorphine is its cost. Without health insurance, she can’t afford it, and she worries about the possibility of her employer cutting her insurance benefits.

Counseling is critical
“I always stress to clients that Suboxone is not the ‘magic pill,’” says Trish Lewis, psychiatric clinician. “Like people with diabetes, heart disease and any other medical condition, people with addiction must make lifestyle changes.” Because addiction occurs at both physical and psychological levels, HCC patients are required to undergo counseling as part of buprenorphine treatment. Like many patients whose substance abuse has gotten out of control, Stacey started with an intensive outpatient substance abuse program three days a week. She now attends Lewis’ weekly relapse prevention group, one of several, specialized substance abuse groups the hospital offers. Others include women’s issues, recovery skills, trauma skills training, and an early intervention group, for people who aren’t sure if they have an addiction. Some substance abuse patients also receive counseling through other HCC Outpatient Behavioral Health programs, including trauma-based treatment and specialized programs for people with anxiety, depression, bipolar disorder and other types of mental illness. The hospital’s Hispanic Counseling Center offers substance abuse and mental health programs in Spanish. Many people addicted to drugs and alcohol also have mental illness, Borzellino says. In some cases, substance abuse itself causes or exacerbates mental illness, but for many, the illness comes first, and people begin using drugs illegally to self-medicate. “The vast majority of our patients have experienced some form of childhood trauma that develops into anxiety or depression that doesn’t get treated, so they end up with substance abuse,” Borzellino says. “When we’re treating someone for addiction, we don’t push them into addressing the trauma that might have prompted their addiction, but some do have an epiphany.”

In both its substance abuse and other mental health programs, the hospital offers individual and group counseling. Group counseling can be particularly helpful to those with addiction because many patients are in denial about their problem, Lewis says. “When they’re sitting with peers who have the same issues, it helps people accept their diagnosis,” she says. “Once they accept that they have a problem, they can start working on it.” The relapse prevention group’s eight members share their concerns and struggles, and ideas on how to deal with them. Lewis teaches the group coping and other skills and helps them develop a support system they can use after treatment. “The support system is critical because they won’t be here forever,” she says. Stacey says her parents have been very supportive, despite all they’ve been through. “They’re definitely here for me.” Keeping busy has also helped her stay clean. In addition to the relapse prevention group, she attends Alcoholics Anonymous and Narcotics Anonymous meetings and works — a lot. “Working makes me feel like a human again,” says Stacey, who hopes to return to graduate school someday. “I’ve learned that no matter how much I might think I want drugs, if I just do something else the craving will pass.”

For information on The Hospital of Central Connecticut’s Substance Abuse Services, call (860) 224-9985. For information about other Outpatient Psychiatry and Behavioral Health programs, call (860) 224-5804.