We’re going to move now into specific substances of abuse. Cocaine has a long history of use. The cocaine problem absolutely preceded George W. Bush’s youthful indiscretions. Actually, it even preceded Henry Hyde’s youthful indiscretions and I almost wish, it’s as old at least as Benjamin Franklin but he was public and he didn’t really stop his indiscretions just for political life and I respect a man like that. Some people would say that our president hasn’t really stopped his youthful indiscretions for his political life either. Cheap nexium without prescription.
But it does show that this is a ubiquitous problem. All classes are affected. Cocaine has really gone through the gamut from people at the highest level of society to the bottom and it tells you that one’s morals, one’s upbringing, one’s wealth, education is no defense against the physiological processes of these substances. So when I talk about cocaine I want us to understand what these physiological processes are.
The neuropharmacology of cocaine has been important for understanding addiction but also for understanding how the brain works and that’s partly why there’s such a big investment in this. Reinforcement is so powerful with cocaine in animal laboratory experiments that rats, given freedom to press a lever to get a full squirt of cocaine into the brain or the bloodstream will press it continuously until they stop eating, stop mating, stop drinking and begin dying in 14 days mostly of cardiopulmonary disease. They also develop rapid infection and 90% will be dead in 30 days and that is the most deadly of the common drugs of illicit use. So that’s an important factor to have in mind. Viagra professional canadian medications.
Administration of drugs that are rewarding isn’t limited to the drugs themselves. How do we know where this happens? Well, we know by putting electrodes into the brain at different places and giving the animal free rein to move around the cage and hit the lever once in awhile and get a little microampere jolt, not to do damage but to see is there a synapse that likes this stimulation.
What we find is there is a nucleus accumbens capsule that is the most potent site of the brain. That is, it takes the least amount of current for self administration to be rewarded so the rats or mice or whatever animal we choose will press that lever again and again to get that little tiny bit of current. So we have a site. We know that lesions of this site will block the acquisition of that self administration behavior. So this is convincing evidence.
What else is involved here? Well, endorphins are not primarily involved. Opiates have actually some bearing on it and we’ll talk about that later but they’re not primarily involved and the anesthesia is not the reason that the animal does this. That’s a peripheral effect.
What about other substances? Well, heroin will yield that kind of rapid self administration too. To get a squirt of heroin, animals like rats will press again and again hundreds of thousands of times in a day believe it or not and if they’re given free rein every time they press they get a squirt, about a third will be dead in a month. So you can now compare cocaine’s lethality to heroin’s lethality which is opposite to what we thought in the ‘80s, by the way. We thought heroin was the real killer and cocaine, you know, yeah it’s fun. Some people get carried away with it. Now we know different.
So we have this problem but there are some other physiologic processes with stimulants of cocaine as well. One is stereotypy. What is stereotypy? It will show up on the boards and it is a process of compulsive repetitive purposeless behavior. In a cat, it might be grooming to the point that the cat actually wears off its fur and digs into its skin and is bleeding from it. In human beings stereotypy with cocaine is pacing around the coffee table in the den where he uses his cocaine and wearing out a track in the shag carpet. Generic pharmacy blog.
Action is going to the AA meetings, going to the counselor, seeing a psychiatrist for the evaluation of psychiatric symptoms that might promote relapse, maybe day treatment and so forth. That might be a phase of weeks or months or even years but eventually a patient succeeds and more than 70% of our patients succeed and have good recoveries in which their lives are improved and they reintegrate into society.
But that’s not enough because if they don’t practice periodic maintenance actions, they are vulnerable to relapse. When? Well, maybe the next New Year’s party or maybe their next birthday. Maybe the anniversary of one year of sobriety. So we need maintenance steps to help prevent specific risks after the day to day worry about relapse seems to have been effective and is no longer necessary. When people relapse, what’s the trick? Well, help them get back into contemplation quickly. They can cycle through this much more rapidly with less damage, with less severity and quantity of substances so that they can learn quickly “What was the one thing that blind sided me that I need to work harder on for next time?” Ask google!
Well, the different treatments that we have at our disposal fall into about four categories – hospital care, daily medical management but that’s for people with severe withdrawal risks, 24 hour acute medical care needs, maybe because of liver disease or pancreatitis that’s acute and psych or behavioral complications that need 24 hour care for instance suicidality. But it’s not for housing, it’s not because the urges to relapse are strong. We don’t use the hospitals for that. It’s too expensive and not specific. Instead we use medically monitored inpatient care which is simply a residential program where there is some nursing care and maybe a visiting or consulting physician. For this, there still can be some withdrawal risk and some medical monitoring required or psychiatric monitoring required but the patient shouldn’t have the severe containment needs that a hospital provides. Cheap female viagra at online us pharmacy.
Intensive outpatient can be day treatment or partial hospital or a several times a week evening program and patients with all of these types of problems fit in here as long as the medical and psychiatric ones are not severe. For outpatient once a week care, it’s important that we meet the criteria of no severe withdrawals, no severe medical risks, no severe psychiatric risks and the motivation has to be partial at least. The relapse potential has to be manageable in outpatient so if we discharge somebody from the hospital after acute cellulitis and they use heroin on their way home from the hospital the answer is not to put them in Level 1 care. It’s they all come once a week to therapy and we’ll talk about it even if managed care says that’s without proof and we have this problem with managed care.
You know, there’s plenty of evidence of the cost saving benefit of this treatment to society. California did a huge study, tens of thousands of cases analyzed, to see what does one dollar spent on treatment get you. What they found, and this is on page 281 in the middle, that you spend a dollar on inpatient you save four dollars subsequently. If you spend one dollar on outpatient treatment because it’s so inexpensive you save twelve dollars. On average, and this is probably the thing you should write down here because I wouldn’t be surprised to find it on the boards, the average of those two, taking into account all the different sample sizes, is one dollar spent on addictions treatment saves seven dollars mostly in health and crime costs.
So we see a big societal savings and there’s more to it. What about savings on prison treatment? Well prison treatment can reduce relapse to prison short term three-fold. So if we spent the money, what we would buy would be less crime, probably less homelessness, less unnecessary utilization of our Emergency Rooms and ICUs. So the one dollar per seven dollar ratio is important for you to have in mind. Unfortunately this argument is not yet fully bought although there is a big parity debate that they’ll have in Congress this year and I hope it will go to some lengths to cure the crisis that this slide exemplifies. The mental health services drive-thru.
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