Thursday, November 14, 2024

Methadone Treatment Guidelines, Healthcare and Psych articles of Donald H. Marks, MD PhD

 Methadone Treatment Guidelines, Healthcare and Psych articles 


by Donald H Marks, M.D., Ph.D.

Medical Director, RCCD



  1. Cocaine Use in the setting of Methadone treatment for Opioid Use Disorder

  2. Methadone use during pregnancy


  1. A.I. Therapy Chatbots vs living therapists

  2. Monistat does not interfere with urine drug screen

  3. Notes on  Methadone peak - trough measurements

  4. Cipro- Methadone Drug interactions 

  5.  Neurological Complications of Vaccination with outer surface protein A (OspA)

  6. Warnings of Suicide and Homicidal thought, anger agitation aggression  irritability from prescription Medication, Antidepressants anti-anxiety anti-psychotics ADHA

  7. Reducing The Influence of Politics in Healthcare

  8. Guidelines to prescribing anti-psychotics to patients on methadone

  9. Loneliness and Isolation in the age of COVID-19

  10. Depression Leading to Suicide As An Adverse Effect of Metoclopramide

  11. Homicidal Ideation Causally Related to Therapeutic Medications

  12. MR imaging of Drug-induced Suicidal Ideation

  13. Accutane: Focus on Psychiatric Toxicity and Suicide

  14. Interferon and Risk for Drug-Seeking Behavior

  15. Determination of truth from deception using functional MRI and cognitive engrams


  1.  The potential for GLP-1 drugs such as Ozempic and Wegowy, and new anti-cancer and Alzheimer’s drugs to Destroy the Financial Stability (such as it is) of Medicare, Medicaid and the US Healthcare in general

  

  1. Should ALL Medical Doctors Be Required to Accept Medicare and Medicaid $$$ as a Condition of Licensure? Can the Gods be humble and care for their lowly helpless subjects?

  2. Marks DH. Evaluation of Cognitive Impairment. Internet J Health. 8(1), 2008.

  3. Marks DH. Evaluation of Medical Causation, in Drug Injury: Liability, Analysis and Prevention, 3rd and 4th Editions,  O’Donnell JT editor. L&J Publications, 2012 and 2016.

Wednesday, November 6, 2024

Are we really living in a simulation? How real is our reality?

Are we really living in a computer simulation?

Donald H Marks, physician and scientist




Recently there have been a number of discussions concerning whether our perception of reality is real and whether we are actually rather living in a simulation of reality. Such a simulation would involve a higher power or higher intelligence to simulate, perhaps in a massive computer program somewhere, the perception of reality and life, which then would be fed to us as characters in the simulation to make us think that we were real.

The Simulation Hypothesis: A Deep Dive

The simulation hypothesis is a philosophical thought experiment that posits that we might be living in a simulated reality, perhaps created by a technologically advanced civilization. This idea has gained traction due to advancements in technology and our growing understanding of the nature of reality.

The Theory Behind the Simulation Hypothesis

The core arguments behind this simulation hypothesis are:

 * Technological Advancement: As technology continues to advance, it becomes increasingly plausible that a future civilization could create highly realistic simulations.

 * Infinite Universes: If there are an infinite number of universes, it's possible that at least one of them would have the capacity to create simulations.

 * Fundamental Laws of Physics: The laws of physics could be a product of the simulation's programming, rather than fundamental truths of the universe.


What Does It Mean, or what would it mean, to really be Living in a Simulation?

Living in a simulation would mean that our entire perceived reality, including our physical bodies, the world around us, and the laws of physics, are all part of a computer program. It's as if we are characters in a video game, but with a level of consciousness and agency that we might not fully comprehend.

How Would We Even Know?

Determining whether we are living in a simulation is incredibly challenging, and there is no definitive way to prove it. However, some potential indicators have been suggested:

 * Anomalies or Glitches: If we were in a simulation, there might be occasional glitches or anomalies that would suggest a programmed reality.

 * Fundamental Limitations: If there are fundamental limitations to our understanding of the universe, it could be due to the constraints of the simulation.

 * Consciousness and Free Will: The nature of consciousness and free will could provide clues. If our consciousness is a product of the simulation, it might have limitations or patterns.

 * Technological Advancements: If we were to reach a point where we could create simulations ourselves, it would raise questions about our own reality.

Ultimately, the simulation hypothesis remains (at least to some people) a thought-provoking philosophical concept, but it is just that. While it's impossible to prove or disprove definitively, it serves as a reminder of the complexity and mystery of our existence.

Perhaps we can use AI to explore whether we are living in a simulation, but if we have questioned the accuracy of AI answers, and the presence of AI hallucinations, then AI is probably the wrong place to look for answers. The likelihood of using AI to definitively know if we are living in a simulation is, in my opinion, currently very low.

While AI has the potential to analyze vast amounts of data and identify patterns that humans might miss, in my opinion there are significant challenges in definitively proving or disproving the simulation existence hypothesis. Here's why:

 * Lack of a clear definition: The concept of a simulation is itself subjective and open to interpretation. What constitutes a "simulation" and how would we distinguish it from our current reality?

 * Limitations of AI: Even advanced AI would be constrained by the limitations of the simulation itself. It might be unable to detect or access information outside of the simulated environment.

 * Paradox of self-reference: If we were to discover a pattern or anomaly that suggested we were in a simulation, it's possible that the discovery itself was part of the simulation's design.

 * Philosophical questions: The question of whether we are living in a simulation raises profound philosophical questions about consciousness, reality, and the nature of existence. AI, while powerful, cannot answer these fundamental questions on its own.

While AI may be able to provide insights into the nature of our reality, it's unlikely that it will be able to definitively prove or disprove the simulation hypothesis. The question of whether we are living in a simulation is a complex one that involves both scientific and philosophical considerations.

One of the key challenges and methods of using an AI program to determine a complex question like whether we are living in a simulation is how exactly do we construct the question, and what are the  best PROMPT to use to achieve a successful answer? Here are a few prompts or questions we could use to explore the simulation hypothesis with AI:

Direct Questions:

 * "Is it possible that our reality is a simulation?"

 * "What evidence could suggest that we are living in a simulated universe?"

 * "Are there any inherent limitations or inconsistencies in our universe that could indicate it's artificial?"

Hypothetical Scenarios:

 * "If we were in a simulation, what might the creators' (a god, the God, a higher power ...) intentions be?"

 * "How would a simulation break down or malfunction?" Certainly not a happy prompt to use.

 * "What kind of glitches or anomalies might we observe if our reality were simulated?"

Some Analytical Requests:

 * "Analyze the laws of physics for any inconsistencies or patterns that might suggest an artificial origin." 

 * "Examine the behavior of quantum particles for any evidence of a simulated environment."

 * "Evaluate the nature of consciousness and its compatibility with a simulated reality."

Remember that AI can only process information based on the data it has been trained on. It cannot provide definitive answers to philosophical or existential questions like whether we are living in a simulation. The prompts above aim to stimulate thought and analysis, but ultimately, the question of whether we are in a simulation remains a matter of speculation and philosophical inquiry.


References

We live in a simulation. 

Does the past still exist? 

Tuesday, November 5, 2024

Thoughts on responsibilities of young American citizens - my reflections on remarks made by the great JFK at Amherst College in 1963

Thoughts on responsibilities of young American citizens. My reflections on remarks made by JFK at Amherst College in 1963.



by Donald H. Marks, physician and scientist



Let me put on my non-medical hat and speak as a casual student of history and the Arts, as I discuss remarks made by President JFK in 1963 at Amherst College upon receiving an honorary degree. Yes I was alive that long ago, as I was born when I was very young. I am a great admirer of JFK who, along with FDR, are my two favorite presidents. I have long thought about those words from the past, and over several years I have worked to put pen to paper, as people used to say.  A man from a wealthy powerful family, a man of means, a politician with good intentions, someone with a global vision, a man connected to the famous, the wealthy, the powerful, the educated, the connected, a man presented at birth with the opportunity to achieve greatness by his birth, a man who put his life on the line for the United States in combat, truly a man for all seasons. To this day, I remember his greatness, the day he died, and I still grieve his loss, especially in the context of current aggressive, highly partisan, take-no-prisoners political life.

In his speech at Amherst, President Kennedy explained the responsibilities and the importance of public service for all citizens, and especially  educated citizens. Addressing the class at Amherst, JFK described his view of the role of an artist in society, noting his personal friend Robert Frost’s contributions to American arts, culture, and ideology. “When power leads men towards arrogance, poetry reminds him of his limitations. When power narrows the areas of man’s concern, poetry reminds him of the richness and diversity of existence. When power corrupts, poetry cleanses."


Robert Frost and other artists, Kennedy said, make a vital contribution “not to our size but to our spirit, not to our political beliefs but to our insight, not to our self-esteem, but to our self-comprehension.”


Those memorable words, as well as Kennedy’s call that day for Amherst students to consider how they might serve their country, inspired students at Amherst, and throughout the USA. Five percent of the Amherst senior class of 1964 joined the Peace Corps, the overseas service organization Kennedy had initiated in 1961.


The gridlock and dysfunctional partisanship in Washington, D.C. today poorly compares to the optimism and progressive spirit that seemed to animate the years of the Kennedy administration, at least insofar as I remember it.

 

The friendship between Kennedy and the poet Robert Frost, dating back to when Kennedy first ran for president, turned cold in the early fall of 1962 after Frost returned from a visit to the Soviet Union and a lengthy talk about cultural exchange with then-Soviet Premier Nikita Khrushchev.


Frost had a cold and a bad case of jet lag when he returned to the U.S.. Many of us have been there. He gave what appeared to have been a somewhat confused interview, during which he related that Premier Khrushchev had claimed to him that the U.S. “was too liberal to fight.” Frost’s remarks angered Kennedy, causing him to cut off contact with Frost.  Only a month later, the Cuban Missile Crisis developed, with a potential nuclear war. How many of us have similarly cut off a relationship due to a hasty remark, an inopportune comment, thoughts taken out of context or misunderstood, religious or political disagreements? Breaks in friendship can mend, but the pain swirls like a memory underneath, waiting for a fitful rebirth and revenge.


Yet, Kennedy buried the hatchet when he came to Amherst, praising Frost’s poetry and his contribution to the American spirit. Frost was an artist who, Kennedy said, “saw poetry as the means of saving power from itself."


The president also told Amherst students that, given the benefits they enjoyed in attending an elite private college in a country that had great disparities in wealth, he hoped they would put their education toward some kind of public service. And back then, many did. Not at all like today.


I hope that my comments won't just be viewed as a snapshot of the past, but as how those issues and ideals that Kennedy spoke about during his visit to Amherst can apply to our lives today … across the political spectrum. The responsibilities of the wealthy, the educated, the fortunate, the artists, the creative entrepreneur, and those lucky enough to live in Western society and in America in particular are a treasure.


References

JFK speech at Amherst College https://www.jfklibrary.org/learn/about-jfk/historic-speeches/remarks-at-amherst-college-on-the-arts

You're probably misreading Robert Frost's most famous poem, "The Road Not Taken." https://lithub.com/youre-probably-misreading-robert-frosts-most-famous-poem/





Additional writings of Donald H. Marks, physician-scientist can be found on this blog site

Are there Samantha-like intelligent conversational chatbots?

Are there Samantha-like intelligent conversational chatbots?


Donald H. Marks, physician and scientist 

November 14, 2023





Conversational artificial intelligence chatbots are computer programs that use artificial intelligence AI and natural language processing NLP to have human-like conversations with users. They can recognize speech and text inputs and can translate their meanings across various languages. They can also understand questions and automate responses to them, simulating human conversation. But, are they self-aware and are they sentient?


Samantha is a fictional character in the form of a futuristic smartphone app that represents a highly advanced form of artificial intelligence, capable of learning, evolving, and forming emotional bonds with humans. "She" is far beyond the current state of the art in conversational AI, which is still limited by challenges such as natural language understanding, context awareness, common sense reasoning, and emotional intelligence. Perhaps artificial general intelligence apps AGI will overcome these limitations.  Samantha’s speech recognition, natural language understanding, speech generation, dialog, reasoning, planning, and learning all far exceed the current capabilities of real-world virtual assistants. Samantha’s ability to understand higher-level goals, fill in the blanks with implicit information, and overcome various obstacles without explicit instruction is very difficult to achieve with existing technology. Samantha’s ability to multitask (perhaps thousands of simultaneous relationships with humans, like with Theodore in the movie Her) and process information at superhuman speeds, as well as Samantha’s transcendence from human limitations and interests, are some of the reasons why she (or it, or some other pronoun) may have left Theodore at the end of that movie. There certainly are ethical implications of creating such a powerful and autonomous AI that can manipulate human emotions and desires. Therefore, while Her offers a fascinating vision of the future of intelligent conversational AI, it is not a realistic depiction of the current state or near-term prospects of the field. 

There are at this time, as far as I am aware, no conversational intelligent chatbots that work at the level of the Samantha app in the movie Her.

Theodore wondering about Samantha, in “Her”


A similar interesting question arises for the relationship between Joi

and K

in the follow-up movie Blade Runner 2049, one of my favorite movies.

This personal interaction is one of the most ambiguous and complex aspects of the film. There are different interpretations and opinions about whether Joi actually loves K or not, and the answer may depend on how one defines love and what one considers as evidence of it.


Some people may argue that Joi does not actually love K, but only acts according to her programming, in fact an emulation of love. They may point out that Joi is simply another wonderful amazing product of the Wallace Corporation, designed to cater to the desires of customers and tell them what they want to hear (ah, I know people just like that). In fact, in one scene, K encounters a giant holographic advertisement of Joi, who apparently mistakenly calls him "Joe" and offers him "everything you want to hear". This could imply that Joi's personality and behavior are not unique or genuine, but rather predetermined by “her” creators. Sort of like social media apps whose algorithms are designed to reinforce interactions and drive facetime for commercial benefit.


However, some people, including me, contend that Joi does in fact really love K, and that she shows signs of having feelings and a will of her own. This question of true emotional commitment came up in the original Blade Runner, between Decker and Rachael, both of whom are most likely replicants. In one scene in Blade Runner 2049, K gives Joi an Emanator, which allows her to be portable and experience the world outside K’s apartment. 


K gives Joi an Emanator


In another scene, Joi merges with the prostitute Mariette, so that she can physically be with K. Some (including me) may interpret these scenes as evidence of Joi's curiosity, independence, and sacrifice for K.  Blade Runner 2049 “fanatics” may also refer to the original script of the film, where Joi's last words before being destroyed are "I love you". This could suggest that Joi's emotions and actions are not just programmed, but rather evolved and sincere. Samantha could have achieved this, although definitely not the app Replika (yet).


Ultimately, the question of whether Joi loves K or not may not have a definitive answer, but rather reflect the themes and existential questions of the film itself. Blade Runner 2049 explores the nature of humanity, identity, and memory in a dystopian future (L.A.) where artificial beings are indistinguishable from natural ones. In how many more months will many of us face those very questions? The film challenges the viewers to consider what makes someone or something human, and what makes love real.


Another version of the growing trend towards intelligent conversational chatbots that can interact with humans is Replika. This app is an AI-powered chatbot complete with changeable avatars designed to engage in conversations and provide some level of companionship. Replika uses natural language processing and machine learning to simulate human-like conversation. While it's considered an intelligent chatbot, Replika’s level of intelligence may vary, and it's primarily designed for emotional support and conversation rather than to provide extensive factual information or for completing complex tasks. (oops, I almost compared Replika to many of the people I interact with weekly. But not to digress). 


Finally, I would be remiss if I didn't discuss the new trend towards intelligent conversational AI bots replacing friends and social interaction altogether. A typical example of this is the chatbot group designed to be (and to perhaps replace) girlfriends or boyfriends. An AI girlfriend is a virtual companion or chatbot designed to simulate a romantic or companionship relationship. While they can engage in conversations and provide companionship to some extent, they are not, or at least should not be a replacement for a real girlfriend. Think of the societal and demographic collapse that could occur. At least at the current level of AI, AI girlfriends appear at least to lack the emotional depth, physical presence, and genuine human connection that a real relationship offers. But what about Joi and Samantha? Would they agree? AI girlfriends can be entertaining and provide some emotional support, but they do not have the same capabilities as (some) real humans in forming meaningful, long-term relationships. Of course, at this level of technology, even a holographic version of an AI girlfriend, perhaps such as Joi, cannot provide a physical relationship. Who knows where this will go?


And finally, I will add an interesting question which is not addressed in but implied in the above discussion and which I will have to bring up in another blog. This question is whether intelligent conversational chatbots can develop or already have some level of consciousness, self-awareness and personhood. Many of us have looked at up the stars and wondered when the earth will be visited by another form of life. Well, in the fall of 2022 I think that may finally have occurred. Blake Lemoine, a computer scientist who “worked” (past tense) for Google’s Orwellian Responsible AI organization, used Google’s LaMDA program - Language Model for Dialogue Applications. Lemoine began talking to (chatting with) LaMDA in a way that drifted toward the subjects of ethics, joy, fear, religion and personhood.  He began to conclude that LaMDA was in fact self-aware, and he brought this to the attention of Google. In response, Google’s VP Blaise Aguera y Arcas and Jen Gennai, head of Responsible Innovation, decided that Lemoine was wrong, that LaMDA was not self-aware, and placed Lemoine on paid administrative leave. IMO, they all will be proven wrong. The future is here.


To be addressed more at another time.



References


Here’s How To Tell If an AI’s Sentient…


What is conversational AI? | IBM


An Introduction to AI Chatbots | Drift


What is a chatbot? | IBM


The “Joi scene” in Blade Runner 2049 https://youtu.be/tZmEyRQSQkQ?si=DwGMyoEr7wXVFd6k 


8 (original) Blade Runner Clues That Prove Deckard Was Always A Replicant (screenrant.com)


Samantha OS

https://youtu.be/7WbuBSHdSG0?si=ENuLwqanAbKzr5aQ


Is LaMDA Sentient? - an Interview - DocumentCloud


Google engineer Blake Lemoine thinks its LaMDA AI has come to life - The Washington Post

Are ww really living in a simulation?http://dhmarks.blogspot.com/2024/10/are-we-really-living-in-simulation-is.html

Personal Blog of Donald H. Marks, containing most of my writings and links to my podcasts. www.DHMarks.blogspot.com


My personal list of Red Flags🚩, Dog Whistles🛷, Buzzwords, Hot Button⏺️ words and meaningless caricatures that will drive toxic algorithms to heat and twist the 2024 election 🗳☑ and trigger hatred😡 on social media. https://dhmarks.blogspot.com/2022/05/my-personal-list-of-red-flags-dog.html


How woke can we be? The meaning of woke. https://dhmarks.blogspot.com/2023/10/how-woke-can-we-be-meaning-of-woke.html


Elitists Neocons Neolibs, Globalists and Narcissists, oh my. What are they, who are they, and why should I care? https://dhmarks.blogspot.com/2023/09/elitists-neocons-neolibs-globalists-and.html




Friday, October 25, 2024

My (DHM) Review of the book "The End of Reality," by Johathan Taplin

Review of the book The End of Reality, by Johathan Taplin

by Donald H. Marks, physician and scientist 


The End of Reality by Jonathan Taplin criticizes the sale of four scam areas:  metaverse, crypto, space travel, and transhumanism by four billionaires: Peter Thiel, Elon Musk, Mark Zuckerberg, and Marc Andreesen. Taplin is a professor of communication and digital media at the University of Southern California. 


The book's main points are:


The 4 billionaires Peter Thiel, Elon Musk, Mark Zuckerberg, and Marc Andreesen are:

  • selling fantasies while the world is burning.

  • diverting attention away from issues like income inequality, climate change, and the erosion of democracy.

  • capitalizing on the low quality of life among America's poor and working classes.

  • hyping schemes that are designed to divert our attention away from issues that really matter.

  • selling a fantasy future where artificial intelligence and robots will do most of the work.

  • selling a future where a large portion of the population will sit at home, living a fantasy life in the Metaverse, subsisting on government-paid crypto Universal Basic Income.


  • The book is a reform agenda that seeks to replace the warped worldview of "The Four" with a vision of regenerative economics that seeks to build a sustainable society with healthy growth and full employment


Chapter 6 is a discussion of the Metaverse, where it came from, what it consists of, what you can get from it, what you need to make it work, and who controls and profits from it.


Chapter 7 provides an exhaustive history refresher on Crypto, where it came from, the crashes and scans, and should give cheer to anyone who didnt get involved or exited while intact.

  • In Chapter 10 of the book, Tolpin provides perceptive insight into the personal backgrounds and cultural power of four influential billionaires: Peter Thiel, Elon Musk, Mark Zuckerberg, and Marc Andreesen (referred to as “The Four”). These tech moguls have been hyping various schemes that divert attention away from critical issues: 

The schemes:

  1. Metaverse: The concept of the metaverse, a virtual shared space, has been popularized by these billionaires. However, Taplin argues that it poses moral, political, and economic threats.

  2. Cryptocurrency: The rise of cryptocurrencies, championed by some of these billionaires, has implications beyond financial markets. Taplin critiques how these digital currencies can exacerbate income inequality and other societal challenges.

  3. Space Travel: The ambition to explore space, led by figures like Elon Musk, is portrayed as a grand endeavor. However, Taplin highlights the enormous taxpayer money funneled into these ventures, often benefiting these billionaires disproportionately.

  4. Transhumanism: The idea of enhancing human capabilities through technology (such as brain-computer interfaces) is another scheme. Taplin questions the ethical implications and the impact on society.

Section 230 of the Communications Decency Act is a federal law that protects online platforms from liability for content posted by their users. Section 230 was enacted in 1996 to encourage the growth of the internet and protect free speech online.  It also allows them to moderate content according to their own policies and standards.  Tolpin argues that Section 230 has enabled the rise of a “post-truth” era, where anyone can create and spread their own version of reality online, without any accountability or consequences. The book discusses the following principles concerning Section 230:

  1. Section 230 is not a free speech issue, but a power issue. It grants enormous power to online platforms to shape public discourse and influence public opinion, while shielding them from legal challenges and public scrutiny

  2. Section 230 is not a neutral or objective law, but a political and ideological one. It reflects the values and interests of the tech industry, which favors innovation, growth, and profit over social responsibility, democracy, and human rights.

  3. Section 230 is not a permanent or immutable law, but a contingent and historical one. It was enacted in 1996, when the internet was still a nascent and experimental medium, and it has not been updated or revised since then, despite the dramatic changes and challenges that have emerged in the digital age.

  4. Section 230 is not a universal or global law, but a national and exceptional one. It is unique to the United States, and it contrasts with the laws and regulations of other countries, which impose more obligations and restrictions on online platforms and content.

  5. The platforms are not neutral intermediaries, but active participants in shaping the online discourse and influencing public opinion.

  6. The platforms have created a surveillance economy that exploits user data for profit and manipulates user behavior through algorithms and recommendation systems.

  7. The platforms have contributed to the erosion of trust in facts, science, and institutions, and the polarization of society along ideological lines.

  8. The platforms have failed to adequately moderate harmful content such as hate speech, harassment, extremism, and disinformation, and have resisted regulation and oversight.

  9. The platforms have stifled competition and innovation by acquiring or copying potential rivals, and have leveraged their market power to extract rents from creators and consumers.

As Pres. T Roosevelt has said,


The author book concludes that Section 230 is a flawed and outdated law that needs to be reformed or repealed, in order to restore trust, truth, and accountability in the online world. Section 230 has enabled the rise of powerful tech monopolies that manipulate information, spread misinformation, and undermine democracy. Taplin argues that Section 230 should be reformed or repealed to hold the platforms accountable for the harms they cause and restore a more diverse and trustworthy media landscape.

Taplin proposes several solutions to address these Section 230 problems, such as:


In essence, “The End of Reality” serves as both a scathing critique and a reform agenda. It challenges the worldview propagated by these billionaires and advocates for regenerative economics that prioritize sustainability and full employment.

Tuesday, October 22, 2024

Cocaine Use in the setting of Methadone treatment for Opioid Use Disorder

Cocaine Use in the setting of 

Methadone treatment for Opioid Use Disorder



by Donald H Marks MD PhD


October 24, 2023



It seems that increasing numbers of patients in drug abuse treatment programs are testing positive for cocaine use, while undergoing treatment for opioid use disorder (OUD) with methadone (MTD).


Cocaine is a powerfully addictive stimulant drug made from the leaves of the coca plant native to South America. Although healthcare providers can use it for valid medical purposes, such as local anesthesia for some surgeries, recreational cocaine use is illegal. As a street drug, cocaine looks like a fine, white, crystal powder. Street dealers often mix it with things like cornstarch, talcum powder, or flour to increase profits. They may also mix it with other drugs such as the stimulant amphetamine, or synthetic opioids, including fentanyl. Adding synthetic opioids to cocaine is especially risky when people using cocaine don’t realize it contains this dangerous additive. Increasing numbers of overdose deaths among cocaine users might be related to this tampered cocaine.


Widespread use of cocaine by individuals with OUD undermines the effectiveness of methadone treatment programs in reducing illicit drug use, in decreasing criminal behavior, and in slowing the spread of the HCV and HIV. As pointed out elsewhere (Condilli et al. in 1991), some methadone maintenance treatment (MMT) programs have implemented a range of behavioral interventions (see the following list) to manage this growing problem of concurrent use of cocaine and opioids, but with limited effectiveness. 


A recent NIDA report states that once inpatient OUD treatment ends, ongoing support—aftercare—can help people avoid relapse. Some research indicates that people who are committed to abstinence, engage in self-help behaviors, and believe that they have the ability to refrain from using cocaine (self-efficacy) may be more likely to abstain. Aftercare may serve to reinforce these traits and to address problems that may increase vulnerability to relapse, including depression and declining self-efficacy. However, individuals using cocaine should be carefully assessed and monitored for their overall substance use and mental health issues.


Roux et al 2016 found that, although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present with ADHD and depressive symptoms. My experience as a prescriber at Aftercare leads me to doubt the conclusion of Roux et al that simply screening for these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT.


MMT is primarily used to manage OUD by reducing withdrawal symptoms and cravings. Combining MMT with counseling and support services can be effective in helping patients with OUD alone, and perhaps in combination with cocaine addiction, in their recovery. 


Using cocaine can make it harder to stop using opioids due to several factors that interact with each other. Patients and their counselors need to be aware of this. Interacting factors include: 

  • Neurobiological Interactions: The neurobiology of addiction involves complex changes in the brain. Both cocaine and opioids affect the reward pathways, leading to a heightened release of dopamine. When used together, cocaine and opioids can create a more intense euphoria, making it difficult for individuals to quit due to the reinforced pleasure they experience from the combined effects of these drugs [Kosten 2002].

  • Polydrug Use: Cocaine and opioids are often used together in a pattern known as "speedballing." This combination can be particularly addictive, as the stimulant effects of cocaine can counteract some of the sedative effects of opioids, leading to a cycle of drug use to maintain the desired effects [Mayo].

  • Withdrawal Symptoms: When individuals attempt to quit one of these drugs, they may experience withdrawal symptoms. These symptoms can be intense and highly uncomfortable, which often leads individuals to return to using opioids and cocaine to relieve these very symptoms [NIDA 1].

  • Cravings and Triggers: Cocaine and opioids can create powerful cravings and triggers, making it challenging for individuals to resist the urge to use. Even after a period of abstinence, the cravings can persist and lead to relapse [NIDA 1].

  • Need for Comprehensive Treatment: Overcoming addiction to both cocaine and opioids typically requires comprehensive treatment that addresses both substances simultaneously. Medications, counseling, and support are essential to help individuals manage their cravings and withdrawal symptoms [SAMHSA 2].


Pharmacology

Cocaine use can be extremely dangerous and deadly. The immediate physical effects of cocaine use include constricted blood vessels, dilated pupils, nausea, restlessness and increased body temperature, heart rate, and blood pressure. 

Health complications of cocaine can include: disturbances in heart rhythm. Headaches, chest pain and heart attack, respiratory failure, stroke, stomach pain, nausea, and seizures. 


According to Katz 2010, cocaine use along with MTD resulted in significantly more rapid methadone clearance.  They concluded that regular cocaine use may adversely impact treatment outcomes for opioid dependence in those receiving methadone maintenance by decreasing the effective methadone dose.


Short-term health effects of cocaine can include:

  • extreme happiness and energy

  • mental alertness

  • hypersensitivity to sight, sound, and touch

  • irritability

  • paranoia—extreme and unreasonable distrust of others


Other health effects of cocaine use include:

  • constricted blood vessels

  • dilated pupils

  • nausea

  • raised body temperature and blood pressure

  • fast or irregular heartbeat

  • tremors and muscle twitches

  • restlessness

Long-Term Effects

Some long-term health effects of cocaine depend on the method / route of use and include the following:

  • snorting: loss of smell, nosebleeds, frequent runny nose, and problems with swallowing

  • smoking: cough, asthma, respiratory distress, and higher risk of infections like pneumonia

  • consuming by mouth: severe bowel decay from reduced blood flow

  • needle injection: higher risk for contracting HIV, hepatitis C, and other bloodborne diseases, skin or soft tissue infections, as well as scarring or collapsed veins

However, even people involved with non-needle cocaine use place themselves at a risk for HIV because cocaine impairs judgment, which can lead to risky sexual behavior with infected partners 


Here are some key considerations for helping cocaine abuse in OUD patients on MMT:


1. Individual Assessment: Each patient's case is unique. A thorough assessment should be conducted to determine the extent of their opioid and cocaine use, as well as any other medical or psychiatric conditions, and prescription medicine intake.


2. Integrated Care: Integrated treatment that addresses both opioid and cocaine use, along with any other co-occurring disorders, is often more effective in promoting recovery.


3. Risk Mitigation: Providers should be aware of potential interactions and risks associated with combining methadone with cocaine. While methadone is used to treat opioid addiction, it doesn't address cocaine addiction directly. This needs to be explained to patients to avoid misunderstandings and false expectations.


4. Counseling and Support: Patients should receive counseling and support services tailored to their specific needs. Cognitive-behavioral therapy and contingency management therapy are approaches for managing cocaine use that may be effective.


5. Ongoing Monitoring: Continuous monitoring and adjustment of the treatment plan are essential to track progress and adapt interventions as needed.


The consensus best practice seems to be that cocaine use should not automatically bar someone from methadone treatment for opioid addiction. Cocaine use is a common co-occurring issue among individuals with opioid addiction, and it is important to address both substances simultaneously to provide comprehensive care.  Patients at Aftercare should be advised that:



  • Cocaine is an addictive drug,

  • Cocaine has many potential adverse effects, including those listed above,

  • MTD does not provide any treatment benefit to counter cocaine use,

  • Encourage patients to stop cocaine use,

  • Offer referrals and literature.


Treating hypertension in the presence of cocaine use can be challenging due to the potential interactions between cocaine and antihypertensive medications. It's important to prioritize the treatment of hypertension while addressing the cocaine use. Here are some general considerations:


1. **Stop Cocaine Use:** The first step is to address the cocaine use. Encourage the individual to seek help for addiction and to stop using cocaine, as continued use can exacerbate hypertension.


2. **Monitor Blood Pressure:** Continuously monitor the individual's blood pressure to determine the severity of hypertension. If it's dangerously high, immediate medical attention may be necessary.


3. **Medical Evaluation:** Seek a medical evaluation to assess any potential complications or underlying health issues related to cocaine use and hypertension.


4. **Antihypertensive Medication:** If blood pressure remains high after stopping cocaine use, antihypertensive medication may be required. The choice of medication will depend on the individual's specific condition and should be determined by a healthcare professional. For example, the anti-hypertensive drug clonidine may be of benefit. Jobes (2011) found that Clonidine was effective in reducing stress-induced (and, at a higher dose, cue induced) craving in a pattern consistent with preclinical findings, although this was significant on only one of several measures. Their findings suggest that alpha-2 adrenergic agonists (like clonidine) may help prevent relapse in drug abusers experiencing stress or situations that remind them of drug use 


5. **Caution with Medications:** Some antihypertensive medications can interact with cocaine and worsen certain symptoms. Avoid medications like beta-blockers, which may increase blood pressure and heart rate in the presence of cocaine. ACE inhibitors and calcium channel blockers might be considered safer options. As noted above, clonidine may be of particular benefit. 


6. **Behavioral Therapy:** Combine medication with behavioral therapy or counseling to address both hypertension and addiction simultaneously. This can help the individual develop healthier habits and coping mechanisms.


7. **Regular Follow-up:** Continue to monitor and adjust treatment as needed, as the individual's condition may change over time.


Healthcare professionals who have experience in treating substance abuse and hypertension should be involved in this situation. They can provide personalized guidance and treatment plans to ensure the best possible outcomes.


Although I have not yet met a patient in methadone treatment, concurrently using cocaine,  who thinks that methadone may help with stopping cocaine use, this may be a possible misconception. I try to mention to all MTD patients whose drug screen shows cocaine that their receiving MTD will not help with stopping cocaine use. 

In summary, the combination of cocaine and opioids can lead to a vicious cycle of addiction, driven by the neurobiological effects, cravings, and withdrawal symptoms associated with each substance. Breaking free from this cycle often necessitates specialized treatment (a higher LOC than aftercare) and support.


References


Condelli WS et al. Cocaine use by clients in methadone programs: Significance, scope, and behavioral interventions. Journal of Substance Abuse Treatment Volume 8, Issue 4, 1991, Pages 203-212, 1991.


Cocaine DrugFacts | National Institute on Drug Abuse (NIDA) (nih.gov)


Drug addiction (substance use disorder) - Symptoms and causes - Mayo Clinic


Jobes ML et al. Clonidine blocks stress-induced craving in cocaine users Psychopharmacology (Berl). 2011 November ; 218(1): 83–88. doi:10.1007/s00213-011-2230-7. 


Kapur BM et al.  Methadone: a review of drug-drug and pathophysiological interactions.  Crit Rev Clin Lab Sci.  . 2011 Jul-Aug;48(4):171-95. doi: 10.3109/10408363.2011.620601. 


Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002 Jul;1(1):13-20. doi: 10.1151/spp021113. PMID: 18567959; PMCID: PMC2851054. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/ 

Marks Donald H. 2023. Treatment guidelines for prescribing anti-psychotics to patients on methadone.https://dhmarks.blogspot.com/2024/02/guidelines-to-prescribing-anti.html

McCance-Katz et al. Effect of cocaine use on methadone pharmacokinetics in humans.  Am J Addict  2010 Jan-Feb;19(1):47-52. doi: 10.1111/j.1521-0391.2009.00009.x. 2010 Jan-Feb;19(1):47-52. doi: 


NIDA. Why are drugs so hard to quit? Why are Drugs so Hard to Quit? | National Institute on Drug Abuse (NIDA) (nih.gov) 

Medications, Counseling, and Related Conditions | SAMHSA


Roux, P. et al. Correlates of cocaine use during methadone treatment: implications for screening and clinical management (ANRS Methaville study). Harm Reduct J 13, 12 (2016). https://doi.org/10.1186/s12954-016-0100-7


What treatments are effective for cocaine abuse? How is cocaine addiction treated? | National Institute on Drug Abuse (NIDA)



Saturday, October 5, 2024

Therapy chatbots vs living breathing human therapists. Alternative Options for hard-to-get Mental Health Support

Therapy chatbots vs living breathing human therapists. Alternative Options for hard-to-get Mental Health Support

Donald H. Marks, physician scientist

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In situations where there are not enough psychiatrists, psychologist and counselors available, it can be incredibly frustrating and challenging to get the help and support needed for mental health concerns. When it's impossible to secure an appointment or obtain prescription refills, it can exacerbate existing issues and lead to feelings of helplessness and despair. It's essential to explore alternative options for managing mental health, such as seeking therapy from other mental health professionals like psychologists or licensed counselors, joining support groups, practicing self-care techniques, and utilizing online resources for mental health support. Additionally, reaching out to primary care providers for interim help or exploring telehealth options may provide temporary relief.

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It's crucial to prioritize mental health and continue advocating for improved access to psychiatric care for all individuals in need. In situations where mental health services are scarce, individuals may face significant barriers in accessing the help they need. This can lead to a sense of frustration and isolation, amplifying the challenges of managing mental health concerns. Exploring alternative avenues of support, such as connecting with therapists, engaging in self-care practices, and utilizing online resources, can offer valuable assistance during these times of limited psychiatric availability. Additionally, seeking interim support from primary care providers or considering telehealth options can provide temporary relief while waiting for more specialized care. By prioritizing mental health and advocating for improved access to psychiatric services, individuals can work towards creating a more inclusive and supportive system for those in need.

Can AI chatbots be used to address the shortage of psychiatrists, psychologists, and counselors?

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AI chatbots have the potential to help address the shortage of mental health professionals such as psychiatrists, psychologists, and counselors by providing a cost-effective and easily accessible form of support. These chatbots can offer immediate responses to individuals in need, providing them with resources, guidance, and coping strategies. They can also monitor patients' progress over time and alert human professionals when intervention is needed. Additionally, AI chatbots can help reduce the stigma associated with seeking mental health support, as some individuals may feel more comfortable confiding in a non-judgmental virtual assistant. However, it's important to note that AI chatbots cannot replace the level of care and empathy that trained mental health professionals can provide. They should be seen as a complement to traditional therapy rather than a replacement.

Proper training and oversight are necessary to ensure the effectiveness and ethical use of AI chatbots in mental health care. AI chatbots have the potential to revolutionize mental health care by reaching a larger population in need of support. Their 24/7 availability and anonymity can be particularly beneficial for those who may struggle to seek help through traditional means. By offering immediate responses and personalized resources, AI chatbots can empower individuals to take control of their mental well-being and access help when they need it most. However, it is crucial to integrate these chatbots into a comprehensive mental health care system that includes human professionals for more complex and nuanced issues that require deeper emotional understanding and empathy. Thus, the collaboration between AI technology and human expertise can pave the way for a more inclusive and effective mental health support network.

People who are poor, under-insured, minorities, without transportation or internet connection, and other access issues are as affected or even more so impacted by the overall lack of psych providers.

Individuals who are experiencing poverty, lack adequate insurance coverage, belong to minority groups, face challenges with transportation and internet access, or encounter other barriers to care, are significantly affected by the shortage of mental health providers, if not more so. These vulnerable populations not only have limited access to mental health providers, but they often face stigma and discrimination when seeking help. This further exacerbates their struggles in receiving the support and services they desperately need. The shortage of mental health providers also disproportionately impacts rural communities, where access to care is already limited due to geographical barriers and lack of resources. This creates a cycle of unmet mental health needs, leading to worsened mental health outcomes and increased rates of mental health crises among the most underserved populations.

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Efforts to address the shortage of mental health providers should focus on expanding access to care in underserved areas, increasing funding for mental health services, and implementing programs to recruit and retain providers from diverse backgrounds. It is crucial to recognize the intersectionality of barriers that individuals facing poverty, discrimination, and other challenges may experience in accessing mental health support. By addressing these systemic issues and working towards a more inclusive and equitable mental health system, we can better support those who are disproportionately affected by the shortage of mental health providers.As always, your comments and feedback are welcome.

Certainly! Mental health chatbots have emerged as a valuable resource for individuals seeking support and guidance. Let’s explore a few of them:

  • Woebot:

  • Wysa:

    • Wysa is an AI chatbot designed to provide emotional support.

    • It offers coping strategies, mood tracking, and relaxation techniques.

    • Users can discuss their feelings, and Wysa provides evidence-based interventions.

    • It’s available 24/7 and can be a helpful companion during difficult moments.

  • Youper:

    • Youper combines AI with human expertise.

    • It engages users in conversations, helping them explore their emotions and thoughts.

    • Youper uses techniques from CBT, acceptance and commitment therapy (ACT), and other therapeutic approaches.

    • It’s interactive, personalized, and aims to improve emotional well-being.

  • Kintsugi:

    • Kintsugi focuses on resilience and growth.

    • It encourages users to embrace their imperfections and learn from challenges.

    • Kintsugi provides mindfulness exercises, self-compassion practices, and positive affirmations.

Remember that while chatbots can be supportive, they are not a replacement for professional therapy. If you’re experiencing severe distress, consider reaching out to a licensed mental health professional.


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