I’m at the annual meeting of the American Society of Addiction Medicine and enjoying meeting old friends and colleagues from all over the country. A particular friend I spoke to last night works in a methadone treatment program. As he should, he uses urine drug testing to monitor his patients for adherence to their agreed upon plan of care. He’s been at this a while. His data goes back to 2009. And since 2009 things were stable. Rates of using substances not allowed for in the treatment plan were at low and unchanging levels, until 3 years ago. 

What he noticed then is that something changed and changed acutely. Since 2015, while data on all other drugs were unchanged, rates of use of cocaine went up as rates of use of opioids went down. This is very odd. 

The neurobiology of addiction is such that cocaine is not interchangeable with opioids. Opioids produce greater release of dopamine at the reward center and are useful for relieving symptoms in addiction in those who have decreased dopamine release. Cocaine raises dopamine levels by blocking the reuptake in already released dopamine and is useful only in those who have good release already. Seeing as this is a methadone treatment program, small amounts of illicit opioid use is to be expected and is usually a sign of a need to change the treatment regimen in that patient. And, given that people’s dopamine release is nomalized by methadone, some amount of cocaine use is seen in those needing to get their dopamine even higher. But what is not seen much is a population shifting from opioids to cocaine. What could it mean?

Well you need one more bit of information from my friend. Shortly after he noticed the change, he became aware that illicit fentanyl was entering his community. Prior to that time, it wasn’t useful to test for fentanyl in the general popualation of people with addiction. Unless the patient was a medical professional, almost no one tested for fentanyl in their patients. I should add that because fentanyl is a synthetic opioid, it doesn’t respond to the usual test and has to be looked for separately at added expense. But now fentanyl was becoming available on the street and my friend started testing for it. What he found was interesting.

As positives on the opioid test were going down, and cocaine was going up, the positive rate for fentanyl was rising in parallel with that of cocaine. So it wasn’t the switch between cocaine and opioids that was originally thought, but rather cocaine going up with the use of one opioid as it entered the community. So, the questions remain, why is cocaine use going up with fentanyl and why is fentanyl being used by people on methadone?

Tackling this logically, the cocaine is either being taken separately by fentanyl users or it is found in the fentanyl. Since fentanyl is a somewhat recent addition to the street drug pharmacy, it could differ in what it’s cut with from the heroin it is replacing. Some street dealers know it is more dangerous than heroin and may be including cocaine in the incorrect assumption that the activation from the cocaine will prevent overdoses. It’s not good business to kill your customers. Alternately, if users know they are taking fentanyl, they may take cocaine for the same mistaken reason.

In either case, my colleague is left with the question of what to do. The low level of opioid use in methadone patients has always been a problem, but because methadone prevented anyone using heroin from getting the use reinforced, there was not a big reason to address it. People with addiction may from time to time test heroin to see if they can still get high and when they don’t they don’t use it anymore. That’s sort of how methadone works. But fentanyl is different. Being able to bind to the opioid receptor better than methadone, fentanyl can actually be reinforcing in the methadone patient, so preventing the experimental use becomes a more urgent problem.

This is the problem that my friend had to find a solution to. How do you get someone on methadone from not trying a street drug, because you can no longer count on the methadone to be the agent that eventually stops the use? So he had to go back to the neurobiology.

He understood that there are three reasons people with addiction use. First is the low dopamine tone problem that is primary to the illness. Second is cue induced craving that can induce an internal high and crash and create craving even in a patient with normal dopamine tone. The last is a seeking oblivion when external factors become overwhelming and one just wants to “turn off.” In methadone patients, the first issue is usually fixed by the methadone, and the second is handled by the methadone itself in that any cue induced using is extinguished over time because it just doesn’t work. The third issue is handled by the psychosocial part of the treatment program. 

So my friend had to ask, was there something lowering patients’ dopamine tone in the last 3 years that has brought on more using? It could be. The country is moving to a more moralistic, criminal justice view of addiction than it had been in the previous decade and we know that feeling less than others and physical isolation lower dopamine tone. But it could also be that the cue induced using of the patients, which largely extinguished itself over time, was now a problem that required addressing because of the use of fentanyl instead of heroin. 

There were other possibilities that my friend ruled out. The maker of methadone hadn’t changed and the potency of the medication was no different than it was 3 years ago. The average dose in the clinic hadn’t changed. Neither had the clinic become harsher or less friendly to patients lowering their dopamine tone.

My friend had decided he needs to test for the effect of cue induced craving, and he’ll start by treating a small group of patients who are saying they are using fentanyl with a medication for cue induced craving. But why am I blogging on this on a site about Theory of Constraint? My friend didn’t use any of the TOC thinking processes? He drew no logical trees? He didn’t ask anyone in his organization to tell him their Undesired Effects. 

But he still used logic, and logic isn’t limited to TOC. Medicine has a long history of logic, but it’s something that’s been forgotten in our modern, insurance driven, healthcare system. If...then logic has always been the basis of the scientific process. Diagnostic medicine too is the search for the fewest assumptions (diagnoses) tha explain all the observed phenomena (symptoms). TOC and medicine go hand in hand. 

So my friend didn’t know about TOC, and he didn’t use any Thinking Processes in his work, but he did use logic. He didn’t stick to his assumptions like so many would have. He didn’t just say, “Well, they’re addicts. That’s what they do.” He questioned his assumptions and looked at the available data. Just like any good TOC practitioner. I’m looking forward to hearing what his experience is with the new treatment.