By CHRISTY HENDRICKS
Leader staff writer
Editor’s note: This is the fourth in a series.
The Psychiatric Research Institute at UAMS in Little Rock houses the Center for Addiction Research. The center has a methadone clinic and a Suboxone clinic that treat opioid addiction. People seeking treatment are supervised as they transition to a medication-assisted treatment.
Dr. Nihit Kumar has been at the addiction center for two years – one year as a faculty member and one year under an addiction fellowship. He also worked in the addiction area during his time as a resident at UAMS starting in 2010.
In addition to his work with addiction, Kumar is an adolescent mental-health and child and adolescent psychiatry specialist.
TREATMENT
When patients come in seeking treatment for opioid addiction, Kumar says they “get them in quickly, within a day or two.” The patient goes through an intake process where they are given a comprehensive evaluation that includes a comprehensive psychiatric evaluation and a full physical exam. They are given a urine drug screen to determine if and what other drugs may be in their system. They are then enrolled in one of two programs –Suboxone or methadone.
Kumar works with patients in the Suboxone clinic.
“Once they get that intake (specifically for the Suboxone program), we induct them on the medication. We do that in the next two or three days,” Kumar said. “We kind of give them a script to stabilize them on a certain dose and then we see them weekly to begin with. They attend in groups. They meet with individual counselors one on one and then they come back the next week. They get a script every week.”
The methadone clinic has a slightly different process, according to Kumar. Patients go through the same intake process, but come in daily six days a week to receive a dose of methadone.
“We actually pour the medication for them, and they take it in front of us. On Saturdays, they come in, they get dosed for Saturday and then they get a dose to take home for Sunday,” Kumar said. “There are some differences in the federal guidelines as to how a methadone program should be and have a Suboxone program should be.”
The methadone program is intensive and is reserved for patients who are not stable or do not handle the weekly prescription. “It has a higher level of structure,” Kumar said.
The Suboxone program works well for those who are so-called “functioning addicts.”
“People that are working and trying to get their life together, it’s hard for them to come every single day. So this way they still have structure, but it’s less of a structure than the methadone,” Kumar said.
“It’s more for a functioning addict trying to get back on their feet. A lot of people are not willing to come to an every-day program, but this way they can come once a week and still have time for their family and loved ones and do whatever they need to do. They can get a job. This program really was meant to expand access to medication-assisted treatment for folks dealing with opiate addiction.”
The clinics are limited to how many patients can be treated. There are restrictions on the amount of prescriptions for the drugs prescribed in the medication-assisted treatments.
“You don’t want doctors just indiscriminately treating patients with this medication because it’s a partial opiate. You do it appropriately,” Kumar said. Doctors must go through special training with the DEA to qualify to prescribe the medications.
The success rate for medication-assisted treatment for opioid addiction varies between 30 and 70 percent.
“The success rates in general for addiction treatment aren’t very good. That’s why there’s a push to increase success rates to get them on medication-assisted treatments. The success rates of those who try to quite opioids without treatment is even lower,” according to Kumar.
Withdrawal from opioids can be extreme with symptoms feeling like a bad case of the flu. There are cravings, nausea, vomiting and irritability.
“You feel really sick. It is not life threatening, but when they go through these withdraws it’s very hard for people to resolve themselves,” Kumar. “Some people do it. Say you manage to get through these three or four days, five days. You’re done with it, but you still have the cravings to use. Those cravings are the urges that trigger your memories of using. Those cravings are pretty strong. Without medication, it is very hard for a recovering addict to maintain their sobriety without relapsing back on opiates. The relapse rate is in the 90 percents – that high without medication assisted treatment.”
There is also a women’s mental health program at the Psychiatric Research Institute that treats pregnant women who are addicted to opiates. “When they deliver, they need opiates, especially if they have a C-section. You need pain medication. But there’s a way to prevent the development of addiction. There’s a way to prevent them abusing the medications. The doctor monitors them during their pregnancy,” Kumar said.
TRENDS
“Arkansas is a little behind the national trend on everything. Things happen and by the time they get to us, it’s already four or five years down the line. That’s what’s been happening with medical marijuana. With opiates, I think prescription opiates are still the biggest issue in Arkansas,” Kumar said.
Most patients seen at the addiction center are between the ages of 18 and 45. Most are using prescription painkillers, but there are some using heroin. Kumar said most addicts begin with prescriptions for recreational use or after being prescribed for an injury.
When addiction sets in, addicts begin shopping doctors or making trips to an emergency room to get a prescription. When those options run out, an addict will start buying drugs off the street and sometimes will turn to heroin because it may be more easily affordable and attainable.
“There are several trends, but it’s not fair to generalize,” Kumar said.
The clinic sees more whites seeking treatment for opioid addiction than African-Americans, but more African-Americans than Caucasians seeking cocaine addiction treatment. More men are seen in the clinics than women, but an increase in the number of women has been seen since opening the women’s mental health program.
“I also moonlight in the Springdale area, and there are a lot more methamphetamine users there than compared to central Arkansas. There are trends geographically. There are trends racially,” Kumar said. “Age-wise it’s usually high teens to young adults is the biggest population. I think ages 12 to 26 use much more opiates. They have the highest use compared to after 26.”
“It’s supply and demand,” Kumar says of the trends with drug addiction. “When I do an intake I ask patients, for example, you started with hydrocodones, then you moved on to using oxycontins, then you went to heroin. Why did you switch? It’s all about supply and demand. It’s what’s available. How cheap it is. What’s easily accessible. I think it’s actually easier to get prescription pain meds in rural areas as opposed to heroin. Heroin tends to percolate in certain areas. The demand is higher I would say Little Rock has more heroin than certain areas.”
Kumar says there is evidence of a growing use of heroin in Arkansas. “It’s been here before. It ebbs and flows, and it’s coming back now. My guess would be the more stringent regulations put on prescribing, the more heroin is going to resurface. It will shift the balance to “getting a pill is so difficult now, why not just use heroin?”
PREVENTION
“You really want to have a lot of education in schools about the negative effects of addiction and mental health,” Kumar said of overdose and addiction prevention. “All these campaigns about saying no to tobacco, for decades, have been beneficial because now we are seeing a significant drop in rates of tobacco smoking.”
He also suggest increased parental monitoring at home has shown to decrease the level of substance abuse in teenagers.
Kumar suggests that educating pain doctors, hospital and primary-care doctors on how to balance the treatment of pain and knowing the signs of addiction can also help prevent patients from becoming dependant on opioids.
Primary care doctors are seeing more cases of addiction in their offices.
“They are not trained to handle that. Improving their training and education through continuing education programs may help,” Kumar said. “If they don’t have the structure to provide treatment in their clinic then they can they can refer them to specialized treatment centers.”
Improving access to treatment by primary-care doctors getting buprenorphine licenses is being talked about. Currently there are only around 10 to 15 doctors in Arkansas who can prescribe methadone or Suboxone, according to Kumar.
Other ideas include increasing access to Narcan, possibly making it a non-prescription medication or reducing the cost of Narcan may help reduce the numbers of overdose deaths related to opioids, according to Kumar.
“As psychiatrists, we see the negative side of addiction. We’re the ones who deal with that. The pain specialists are very good doctors who are treating pain, but if their patient develops an addiction they usually discharge them from the clinic,” Kumar said.
“They cut off their prescription, which is the right thing to do. But usually pain specialists don’t see the addictive side of things. If they don’t have the that feedback, they’re not going to know how big the problem is. We’re on the other side of this. We have all seen the problem.”
For more information on the opioid crisis, visit turnthetide.com.
“It’s a great website there’s a lot of research that’s out there it’s just how do we get people to learn and start to implement those resources,” Kumar says.
The Centers for Disease Control website, www.cdc.gov, is also a good resource for information on opioids.
People seeking treatment can call the Psychiatric Research Institute at 501-526-8400 or show up at the clinic at at UAMS, PRI fourth floor to schedule an intake appointment.
