Why Opioids and Naltrexone Don’t Mix

So you’re thinking about starting naltrexone for an alcohol use disorder, good for you! Before you start, your clinician will ask you about whether you use an opioid. Here’s why.

First let’s get into some semantics, naltrexone is not the same drug as naloxone. Naloxone is a lifesaving drug that is used to reverse the potentially deadly symptoms of opioid overdose. Naloxone, which can be administered as either an injection or a nasal spray, is NOT a long-term treatment for any substance use disorder by itself. It is, however, combined with buprenorphine in Suboxone, Zubsolv, and other buprenorphine/naloxone products. Naltrexone, on the other hand, is NOT used to reverse an overdose by is used for long term treatment for both alcohol use disorder (AUD) and opioid use disorder (OUD). Naltrexone comes in a pill (Reevia) or a monthly injection (Vivitrol). At Workit Health, we prescribe Reevia/Vivitrol for AUD.

Naltrexone (not naloxone) has been FDA-approved to treat AUD since 1994. It is also approved to treat OUD. The other two approved OUD treatments buprenorphine and methadone, do not treat AUD. Naltrexone is able to treat both AUD and OUD because it is an opioid antagonist (naloxone is also in this category but don’t get them confused).

So what’s an opioid antagonist?

While we all know about opioids like heroin and oxycodone, did you know that your body makes it own opioids? Yes! These own-opioids are at work in your body all the time and bind to the four types of opioid receptors in the brain (mu, delta, kappa, and ORL-1). Heroin and other opioid drugs bind to the mu receptor just like your own-opioids to cause the pain relief, euphoria, and respiratory depression that is associated with opioids. While alcohol does not bind to the opioid receptors directly, our own-opioids released when we drink alcohol and it is thought that the opioid receptor system is thought to play an important role in AUD.

Naltrexone binds to the four types of opioid receptors but instead of activating them like an opioid would, it blocks the effect of the opioids floating around in the body. It is this blocking effect is why you shouldn’t take opioids while you are on naltrexone.

Let’s say you are taking naltrexone to help you quit alcohol.

Tiny naltrexone molecules are bonded to your opioid receptors, reducing your cravings for booze. Then let’s say that, for any number of reasons, you take an opioid. Because the naltrexone is bonded to your opioid receptors, it blocks the effects of the opioid. You won’t feel anything, no high and no pain relief. This can be dangerous for two reasons. First, because a person feels nothing when they take their normal dose of opioid, they make take more (DO NOT DO THIS). Eventually, a high dose of opioids will be able to overcome the blocking effect of naltrexone and bond to opioid receptors. However, the body has not built up a tolerance to this higher dose and a potentially fatal overdose occurs. Second, once you stop naltrexone, your body will likely have a lower tolerance for opioids, meaning that even your normal dose might lead to an overdose.

If you take an opioid medication for pain or if you struggle with opioid misuse or addiction, talk to your healthcare provider if you are interested in starting naltrexone for alcohol use disorder. Naltrexone is not for everyone but there are other FDA-approved medications to help you beat alcohol.

Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation’s capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.

Why Governments Are Suing Drug Companies for Their Role in the Opioid Crisis

It is widely accepted that overly aggressive and deceitful marketing tactics by the companies that make oxycodone, fentanyl and other opioids helped start the opioid crisis in the 1990s. Now, thousands of lawsuits at both the federal and state level have been filed to hold these companies to account. 

The role opioid makers have played in the current crisis is so well known that even comedians John Oliver and Hasan Minhaj have addressed the matter.

The story of the current opioid epidemic began about thirty years ago when the federal Food and Drug Administration (FDA) began approving new forms of opioids like morphine-containing MS Contin (1987, first extended-release opioid product), fentanyl-containing Duragesic (1990, first opioid skin patch), and oxycodone-containing OxyContin (1995). At the same time, a sea-change was occurring in how medical professionals thought about pain. The “Pain is the 5th Vital Sign” movement began (p. 2-3) in 1990 with a call to action by Dr. Mitchell Max, then president of the American Pain Society, and culminated in The Joint Commission, which sets healthcare standards, published its Pain Standards in 2001. While the Joint Commission’s standards and the broader pain movement were well intentioned, the drug companies that made the newly approved opioids took advantage of them. Doctors at the time were well aware of the addictive potential of opioids and would often only prescribe them to cancer patients whose pain was too severe for other medication. The drug companies aggressively marketed to doctors, using their new concern about patient pain and knowingly mislead them about the addictive potential of their new drugs, to ramp up sales. Drug companies employees were even directed to lie about patients cancer status to health insurance companies to get more sales. Prescriptions and sales of OxyContin and other opioids skyrocketed (p. 5) from 76 million in 1991 to 219 million in 2011, a 188-fold increase.

In 2017, opioid prescribing rates vary from 39.5 per 100 people in California to 74.2 per 100 people in Michigan and 107.2 per 100 people in Alabama (the highest in the country). While prescription rates and overdose deaths from prescription opioids have falled modestly in recent years, the bell cannot be unrung. The country has experienced drug epidemics before, this current crisis has direct links to the drug companies that made massive profits off of addiction.

United States v. Insys Therapeutics

In June of this year, the company Insys Therapeutics entered into a settlement with the US Department of Justice that made them the first drug company to file for bankrupcy over costs levied against them because of their practices. The US Attorney for the District of Massachuessets, Michael E. Lelling, had charged Insys for using “speaker series”, which were supposed to educate doctors on their fentanyl product Subsys, for exchanging bribes to get doctors to prescribe more of their product. On physician’s assistant from New Hampshire, who had prescribed no Subsys before attending one of these events, wrote 672 Subsys prescriptions after being given over 40,000 dollars from Insys. For this crime, Insys agreed to pay $225 million dollars. Seperately, five former Insys executives were convicted of racketering, the crime of maintaining a continous illegal operation, in a Boston federal court. Three other executives were convicted of other crimes related to this scheme.

Oklahoma v. Johnson and Johnson

In another major victory, Oklahoma’s Attorney General, Mike Hunter, successfully sued Johnson and Johnson (yes, the baby powder company) in state court. The original lawsuit also included Purdue and Teva pharmaceuticals, both opioid manufacturers, but each company settled for $85 million and $270 million respectively. Johnson and Johnson, which did not settle, ended up being fined $572 million, though Hunter originally sought $17.5 billion. While Johnson and Johnson’s opioid products, sold through their subsidiary Janssen Pharmaceuticals, make up less than 1% of the opioid market in Oklahoma; the company makes and supplies most of the raw ingredients used by other companies to make opioids like OxyContin. While the $572 million fine will likely fund Oklahoma’s opioid response for only a year, Johnson and Johnson has vowed to ask the court to put the fine on hold while they appeal the judge’s decision to appellate court.

The National Prescription Opioid Litigation

In the US District Court for the Northern District of Ohio, headquartered in Cleveland, over 2000 lawsuits brought against the drug manufacturers, drug distributors, chain pharmacies and doctors that federal, state, tribal and local governments believe perpetuated the opioid epidemic have been consolidated into one proceeding overseen by US District Judge Dan Polster. Judge Polster has selected the suits brought from Summit and Cuyahoga counties in Ohio for a bellwether trial next month, although Ohio Attorney General Dave Yost has asked that the trial be halted. In multidistrict litigations like this, a bellwether trial serves as a test run. Just like in Oklahoma, many companies would rather settle than go through a long, expensive trial. For example, Mallinckrodt, the largest maker of generic oxycodone, settled with the bellwether counties for $30 million. This wasn’t the first settlement Mallinckrodt entered for its practices, either. In 2017, the company agreed to pay $35 million in another settlement with the federal government.

However, the most talked-about settlement related to the National Prescription Opioid Litigation is the one recently entered by Purdue Pharma and its owners, the Sackler family. As part of the $10 billion dollar settlement, if enacted, Purdue would file for bankruptcy and divest from its worldwide pharmaceutical holdings. The company would then reopen under non-Sackler leadership and all future profits from OxyContin would be put into a trust to help communities with their response to the opioid epidemic. The Sackler family will also have to pay $3 billion from their own wealth. This settlement is seperate from the $85 million Purdue agreed to pay in the Oklahoma state court case.

Many see the Purdue settlement as a major victory and 26 state attorneys general have indicated that they would take the settlement, attorneys general from the 24 other states and the District of Columbia, like Massachesetts AG Maura Healy and North Carolina AG Josh Stein, have decided to say no to the settlement and go after Purdue and the Sacklers in their own lawsuits.

Despite settlements from Mallinckrodt, Purdue and others, the National Prescription Opioid Litigation will continue in Cleveland.

Why are governments suing?

Civil litigation has been used by governments before to hold private companies accountable for a public health crisis. In 1998, 46 states, 5 US territories and DC reached a settlement with the largest tobacco companies, known as the Tobacco Master Settlement Agreement (MSA), which requires yearly payments from the companies to states and territories forever. In 2018, MSA payments totaled $27.5 billion. In addition to the payments, the MSA forced tobacco companies to stop certain practices and to make public thousands of documents detailing their deceptive marketing practices. Many parallels can be drawn between MSA and the ongoing opioid litigation, including the reckless practices of both the tobacco and opioid companies.

Lawsuits cannot be the only solution the the opioid epidemic but addressing the crisis has put significant financial strains on many of our public systems. The government attorneys arguing these lawsuits are trying to get drug companies like Insys and Purdue to pay for the damage they have caused to make their billions.

Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation’s capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.

What’s this About Vaping Being Dangerous? Your Questions, Answered

Recent cases of severe lung disease in several states have been linked to vaping. Here’s what we know and don’t know about the vaping-related illness and how you can reduce your risk.

The Centers for Disease Control and Prevention (CDC) and state health departments are investigating almost 300 cases of severe lung disease across 23 states that have occurred this summer (NOTE: New cases are being reported daily and this number is likely outdated by the time you read it). While there have been cases in people as old as 72 in North Carolina, the average age of those afflicted with this severe lung disease matches the age range where vaping is most popular: teens and young adults.

Vaping among young people, who are being effected by this lung disease, has been a known public health concern for years. Several states have begun taxing e-cigarettes to decrease demand and earlier this week Michigan became the first state to ban the sale of flavored vaping products, which are particularly popular with minors, when Governor Gretchen Whitmer announced an emergency administrative rule to ban the sale of flavored vaping products for at least 6 months.

Symptoms of this severe lung disease include coughing, shortness of breath, pain in the chest and vomiting. In severe cases, patients have developed eosinophilic pneumonia, a type of pneumonia where immune cells called eosinophils, which are also involved in allergies and asthma, accumulate in the lungs. Patients with eosinophilic pneumonia have had to be put in a medically-induced coma. Unfortunately, one patient has died in Illinois due to lung disease believed to be linked to vaping.

  U.S. States with confirmed or suspected cases of severe lung disease. U.S. States with confirmed or suspected cases of severe lung disease.

What do we know so far?

Severe lung disease in young people is a rare occurrence and reports of such cases, including 30 in Wisconsin where state health officials have named it “severe chemical pneumonia”, began coming in late June 2019. Before that, only two cases of severe lung disease, acute eosinophilic pneumonia to be precise, were reported in the medical literature. Like with all cases of strange illness, medical and public health professionals began looking for the possible causes of lung disease patients who had otherwise been healthy. The common thread throughout: vaping.

“The common thread throughout these cases of lung illness: vaping. ”

It is important to note that this information is coming from surveillance, not scientific experiment. While we cannot yet establish causality between vaping and these cases of lung disease, nor do we know the biochemical underpinnings of the relationship, we can see a correlation. (Causality vs correlation is a confusing subject, so here’s a good explanation from Sal Khan.) You will likely hear people claim that “They can’t prove that vaping causes this disease,” and while that is a fair assertion, it also misses the point. The CDC and other health leaders are warning the public about vaping and its potential connection to these cases of lung disease because they have strong evidence that the two are connected. It is important to remember that for years big tobacco companies fought government regulation by saying “They can’t prove that smoking causes lung cancer” (they can) and that some people, even scientists, still believe that HIV doesn’t cause AIDS (it does).

What could be causing the severe lung disease?

Vaping and e-cigarettes are a diverse set of products and it remains unclear whether all or just some products are causing these cases of lung disease. It seems that many afflicted patients were vaping liquid that contained THC, however, cases have also been reported where the liquid contained nicotine. Health leaders are beginning to suspect that contaminants or the type of solvent used in the vape liquid may be to blame. A solvent is what the active ingredients of the vape liquid, such as flavoring, nicotine and THC, are dissolved in. Of particular concern are black market or homemade vape liquids which can be made with toxic solvents mislabeled as safer ones. This is why it is highly recommended that people who vape do not consume products made at home or sold on the streets.

“One expert said vaping was like inhaling a chemistry experiment into your lungs. ”

Even vape products sold in stores may not be free of toxins. The e-cigarette industry is unregulated by the FDA and previous studies have shown that potentially dangerous chemicals can show up in the vapor of certain flavored vape liquids. One particularly concerning chemical, diacetyl, was actually banned as an additive in microwave popcorn after workers in an Omaha factory came down with a fatal lung disease called bronchiolitis obliterans, also known as “popcorn lung” from inhaling diacetyl that was being used in the butter flavoring. A 2015 Harvard study found that out of 51 flavored vape liquids, 39 had diacetyl in their vapor. What’s more, it wasn’t just buttery flavors that contained diacetyl but fruit, candy and cocktail flavors as well. Another potentially hazardous chemical found in e-cigarette vapor is formaldehyde which is known to cause illness ranging from migraines to cancer. While no study to date has linked diacetyl or formaldehyde in e-cigarette vapor to illness, some consumers may rightfully want to avoid these chemicals. Because vape products are unregulated, manufacturers are under no obligation to remove these chemicals or to let their customers know what they are putting in their bodies. One expert said vaping was like inhaling a chemistry experiment into your lungs.

So, what can you do to protect yourself?

If you vape, regardless of what product you use, you should speak with your doctor or other healthcare provider. They can help you better evaluate your risk and help you quit vaping if that is what you choose to do. If your vape product(s) of choice contain nicotine, their are FDA-approved medications such as nicotine replacement therapy, Zyban (buproprion) and Chantix (Varenicline) that can help combat cravings to make quiting easier. The Truth Initiative has also expanded their tobacco quit program to include tools to help young people quit vaping. For those who vape, this recent news of severe illness and death is likely very scary. Vaping, even with products that contain no nicotine or THC, is an addictive habit. However, you can beat vaping addiction and live a happy, healthy life.

Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation’s capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.

Are Opioids Safe for Postpartum Pain?

According to a new University of Michigan (U of M) study published in the Journal of the American Medical Association (JAMA), women who give birth and are prescribed opioids for postpartum pain are at risk for opioid addiction. 

Experiencing pain after giving birth, also known as postpartum pain, is a normal experience for most women. The perinum that surrounds the vaginal opening might be bruised or torn after giving birth and a doctor may have to make an incision through the vaginal wall called an epistiotomy to help the birthing process. This damage will heal but may be the cause of pain. For women who give birth via cesarean section (aka C-section), which requires an incision through the full thickness of the abdominal wall, pain at the incision sight can make it painful to do everyday things like walking, laughing or coughing. The uterus also contracts after childbirth causing cramps known as afterpains. Postpartum pain for both C-section and vaginal births usually goes away by six weeks after the delivery.

While postpartum pain is perfectly normal, it can still make life uncomfortable for new mothers. For this reason, doctors prescribe painkillers to help manage postpartum pain. Sometimes doctors will prescribe acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Motrin, Advil). Other times, however, a woman experiencing postpartum pain may be prescribed an opioid. Herein lies the problem.

“2.2% of women who had gotten a C-section and 1.7% of women who gave birth naturally went on to refill their opioid prescription at least twice and up to a year after childbirth.”

The U of M study, conducted by Dr. Alex Friedman Peahle, M.D., focused on women with private health insurance across America and found that among those who had a C-section, 76% would be prescribed an opioid. For vaginal l births, the figure was 27%. Of course, C-sections cause more postpartum pain so the difference in opioid prescription rates between the two groups is justifiable. The study’s other finding was more troubling: 2.2% of women who had gotten a C-section and 1.7% of women who gave birth naturally went on to refill their opioid prescription at least twice and up to a year after childbirth. That works out to more than 1 in 100 women becoming persistent opioid users after childbirth. Women who are younger and with a history of mental health/substance use disorders and/or other pain are more likely to develop an addiction after childbirth.

Another study published in 2019, this time of Tennessee women on Medicaid, from Vanderbilt University and published in the American Journal of Obstetrics and Gynecology (AJOG) found much higher rates of opioid prescriptions for postpartum pain: 89% for C-sections and 53% for vaginal births. Similar to the U of M study, the Tennessee study found that the rate of persistent opioid use among women prescribed opioids after childbirth was low but that rates were higher in women with C-sections than those who had vaginal births. Both studies focused on women who were opioid naive, meaning that they had not filled an opioid prescription within a certain period of time before giving birth (365 days in the U of M study, 180 days in the Tennessee study).

While the rate of persistent opioid users found in these studies may seem small, it is important to remember that there were almost four million births in the US last year. To convert percents to number, the 2.2% from the U of M study calculates out to 2,633 women who became persistent opioid users after their C-section. The rates in the U of M study may be lower than the actual rate of opioid misuse among new mothers, because the study did not include women with Medicaid or no health insurance, who are a more vulnerable population.

“A 2017 government study found that after just three days of opioid use, the risk of addiction increases daily.”

Doctors have the best of intentions when prescribing opioids to women after childbirth and these drugs can make life easier. However, opioids are extremely addictive. In fact, a 2017 government study found that after just three days of opioid use, the risk of addiction increases daily. There is some good news though. The U of M study found that doctors prescribed less opioids to women after childbirth in 2016 than they did in 2008, likely due to increased awareness of the problem of addiction. Additionally, the C-section rate is the lowest since 2009 and the number of women who previously had a C-section who choose vaginal birth during their next pregnancy increased by 13.3% between 2017 and 2018. While not always the case, vaginal births can have less postpartum pain than C-sections. Both the U of M and Tennessee studies show that doctors are less likely to prescribe opioids to women who give birth vaginally.

Fortunately, the medical community is taking notice of this issue. The Michigan Opioid Prescribing Engagement Network (Michigan OPEN)  and other advocates are recommending that doctors prescribe less opioids when they do decide to prescribe them for postpartum pain (i.e. 20 pills instead of 30). When talking to Bridge Magazine about her study, Dr. Peahle said that she believes that doctors prescribe opioids to make womens’ lives easier after childbirth, meanwhile, the women take them because their doctor prescribed them. This well-intentioned but potentially risky cycle can be interrupted by a conversation between doctors and their patients experiencing postpartum pain.

Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation’s capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.

This blog was reviewed for medical accuracy by Dorothy Moore, FNP.

What Is Supportive Housing And How Can It Help?

Beating opioid addiction and other forms of substance use disorder takes time and requires various levels of support. Supportive housing can help people reach their recovery goals and live better lives.

Homelessness is a complex social problem with many causes- poverty, unaffordable rent, domestic violence, mental and physical illness et cetera. Living without stable housing can make recovery more difficult than it already is. The stress associated with housing insecurity can lead to relapse and being constantly on the move can interrupt treatment. People experiencing both addiction and homelessness are more likely to use costly emergency room services and more likely to be incarcerated.

Housing assistance that gets people off the streets can help alleviate this problem, but for many people, more is needed. Realizing this, public health and housing advocates embrace supportive housing as a solution.

Supportive housing is housing designed to help residents in all aspects of the recovery process. Residents are provided with a wide variety of services that includes treating their condition while also providing services to help them apply for disability benefits and find employment. The services provided are not mandatory but are always available. No resident has to fear eviction because they choose not to use any provided service.

While many inpatient rehabilitation programs with a housing component require people to maintain sobriety or risk eviction, supportive housing embraces a Housing First approach. In Housing First, getting people into stable housing is given the top priority. Many cities in the US and Canada have embraced Housing First in their policies aimed at addressing homelessness.

“Supportive housing is housing designed to help residents in all aspects of the recovery process”

There are two types of supportive housing: tenant and project-based. In a tenant-based approach, rental assistance that help people afford housing can be used on any apartment or home while in project-based supportive housing, the rental assistance is tied to specific rental units. The project-based approach allows for many supportive housing units to be in the same place. Project-based programs allow many supportive housing units to be close together so that providers can more effectively deliver services, such as through an in-house clinic in an apartment complex. A tenant approach, on the other hand, allows residents maximum freedom to choose where they want to live. Choice is a critical component of Housing First policies as it allows people to live in their communities.

Not only are supportive housing programs good for residents, they are good for society as a whole. Supportive housing that combines affordable housing with services that help people rebuild their lives can greatly reduce healthcare spending by reducing days spent in the hospital, emergency room visits and days in nursing homes.

Housing programs were a major part of the Ryan White HIV/AIDS Program, which is credited with helping reverse the devastating effects of the AIDS pandemic in America. In fact, a study in Chicago showed that people with HIV who were previously homeless in supportive housing were 63% more likely to be alive than those without. Now that we are faced with a public health crisis of similar magnitude to HIV/AIDS, housing must again be part of the solution.

“Supportive housing that combines affordable housing with services that help people rebuild their lives can greatly reduce healthcare spending by reducing days spent in the hospital, emergency room visits and days in nursing homes. ”

Supportive housing is funded by a combination of government programs. Providers in supportive housing can bill Medicaid for many of their services. The Housing Choice Voucher Program, which helps people afford rent, can be used to pay for both tenant and project-based supportive housing. There are also federal grants that can fund parts supportive housing but each individual grant program is usually focused on a specific set of services- i.e. substance use treatment- or populations such as veterans or young people.  In project-based housing, new complexes are often funded through federal development grants or through “pay for success” partnerships. In “pay for success”, private investors provide the capital upfront for building supportive housing units and are paid back by the government after success has been demonstrated.

For community programs especially, the burden of stigma can be a challenge. Landlords and residents might not want those in recovery in their buildings. Luckily, the Fair Housing Act prevents such discrimination based on disability status. Supportive housing advocates and providers can also work to educate landlords and tenants about the reality of substance use disorders to dispel some of those myths and fears.

While supportive housing has proven benefits for people experiencing concurrent homelessness and addiction, there remains a lack of funding. Currently, 2.5 million people, including many struggling with substance use, could be eligible for Medicaid if their states chose to expand the program under the Affordable Care Act. In fact, four of the ten most populus states (Texas, Florida, North Carolina and Georgia) have rejected Medicaid expansion that could fund supportive housing services. Last year, the House of Representatives passed the THRIVE Act to create a five-year pilot program to provide 10,000 housing choice vouchers each year to people in recovery. Unfortunately, instead of creating new vouchers for this worthy program, the legislation would redirect those vouchers from other at-risk populations. The bill did not pass the Senate.

To find sources for this article and learn more about homelessness, substance use and supportive housing:

Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation’s capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.

Opportunities for the Prison System to Fight the Overdose Epidemic

Approximately 50% of the US prison population has a substance use disorder. What role should the prison system play in fighting the opioid epidemic?

Important distinction: While they are often used interchangeably, jails are short-term facilities, often run by local governments, while prisons are long-term facilities that are run by the state or federal government. For this post, I am talking exclusively about prisons.

Every 25 seconds, someone in America is arrested for drug possession. For those who are sent to prison because of their possession, they will join 456,000 people serving time for drug charges, one-fifth of the US prison population. Addiction is a chronic brain disorder that can be incredibly disruptive to a person’s life. A drug charge, especially one that leads to time in prison, only does more harm to a person struggling from a substance use disorder. A person may have to post bail and pay other fines, lose their job while in prison and have a harder time finding a new job after they get out because they must label themselves a convict. Furthermore, in states like Wisconsin, Georgia, and Missouri, a person can have their Medicaid coverage terminated. All of these policies further put people with a substance use disorder in the hole. Fortunately, there is movement to turn the criminal punishment system into a more positive force in confronting addiction.

“A substance use disorder does not resolve itself once a person arrives at prison.”

Drug Courts

Drug courts are specialized court programs that provide alternatives to prison for both those charged and convicted on drug and alcohol charges, as well parents with pending child welfare cases with a substance use disorder. There are over 30,000 drug courts in the United States. Participants in drug court programs are less likely to be re-arrested and less likely to test positive for drugs than those who did not participate in these programs, saving society about $6000 per person overall.

Despite these positive statistics on drug courts, program completion ranges from 30% to 70% across the country. Those who fail to complete the program are often sentenced to long prison sentences, raising concerns about their overall effectiveness in reducing criminal punishment for those suffering from a substance use disorder.

Treatment in Prisons

A substance use disorder does not resolve itself once a person arrives at prison. Access to treatment, including medication-assisted treatment, in prisons is dismal. In 2016, Rhode Island became the first state to offer all three MAT options — methadone, buprenorphine and naltrexone — for opioid addiction to prisoners. Massachusetts recently began providing buprenorphine to prisoners and has plans to offer methadone as well. The evidence from Rhode Island is promising. Prisoners with an opioid addiction are 129 times more likely than non-prisoners to have a fatal overdose two weeks after being released from prison. Rhode Island reduced the rate of fatal ODs in newly released prisoners by 61%. Despite this success, only 30 prisons across the country allow inmates to take methadone and buprenorphine, most forbid the use of these drugs because they believe they poses a security risk. The Americans with Disabilities Act, which was passed in 1990, includes protections for those recovering from a substance use disorder, however, lawyers rarely used the law for patients requiring buprenorphine or methadone in prison. Fortunately, times are changing. The US Attorney for Massachusetts has been investigating prisons for not offering MAT to inmates and court cases in Massachusetts, Maine, and Washington state, although impacting only the plaintiffs, have allowed those in recovery to continue their MAT while serving time. Another good sign was the National Sheriffs’ Association’s endorsement of offering buprenorphine and methadone to inmates.

“A seamless transition of a prisoner’s life, including their treatment, from prison to outside life is a critical factor in helping newly released prisoners stay on the right path. ”

“King of the Jailhouse Drug Trade”

Those who oppose offering MAT opioids in prisons cite the increasingly common practice of prisoners trading their buprenorphine to those who haven’t been prescribed it. The trading of prescription drugs is very common in prisons, for instance, buproprion, a drug used to treat depression and nicotine addiction, is known as “poor man’s crack” and is often abused by prisoners. To address this problem, a new form of buprenorphine which comes in a fast-dissolving wafer, instead of the slower-dissolving films and tablets that prisoners can smuggle in their mouths. However, the company that has patented this buprenorphine wafer, Purdue Pharma, is also behind the aggressive marketing of Oxycontin that many believe to have kickstarted the opioid epidemic. Currently, there is no indication that the involvement of Purdue will slow down the development of buprenorphine wafers, which have not hit the market.

Prisons are unique social environments without access to official currency. In place of bills and coins, prisoners use things like cigarettes, ramen noodle packets and, yes, prescription drugs to create their own economy. This is a fact that policymakers will have to consider when expanding access to MAT in prisons.

Medicaid Access After Prison

Treating a substance use disorder is a long haul that can, and often does, need to continue after a person leaves prison. Depending on what state a person lives in, an adult’s Medicaid coverage can either be suspended or terminated. Because of the SUPPORT Act of 2018, Medicaid coverage for incarcerated juvenilles cannot be terminated and is instead suspended. In 16 states and the District of Columbia, Medicaid coverage is suspended during their sentence but is easily reactivated when they leave.15 states suspend coverage for a limited period of time so people with longer sentences still loss coverage and 19 other states terminate Medicaid coverage regardless of sentence length, forcing newly released inmates to reapply. A seamless  transition of a prisoner’s life, including their treatment, from prison to outside life is a critical factor in helping newly released prisoners stay on the right path.

Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation’s capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.

What Exactly Is Krokodil and Why Is It So Dangerous?

Krokodil’s name in Russian means “crocodile” and it is also known as the “flesh-eating” or “zombie” drug.

The street drug krokodil is an illegal preparation of the drug desomorphine, a semi-synthetic opioid derived from morphine. Desomorphine is about ten times as strong as morphine because it has one less hydroxyl group (morphine has two, desomorphine has one) which allows it to more easily cross the blood-brain barrier. Desomorphine as gets to work sooner but the high does not last as long. While a heroin high lasts about four hours, a krokodil high lasts half that time. Therefore, a user needs to inject more desomorphine which leads to a greater chance of developing an addiction. Some people become dependent to desomorphine after just a few days.

While desomorphine was originally developed in the 1930s as an alternative to morphine, it soon fell by the wayside in mainstream medicine due to the abuse potential. Desomorphine largely disappeared from the world for 70 years before it came to Russia in 2003 as krokodil.

Due to its proximity to Afghanistan, the world’s largest producer of opium, heroin addiction is a major public health problem in Russia. In 2003, when the Russian government took action to curb the trafficking of Afghan heroin, the price of the drug skyrocketed on the streets. Therefore, those with an opioid use disorder had to turn to other option, one of which was desomorphine.

Desomorphine can be cooked in a home lab similarly to methamphetamine. To begin, one needs codiene tablets, which were available without a prescription in Russia. Then a solvent such as gasoline, paint thinner or battery acid is added to the tablets as well as iodine, red phosphorus and strong acids and bases. The end product is krokodil which is then injected into a person’s veins. While krokodil contains desomorphine, the solvents and other chemicals are not removed from the final product. In fact, the average pH of krokodil is 3, the same as lemon juice. Imagine injecting a toxic, acidic solution into your veins twice as often as heroin: that is krokodil. The name is thought to come from the green, scaley appearance a person’s skin becomes after long-time use.

Lets not sugar coat this, krokodil is very dangerous. If you wouldn’t think to inject any of the things used to make krokodil into your body then heed our warning because those chemicals are not properly removed from krokodil no matter what you’ve been told.

The health consequences of krokodil are numerous. In addition to green, scaley skin gangrene (tissue death), phlebitis (inflammation of the veins), blood clots, pneumonia, meningitis, blood and bone infections, and damage to the liver, kidneys and brain are all common side effects of krokodil. Long-time users often have to get limbs amputated and, unfortunately, people typically die after two to three years of use.

We understand that opioid dependence is a powerful force that makes us do things we never thought we would do. Workit Health is here with customized treatment based on the latest science to help you get your life back from krokodil.

Ali Safawi is a Workit Health researcher in Michigan. He will be graduating from the University of Michigan with a BA in Community and Global Public Health. His interests include mental health, substance use and healthcare reform.

6 Federal Laws for Substance Use

While opioid addiction and other substance use disorders are often thought of as medical issues, legislation passed in Washington, sometimes decades ago, can have a huge impact on your treatment experience.

1. Controlled Substances Act of 1970

Before the CSA, the federal government had several laws regulating controlled substances. When it was signed by President Richard Nixon in 1970, all federal regulations were pooled into five “schedules”:

Schedule I is for substances with a high potential for abuse and no accepted medical use. They are also not considered safe. Schedule I controlled substances include marijuana*, heroin, LSD, ecstasy and bath salts.

*Marijuana is still Schedule I even though it is fully legal under state law in ten states and D.C.

Schedule II is for substances with a high potential for abuse but do have accepted medical uses. Abuse of these substances can lead to serious physical and mental health problems. These controlled substances include prescription stimulants (e.g. Adderall and Ritalin) and most prescription opioids (e.g. Oxycontin and Norco).

Schedule III is for substances that have less addiction potential than those in Schedule I and II.  They have accepted medical uses but abuse can lead to moderate physical health problems and severe mental health problems. Schedule III controlled substances include testosterone and estrogen replacements, medicines with codeine and buprenorphine (e.g. Suboxone and Sublocade).

Schedule IV is for substances that have accepted medical uses and a lower potential for abuse as compared to Schedule III. They include Xanax, Ambien and Valium.

Schedule V is for substances that have less abuse potential than any other schedule. Most drugs occupy this schedule.

The CSA is enforced by the US Drug Enforcement Agency (DEA) which was established by a separate act in 1973. You can read more about the CSA here and find out which drugs are in which schedule here.

2. Narcotic Addiction Treatment Act of 1974

This bill amends the CSA to legalize the use of methadone (a Schedule II controlled substance) to treat opioid use disorder. It established the system where methadone for addiction treatment must be dispensed in clinics, called opioid treatment programs (OTPs), that are registered with the DEA, the federal Substance Abuse and Mental Health Administration (SAMSHA) and their state’s methadone agency. Before the Narcotic Addiction Treatment Act, the Hatch Narcotics Tax Act of 1912 (yeah, its OLD) prevented clinicians from prescribing opioids to those with an addiction. You can read more about this law here.

3. Drug Addiction Treatment Act of 2000

Before the 1990s, methadone was the only FDA-approved drug for medication-assisted treatment. That was until buprenorphine (Suboxone, Zubsolv, Sublocaid) entered the scene. Before buprenorphine was approved for MAT in 2002, Congress passed the Drug Addiction Treatment Act of 2000 (DATA 2000) which would allow physicians to treat opioid addiction with opioids that are Schedule III-V (buprenorphine is Schedule III) in settings outside of OTPs provided the get a waiver from the DEA. In order to obtain the waiver, a physician must take a course, now often online, on opioid addiction treatment. DATA 2000 also establishes a cap on how many patients a clinician can have on buprenorphine depending on their qualifications and year as a waivered provider. You can read more about DATA 2000 here.

4. Ryan Haight Online Pharmacy Consumer Protection Act of 2008

The Ryan Haight Act is named after an eighteen year old who overdosed on Vicodin that he bought at an online pharmacy. The bill is complex but the main concern for those seeking treatment for opioid addiction through telehealth. Under the Ryan Haight Act, a clinician cannot prescribe a controlled substance, including buprenorphine, without first seeing that patient in-person. There are other regulations on whether or not another physician can prescribe controlled substances if their original prescribing physician (who saw them in-person) is unavailable. You can watch a video about the Ryan Haight Act here.

5. Comprehensive Addiction and Recovery Act of 2016

CARA was the first addiction-related bill to be passed in Washington in 40 years. The bill, which was signed into law by President Barack Obama, allocated $181 million federal dollars for fighting the current drug overdose epidemic. CARA focused on investing in prevention and expanding access to treatment, especially evidence-based treatment. While the $181 million has been allocated, it is up to Congress to determine when and where the money goes. One of the first use of CARA funds was by SAMSHA, which gave out $2.6 million in grants to community organizations to build addiction recovery networks across the country. SAMSHA also awarded $9.8 million in grants to pilot state programs to help new and expecting mothers deal with opioid and other substance use disorders. In addition to increased funding, CARA temporarily authorized nurse practitioners and physician assistants to prescribe buprenorphine once they go through a waiver process. You can read more about CARA here.

6. SUPPORT for Patients and Communities Act of 2018

This newest opioid bill, signed by President Donald Trump last year, aims to increase access to evidence-based treatment for opioid addiction, including MAT with buprenorphine or methadone, and follow-up care for vulnerable populations such as pregnant women and people in rule areas. The bill does not do much to change the overall strategy of the federal government when it comes to the opioid crisis. The SUPPORT Act further loosens the restrictions on buprenorphine providers by making CARA’s temporary authorization for NPs and PAs permanent, temporarily authorizing other nurses with advanced training to prescribe buprenorphine, and increasing the number of patients a waivered clinician is allowed to take on. You can read more about the SUPPORT Act here.

What’s next?

There is movement in Washington to amend the Ryan Haight
Act to make it easier for telehealth providers to prescribe MAT. Senator Elizabeth Warren of Massachusetts and Congressman Elijah Cummings of Maryland have introduce the Comprehensive Addiction Resources Emergency (CARE) Act which is modeled after the Ryan White Act which has been instrumental to slowing the HIV/AIDS epidemic in the United States. The CARE Act would provide $100 billion dollars to states and communities over ten years to address the drug overdose epidemic.

Ali Safawi is a Workit Health researcher in Michigan. He will be graduating from the University of Michigan with a BA in Community and Global Public Health. His interests include mental health, substance use and healthcare reform.

To Vape or Not to Vape

Vaping and e-cigarettes have taken America by storm. But can they really help people quit traditional cigarettes?

“Vaping” is a term for when someone uses an electronic device (often called e-cigarette, e-cig or vape pen) to inhale a vapor that is often flavored and can have a psychoactive substance like nicotine or THC added. According to the CDC, over 9 million adults vape regularly. Vaping really took off about five years ago and since then there has been a lot of confusion over what they are and what they aren’t.

Is vaping addictive?

The liquid used in e-cigarettes, called e-juice or vape juice, can contain addictive chemicals, namely nicotine (found in traditional cigarettes and other tobacco products) and tetrohydrocannabinol aka THC (found in marijuana). Other vape juices contain no nicotine or THC.

Addiction potential, however, is not just about whether a psychoactive additive is present but also how it is delivered. Compare a traditional cigarette to a piece of nicotine gum, for instance. Both contain the same chemical but one is considered addictive while the other is not. When someone smokes a cigarette addiction potential, however, is not just about whether a psychoactive additive is present but also how it is delivered. Compare a traditional cigarette to a piece of nicotine gum, for instance, both contain the same chemical but one is considered addictive while the other is not. When someone smokes a cigarette nicotine is rapidly absorbed in the blood and taken to the brain almost immediately where it triggers a release of dopamine and other neurotransmitters. It is this strong rush of mood enhancing neurochemicals that leads to addiction when a person becomes reliant on nicotine to modulate their mood and arousal. While not all smokers experience nicotine withdrawal, the need to avoid withdrawal symptoms by smoking more is another driving factor in the cycle of addiction. Nicotine gum, on the other hand, releases nicotine much slower, breaking the cycle of dependence that cigarettes started.

Can vaping help people quit smoking?

There is no strong scientific evidence to support the claim that e-cigarettes help or hinder people trying to quit smoking. In fact, there is growing evidence that most people use traditional and e-cigarettes at the same time and that e-cigarettes serve as a gateway to traditional cigarettes for teenagers. While e-cigarettes are safer than traditional cigarettes and your doctor may encourage you to switch if you aren’t ready to quit, e-cigarettes are not a treatment. No e-cigarette has gone through the rigourous FDA approval process like the approved treatments (nicotine replacement, Zyban (buproprion) and Chantix (varenicline)).

It is also important to realize that e-cigarette manufacturers, such as Juul, do not want to help you quit smoking, otherwise they would have gone through FDA approval. Just like tobacco companies, which own three of the top five e-cigarette brands, e-cigarette manufacturers want to sell you more product.

Is vaping safe?

It depends on how you define safe. When compared to traditional smoking, the answer is yes, vaping is safer. When you smoke burning plant matter (be in tobacco, marijuana, even lettuce) you are exposing yourself to harmful chemicals that are produced during the burning process. These chemicals, not the nicotine itself, are what cause lung cancer and other smoking-related diseases.

But when compared to not smoking/vaping, the answer becomes no. Vaping is not harmless. Currently, there is a lack of regulation of e-cigarettes and vape juices. In fact, there is no requirement that manufacturers list the ingredients in their vape juices and they are unlikely to list their ingredients out of benevolence. A recent study of the vapor of 51 flavored vape juices found that 39 of them contained diacetyl. What is diacetyl? Its a chemical that when inhaled can cause a incurable lung disease called bronchiolitis obliterans. This disease is also known as popcorn lung because it was first recorded in workers at a microwave popcorn factory in Omaha, Nebraska. At the time, diacetyl was a common ingredient in popcorn flavoring but has since been removed.

Even if you vape a juice without diacetyl (and how can you know?), there is a danger inherent in the e-cigarette itself. Fires and explosions are a real risk, 195 cases of such have been reported by US media between 2009 and 2016. The FDA even has tips on how to avoid a battery fire with your e-cigarette.

All this is not to say that e-cigarettes are a dangerous scourge. Most people who vape will never have their device explode. As for the chemicals in vape juice, it is too early to tell whether there will be health effects as they can take years to manifest. Like with any product, e-cigarettes come with a level of risk, much of which can be addressed best with government regulation. In the meantime, it is up to each consumer to do their homework and make the choices they think are safest.

Isn’t the FDA banning flavored vape juice?

Not exactly. Back in 2009, Congress gave the FDA the power to regulate tobacco products and banned all flavors of traditional cigarettes that weren’t menthol. However, there is an ongoing debate as to whether e-cigarettes are themselves tobacco products so a full ban on flavored vape juice would likely lead to a huge court fight.

In Fall 2018, FDA Commissioner Dr. Scott Gottlieb announced a new regulatory push against flavored e-cigarettes to combat teen vaping, which increased 78 percent between the last two years on record. Under the FDA plan, “kid-friendly” flavors like Skittles and Cherry Dr. Pepper (other flavors like tobacco and menthol are exempt) would have to be put in special, age-restricted sections of stores. For online sales, the FDA wants stronger age-verification processes. These proposed regulations, which aren’t final yet, would require the e-cigarette companies, not stores, to make sure these regulations are enforced. Brands sold before August 2016, like Juul, have until 2022 before they have to begin to comply with the regulations.

Is banning flavored vape juice the right solution to teen vaping? Most of the new action on e-cigarettes is identical to earlier tobacco control actions. Currently, nine states (California, Delaware, Kansas, Louisiana, New Jersey, North Carolina, Pennsylvania, West Virginia) and D.C. apply the same special tax on tobacco products on e-cigarettes and many states are likely to follow. These special taxes are considered the most powerful weapon of tobacco control and range from $0.07 in Missouri to $4.35 in New York.

E-cigarette manufacturers are developing their own solutions to teen vaping. Juul, the largest e-cigarette brand, is piloting a program to track retailers who sell their product to minors. Juul also voluntarily pulled certain flavors to preempt FDA action but may return them to stores with age-restricted sections. Time will tell whether these efforts will work.

Ali Safawi is a Workit Health researcher in Michigan. He will be graduating from the University of Michigan with a BA in Community and Global Public Health. His interests include mental health, substance use and healthcare reform. 

Are Plants like Ibogaine and Kratom Helpful or Harmful in Opioid Addiction Recovery?

Can two plants, one from central Africa and one from southeast Asia, help you beat opioid addiction? We explain ibogaine and kratom.


Could the naturally occurring psychedelic ibogaine be the next big treatment for opioid use disorder?

Ibogaine is a drug that is naturally produced by several plant species in tropical Africa including the Iboga tree for which it is named. While it has been used by African tribes for centuries before being imported to France during the colonial period, the potential for ibogaine to treat opioid use disorder was first advocated by American scientist Howard Lotsof. Lotsof, who was addicted to heroin when he was nineteen, accidentally discovered ibogaine while chasing his next high. Per Lotsof’s own account, he and four friends quit heroin immediately after trying ibogaine, their desire for the drug quelled. Lotsof would go on to dedicate his life to bringing ibogaine treatment for substance use disorders into mainstream medicine.

“So, is ibogaine the miracle Lotsof claimed it to be?”

 Shredded bark of Tabernanthe iboga , contains ibogaine. (via) Shredded bark of Tabernanthe iboga , contains ibogaine. (via)

So, is ibogaine the miracle Lotsof claimed it to be? While the drug’s impact on his life is undeniable, the story is much more complicated. Ibogaine is a psychedelic with dissociative properties. It can cause changes in the perception of senses and produces a feeling of detachment from oneself and their environment. Other common dissociative psychedelics include ketamine and phencyclidine (PCP, angel dust). While Lotsof first began promoting ibogaine treatment for addiction in 1962, ibogaine clinics did not start popping up until the 1990s. A majority of clinics are located in Canada, Mexico, New Zealand, Costa Rica, South Africa and the Netherlands. In these and several other countries, ibogaine occupies a legal grey area. In the United States, ibogaine is listed as a Schedule 1 Controlled Substance, however, illegal clinics have popped up only to be busted by law enforcement. In 2015, the Global Ibogaine Therapy Alliance, founded by Lotsof, established clinical guidelines for ibogaine-assisted detoxification. Ibogaine treatment has also been promoted by several recent documentaries based on individuals’ experiences.

In the early 1990s, the US National Institutes of Health sponsored pre-clinical animal trials and Phase 1 clinical trials of ibogaine, however the research was halted. More recent studies have been conducted in Mexico and New Zealand, where ibogaine clinics exist. Despite this, more research needs to be done on ibogaine as a treatment for opioid use disorder. Ibogaine’s benefits are still under question, however, there are some very real risks associated with it. Ibogaine is both cardiotoxic and neurotoxic, having led to over 30 confirmed deaths. While ibogaine advocates will maintain that those deaths could have been prevented by screening for concurrent health conditions, it still remains that the safety of ibogaine has not been properly studied.


Kratom: Is this evergreen leaf a double-edged sword?

We actually encounter kratom at Workit Health. Some members of our Workit program have used it to help them detox off of heroin or pain pills while others come to us for Suboxone to treat kratom addiction. So what is kratom?

Kratom is a tropical evergreen that grows in southeast Asia, from Burma to Papua New Guinea. The kratom leaf actually contains two psychoactive alkaloids: mitragynine and 7-HMG. Both mitragynine and 7-HMG have been shown to be opioid receptor agonists, meaning that they bind to and activate the brain’s opioid receptors like the opioids you know. Kratom also has stimulant properties at lower doses, while its opioid properties are more pronounced at higher doses.

 Mitragyna speciosa (kratom) leaves (via) Mitragyna speciosa (kratom) leaves (via)

“Some members use kratom to help them detox off of heroin or pain pills while others come our Workit Clinic for Suboxone to treat kratom addiction.”

While several states and the US Army have made kratom illegal, it is still largely legal, although imports are routinely ceased by customs. In 2016, the US Drug Enforcement Agency expressed the desire to classify kratom as a Schedule 1 controlled substance like marijuana, ibogaine and heroin. This led to pushback from kratom advocates and several US Senators, however, the DEA has shown continued interest in reclassifying kratom to Schedule 1.

Like ibogaine, there is not enough scientific research on whether or not kratom can effectively treat opioid use disorder. While studies in mice show that kratom is safer than most opioids, kratom overdoses are possible and have claimed lives, although almost always when another opioid is involved in addition to kratom. Frequent use of high doses of kratom can also lead to tremors, anorexia, seizures, psychosis and heart issues. Kratom related deaths have increased markedly in recent years sparking calls for treating the leaf as a public health problem. Furthermore, a Salmonella outbreak from late 2017 to early 2018 that poisioned 28 people in 20 states was linked to kratom supplements.


The Verdict

We can’t say whether or not ibogaine and kratom work for certain, there simply is not enough evidence. What we do know is that compared to these treatments, the three FDA approved assistive medications for opioid use disorder — methadone, buprenorphine and naltrexone — have a far superior record of safety and effectiveness. The dedicated clinical team of addiction treatment experts at Workit Health are happy to talk to you about your options for taking your life back from heroin or pain pills.

Get your life back from opioids with medication & online therapy.

Ali Safawi is a Workit Health associate in Michigan. He will be graduating from the University of Michigan with a BA in Community and Global Public Health. His interests include mental health, substance use and healthcare reform.