Prenatal and Early Childhood Brain Development in Mom’s Using Drugs

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From the blog of Dr. Nora Volkow
Director, National Institute on Drug Abuse
March 11, 2019

The National Institutes of Health HEAL (Helping to End Addiction Long-Term) Initiative, which was launched last April, will support a wide range of studies aimed at improving prevention and treatment strategies for opioid use disorder and pain, including efforts to enhance treatments for infants born with Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome. Specifically, HEAL funds will help support an ambitious longitudinal study—The HEALthy Brain and Child Development (HBCD) Study—co-funded by NIDA and several other NIH institutes and offices, to better understand the impact of early exposure to opioids, other substances, and social stressors on brain development in children.

The HBCD study will follow a large population of children from the prenatal period to age 10 and utilize some of the same assessment methods and imaging technologies used in the 10-year Adolescent Brain Cognitive Behavior (ABCD) study. HBCD is expected to enroll women during their second trimester of pregnancy or after birth of their baby. The study will gather data on potentially important factors about their environment, including drug and alcohol use, and follow them and their children over the subsequent decade.

The potential fruits of a longitudinal cohort study of this magnitude will include much new knowledge about the effects of opioids and other substance exposures during fetal development.  It will also yield a better understanding of the effects of genes that are driving brain development. The study additionally will look at many other exposures, including social interactions, environmental toxins, nutrition, and physical activity. Medicine has thus far lacked detailed baseline standards of normative brain development in childhood, and HBCD will help produce such standards. The information gained from the study will create an invaluable reference for pediatricians, pediatric neurologists, and psychiatrists.

The ABCD study recently accomplished its baseline recruitment of close to 12,000 nine- and ten-year-olds, and already the data gathered from the initial neuro-imaging is yielding interesting findings, such as associations between neuro-development and screen time. Likewise, the HBCD study will gather a rich data set that will be freely available to the wider research community to answer a wide range of research questions. For example, researchers can use the data to investigate how the human brain develops and characteristics that might be associated with the early manifestations of brain diseases, as well as those [with an] underlying resilience to adverse environments. As the data are being collected, they will be released so that discoveries can start well before the completion of these 10-year prospective studies. 

As with ABCD, the HBCD study will have multiple research sites across the country to ensure the study population is representative of the larger population, including all ethnic groups and demographics and even including women who use opioids. Exposure to many substances in the womb or through breast milk may have significant developmental consequences, and a study of this magnitude will greatly clarify the effects of prenatal and early opioid exposure on children. It will also greatly increase our understanding of the developmental consequences of environmental stressors like neglect, abuse, economic uncertainty, and the influence of parental opioid and other drug use during the post-natal period.

As you might imagine, there are many potential challenges to conducting regular brain imaging on young children—being able to remain still in MRI scanners is just one of them. There are also special legal and ethical challenges involved in recruiting and studying opioid-using mothers. In September and October of last year, NIDA in partnership with other NIH Institutes and Centers, hosted two expert panel meetings to discuss, respectively, the methodological challenges of studying neuro-development in children and recruitment and retention of high-risk populations in the study, including bio-ethical questions.

Based on input received during these expert panel meeting, it was determined that before soliciting grant proposals for the HBCD study per se, an initial planning period would be necessary. Thus, NIDA along with the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Child Health and Human Development (NICHD), the National Institute of Environmental Health Sciences (NIEHS), the National Institute of Mental Health (NIMH), the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute on Minority Health and Health Disparities (NIMHD), the Office of Research on Women’s Health (ORWH), and the Office of Behavioral and Social Sciences Research (OBSSR) issued two funding opportunity announcements, one for individual research sites and one for linked, collaborative applications.

The planning grants will be awarded for a period of 18 months, during which time we expect to determine many critical facets of the experimental design. These include how to conduct neuro-imaging in prenatal and early postnatal stages, how to address the legal challenges associated with recruiting opioid- (and other drug-) using participants (which vary by state), how to form partnerships with state agencies and substance use treatment programs, how to retain the mothers in the study, and other practical and ethical issues. Applications are due in the last week of March, 2019. Researchers interested in applying for one of these grants can find more information on RFA-DA-19-029 and RFA-DA-19-036 from grants.nih.gov.

It is a very exciting time for all the sciences that study child health, human development, and the roots of mental health and psychiatric and neurological illnesses. We now have the tools to characterize human brain development in the transition from infancy into adulthood, a time when many of the medical conditions that afflict us later in life originate. The data from the HBCD study will ultimately lead to scientific solutions to addiction, pointing the way to new prevention and treatment interventions and thereby reducing the impact of opioid and other substance use disorders on American families.

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Scientific Findings and Achievements in Drug Abuse Research for 2018

From the Blog of Dr. Nora Volkow, Director
National Institute on Drug Abuse
January 7, 2019

Dr. Volkow noted, “As we enter 2019, it is a good time to take stock of what NIDA accomplished over the past year. As always when I look back at the research being done by NIDA grantees and partners, I am amazed at the wealth of knowledge being created from our investments. Here I want to highlight just a few of the many outstanding developments in basic science, new therapeutics, and epidemiology and prevention research from the year that just ended.”

Basic Science Advances

Recent years have seen major advances in the understanding of receptor functioning. In March 2018, a team of researchers at NIDA’s Intramural Research Program (IRP) reported in Nature Communications on an advance in understanding G protein-coupled receptors (GCPRs), a large family of receptors that play an important role in the brain’s response to drugs. These receptors often assemble into larger complexes, but it has been unknown whether those complexes are merely the product of random collision between signaling molecules as they move across the membrane or whether they pre-form into complexes that serve specific functions.

The IRP team found that two common GCPRs in the reward pathway, adenosine A2A and dopamine D2 receptors (along with their G proteins and target enzyme), assemble into preformed macromolecular complexes that act as computation devices processing incoming information and enabling the cell to change its function based on that information. This knowledge could facilitate the development of more precise medication targets.

In June 2018, a team of NIDA-funded researchers at the University of California–San Francisco, along with colleagues in Belgium and Canada, reported in Neuron magazine that they had developed a genetically-encoded biosensor that can detect activation of opioid receptors and map the differences in activation within living cells produced by different opioids. The fact that opioids bind to receptors on structures within the cell—and not just on the cell membrane—was itself a novel finding, but the team also discovered striking differences in how endogenous versus synthetic opioids interact with these structures.

While endogenous peptides activated receptors on membrane-bound compartments within the cell called endosomes, synthetic opioid drugs activated receptor sites on a separate structure called the Golgi apparatus (which acts as a hub for routing proteins to various destinations in the cell). These very different patterns of activation within the cell may lead to greater understanding of why non-peptide opioid drugs produce tolerance as well as the behavioral distortions seen with opioid misuse and addiction whereas the body’s endogenous opioid peptides do not.

The same month, a team led by neuroscientists at UCLA studying narcolepsy reported research in Science Translational Medicine based on their discovery that postmortem brains from individuals who had been addicted to heroin show greatly increased numbers of neurons producing the neuropeptide hypocretin. Hypocretin helps regulate wakefulness and appetite, and a diminished number of cells in the brain producing it is associated with narcolepsy. The researchers went on to conduct a study administering morphine to mice, which as observed in the postmortem study produced increased numbers of hypocretin neurons. The results suggest that increases in these cells and in brain hypocretin could underlie the complaints of sleep problems in patients with an opioid use disorder (OUD). Since insomnia is a factor that contributes to drug taking in OUD and other addictions, strategies to counteract hypocretin signaling might have therapeutic benefits.

Prevention and Treatment

Last year, NIDA-funded research resulted in new therapeutics and apps for opioid use disorder. In May, the FDA approved lofexidine, the first medication approved to treat physical symptoms of opioid withdrawal. In December, the FDA cleared the first mobile health app intended to help retain patients with OUD in treatment, called reSET-O. It uses interactive lessons to deliver a community reinforcement approach therapy and enables users to report cravings and triggers to their health care provider between office visits, along with whether or not they have used Suboxone. NIDA funded the clinical trial that led to this app’s approval. A version called reSET was approved in 2017 to help with behavioral treatment of several non-opioid substance use disorders.

NIDA-funded research in epidemiology and prevention also added greatly to the knowledge of new drug trends in 2018. Last month’s striking findings on monitoringthefuture.org alerted us to escalating use of vaping devices among adolescents. Although most adolescents in 2017 claimed they used vaping devices only to vape flavors, this year most reported they used them to vape nicotine. Alarmingly, there was also an increase in vaping of cannabis.

Several other studies published in 2018 increased our understanding of factors that may lead youth to experiment with vaping. For example, a longitudinal cohort study by researchers at Yale and reported in Addictive Behavior found that exposure to ads for e-cigarettes on social media sites like Facebook significantly increased the likelihood of subsequent e-cigarette use among middle and high school students in Connecticut. In another study published in Preventive Medicine, the researchers also found that higher socioeconomic status was associated with greater exposure to e-cigarette advertising (which in turn was associated with increased likelihood of use)—important data that can help with targeting prevention efforts. Other work by UCSF researchers and published in Pediatrics found that e-cigarette use in adolescents was positively associated with being a smoker of conventional cigarettes, lending further support to the view that these devices are not diverting youth from smoking cigarettes but may be having the opposite effect in some users.

Looking To The Future

This year the Adolescent Brain Cognitive Development (ABCD) Study successfully completed recruitment of 11,874 participants, ages 9-10, who will be followed for 10 years, through young adulthood. The study, which is being conducted at 21 research sites around the country, is using neuroimaging to assess each individual’s brain development while also tracking cognitive, behavioral, social, and environmental factors (including exposure to social media) that may affect brain development and other health outcomes. The first release of anonymized data was made available so that both ABCD and non-ABCD researchers can take advantage of this rich source of information to help answer novel questions and pursue their own research interests.  Last year alone, the data resulted in more than 20 publications.

 

New Funding Opportunities in Response to the Opioid Crisis

From the blog of Dr. Nora Volkow
Executive Director, National Institute on Drug Abuse
December 10, 2018

Today, NIDA is releasing several new funding opportunity announcements related to the NIH HEAL (Helping to End Addiction Long-term) Initiative. Researchers now can submit proposals for major projects funded through NIH HEAL in the areas of preventing opioid use disorder (OUD), improving OUD care in justice settings, determining the appropriate duration of treatment with medications to treat OUD, and better understanding how to manage mild or moderate OUD.

Prevention

Older adolescents and young adults (ages 16-30) are the group at highest risk for opioid initiation, misuse, OUD, and death from overdose, so targeting this age group for prevention interventions could have a sizeable impact on reducing the toll of opioid misuse and addiction. The research project called Preventing At-Risk Adolescents from Developing Opioid Use Disorder as they Transition into Adulthood will develop and test strategies to prevent initiation of opioid misuse and development of OUD in different healthcare settings (including primary care, emergency departments, urgent care, HIV/STI clinics, and school or college health clinics) as well as workplaces and justice settings. NIDA will fund a suite of integrated studies developing, testing, and validating screening and prevention tools in areas most affected by the opioid crisis or with indicators of an emerging crisis. For more information on funding opportunities related to this project, see the funding opportunity announcements for the Coordinating Center and research studies.

Criminal Justice System

Substantial research over the past several years has highlighted the consequences of untreated OUD in justice-involved populations—for instance, the high rates of overdose death among people recently released from prison—as well as showing the benefits of treating opioid-addicted prisoners using medication. It remains unknown what specific strategies are most effective at addressing opioid addiction in this population and reducing adverse outcomes. As part of the HEAL Initiative, NIDA will fund the creation of a network of researchers who can rapidly conduct studies aimed at exploring the effectiveness and adoption of medications, interventions, and technologies in justice settings.

The Justice Community Opioid Innovation Network will implement a survey of addiction treatment delivery services in local and state justice systems around the country and will develop new research methods to ensure that treatment interventions have the maximum impact.  For more information, please see the funding opportunity announcements for the Coordination and Translation Center, Methodology and Advanced Analytics Resource Center, and the research centers. 

Other Initiatives

In addition to the above referenced projects, NIDA will be partnering with other NIH institutes and centers on several opioid-related research projects. HEAL funds will also be used to answer some important research questions to address the opioid crisis. For example, NIDA’s Clinical Trials Network (CTN) will be utilized to determine the optimal length of medication treatment for opioid addiction and to identify treatment strategies to manage patients who present to primary or integrated care settings with low-level opioid misuse or OUD. Finally, HEAL funds are being considered to support a longitudinal study to understand the consequences of pre- and postnatal opioid and other substance exposure on the developing brain and behavior.

A silver lining of the dark cloud of the opioid crisis is that it has galvanized communities, healthcare systems, and government agencies to take significant steps toward ending opioid misuse and addiction in a compassionate, science-based way. The funds granted by Congress as part of the NIH HEAL. Initiative will accelerate scientific solutions to the crisis and generate new knowledge that will prevent future drug crises, as well as inform many other areas of medicine and public health. Information related to these projects is available on the NIH site.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org

New NIDA Research Reveals the Power of Social Reinforcement

From the Blog of Dr. Nora Volkow, Executive Director
NATIONAL INSTITUTE ON DRUG ABUSE
October 15, 2018

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When it is available and can be delivered appropriately and effectively, medication is a crucial part of treating addiction—but by itself, a pill or an injection may not be sufficient. Social support has long been known to be an important factor in a variety of recovery programs and treatment approaches. Now, for the first time, an animal study conducted by members of NIDA’s Intramural Research Program and a scientist in Italy illustrates just how potent social reinforcement can be, even in animals that are already “addicted” to drugs as reinforcing as heroin and methamphetamine. 

The new study led by NIDA’s Dr. Marco Venniro required rats to choose between social interaction with another rat or access to heroin or methamphetamine. The animals consistently chose social interaction when given the choice, and this was true when they were first given access to the drug or when they were experienced drug takers.

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To assess the level of addiction in their rats, the experimenters used a sophisticated set of behavioral paradigms that attempt to model the kinds of choices made by humans who are addicted to drugs. They include assessing how hard a rat will work for access to the drug and whether responding persists despite punishment (i.e., brief electric shocks). Individual differences emerge in these paradigms; but regardless, the social reinforcer always won out over the drug. Even when the rats were housed with other rats and thus lived in a social environment, they consistently chose further social contact over the option to self-administer the drug.

The experimenters manipulated the social reward by introducing delay and an aversive stimulus in some conditions. Addicted rats were only likely to choose the drug over social interaction (i.e., relapse) when access to other rats was sufficiently delayed or punished. It is a striking set of findings. Even though previous research had established that isolation led animals to self-administer drugs and that social housing was protective against drug use, no studies had given animals the ability to choose one or the other—conditions had always been controlled by the experimenter. (Some studies had used palatable food as a choice alternative, but not social contact.)

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Another surprise concerned the phenomenon known as incubation of drug craving. Rats that regularly self-administer a drug display an increase in drug seeking following a period of abstinence (usually forced), similar to what many human drugs users experience following withdrawal—and often what prompts relapse. However, rats that became voluntarily abstinent by repeatedly choosing social interaction did not demonstrate this incubation effect.

The authors of this study point out that our social needs as humans are far more complex than the social needs of rats. In addition to social interactions and companionship (more immediate forms of social gratification), we also need more distal social expectations like the promise of meaningful participation in our community or society. But the findings of the study provide valuable insight into how recovery programs centered on mutual aid, as well as treatment approaches that emphasize social reinforcement, might help individuals overcome drug problems.

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For example, one of the best-supported behavioral treatments is the community reinforcement approach (CRA), which centers on building a new social support system and increasing the value of other, non-drug rewards in the individual’s life. Other approaches like cognitive behavior therapy also seek to increase the salience of less immediate social rewards when patients are faced with the immediate temptations of drug use. Even recovery groups for people with drug or alcohol addictions based on 12-step or similar models depend in large part on building a new social structure in which the person can function. The new study’s authors argue that their findings lend weight to the argument that these kinds of behavioral approaches that incorporate complex social influences should be more widely studied and utilized.

Using Science to Address the Opioid Crisis in America

FROM THE BLOG OF NORA VOLKOW, MD
September 19, 2018

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The public health emergency regarding opioid misuse, addiction, and overdose affects millions of Americans and requires innovative scientific solutions. Today, during National Prescription Opioid and Heroin Awareness Week, we are sharing news of an important step towards these solutions through the HEALing Communities Study—an integrated approach to test an array of interventions for opioid misuse and addiction in communities hard hit by the opioid crisis.

Six months ago, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-Term (HEAL) Initiative, a bold multi-agency effort to catalyze scientific discoveries to stem the opioid crisis. HEAL will support research across NIH, using $500,000 of fiscal year 2018 funds, to improve prevention and treatment of opioid use disorder and enhance pain management.

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Through HEAL, NIH will harness the power of science to bring new hope for people, families, and communities affected by this devastating crisis. The current menu of evidence-based prevention, treatment, and recovery interventions has not been fully implemented nationwide. An unacceptably low fraction – about one fifth — of people with opioid use disorder receive any treatment at all. Of those who do enter treatment, only about a third receive any medications—which are universally acknowledged to be the standard of care—as part of their treatment. However, even when medications are used as a component of treatment, the duration is typically shorter than clinically indicated, contributing to unacceptably high relapse rates within the first 6 months. 

To take on this challenge, as part of the broader HEAL initiative, NIH has partnered with the Substance Abuse and Mental Health Services Administration (SAMHSA) to launch the HEALing Communities Study. This study will evaluate the impact of implementing an integrated set of evidence based practices for prevention and treatment of opioid use disorders in select communities with high rates of opioid overdose mortality, with a focus on significantly reducing opioid overdose fatalities by 40%. Targeted areas for intervention include decreasing the incidence of opioid use disorder, increasing the number of individuals receiving medications for opioid use disorder treatment, increasing treatment retention beyond 6 months, receiving recovery support services, and expanding the distribution of naloxone.

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Toward this goal, today NIDA issued funding opportunities for cooperative agreements for components of the HEALing Communities Study: a data coordinating center and up to three research sites to measure the impact of integrating evidence-based prevention, treatment, and recovery interventions for opioid misuse, opioid use disorder, opioid-related overdose events and fatalities across multiple settings, including primary care, behavioral health, and justice. We also encourage evidence-based interventions for prevention and treatment that involve community resources such as police departments, faith-based organizations, and schools, with a focus on rural communities and strong partnerships with state and local governments.

The evidence we generate though the HEALing Communities Study, the most ambitious implementation study in the addiction field to date, will help communities nationwide address the opioid crisis at the local level.  By testing interventions where they are needed the most, in close partnership with SAMHSA and other Federal partners, we will show how researchers, providers, and communities can come together and finally bring an end to this devastating public health crisis.

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

“I’ll Quit Tomorrow!”

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It is mind boggling how alcoholism impacts people from all cultures, races, socioeconomic class, gender, religion, profession, and academic background. Interestingly, all alcoholics are ultimately alike. The disease itself swallows up differences and creates a universal alcoholic profile. The personality changes that go with alcoholism are predictable and virtually inevitable.  Alcohol can precipitate the onset of a disease with a predictable, inexorable course. It can ultimately destroy the physical, emotional, spiritual, and mental life of the sufferer. Alcoholism is typified by a progressive mental “mismanagement” and an increasing emotional distress that can reach suicidal proportions.

Hidden costs of alcoholism are not small. Alcohol-related expenses cost federal, state and local governments $223.5 billion. Of that amount, tax payers are footing the bill for $92.4 billion.

Drinking Was Fun, Once Upon a Time

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Early drinking is a mood-swinger, typically in a positive direction. It gives the drinker a warm, good feeling, that may lead to giddiness. When the effects wear off, the drinker feels normal. It does not take long to learn how to set the amount and select the mood. As the typical social drinker gets deeper into the booze, getting drunk begins to have a very different effect. Heavy drinking creates a sort of undertow that drags the drinker back beyond normal and into pain. This might be the point where euphoria is reached at a big cost—if it’s achieved at all. Now the booze is consumed in order to feel no pain. In other words, to get back to some degree of normal. This is the beginning of harmful alcohol dependence.

In addition to dependency, this phase also involves a rising emotional cost. We we see a significant and progressive deterioration of the personality of the alcoholic, and (eventually) a visible physical deterioration. Ultimately, the alcoholic’s whole emotional environment is torn to pieces and destroyed. Of course, most active alcoholics are in complete denial of the impending bottom.

There is now a progressive emotional cost for every single drink. The carefree days are gone, but the alcoholic is dimly aware of this fact at best. The rising cost is willingly paid. This is proof that dependency has become truly harmful. Of course, the drinker fails to comprehend the increasingly clear signs of destruction by alcohol. Frankly, at this point the alcoholic is learning to depend more and more on rationalization. Intellect begins to blindly defend against reason—indeed, against intervention. Eventually, the alcoholic will be completely out of touch with emotions. Internal dialog will become the soundtrack of an increasingly impenetrable defense system.

Denial is Not Just a River in Egypt

The tragedy is that rationalization actually works! This form of defense—which I employed constantly during my active addiction—continues to operate as the disease progresses. The alcoholic’s behavior will become increasingly bizarre, and the innate and unconscious ability to rationalize will be practiced to the point of perfection. The drinker finds it increasingly difficult to accept blame. Time passes, and the alcoholic condition worsens. Over a period of months and years the alcoholic’s self-image continues to wane. Ego strength ebbs. Feelings of self-worth sink low, and excessive drinking continues, producing painful and bizarre behavior. Eventually, emotional distress becomes a chronic condition. The drinker feels distress unconsciously even when not drinking.

Unfortunately, rationalization works. The tragedy is that this form of defense will continue to operate as the illness progresses.

Now, “mood swings” or personality changes are evidenced while drinking. The kind person becomes angry or hostile; the happy person becomes sad or morose; the gentle person becomes violent. Alcohol causes one’s guard to drop, and chronic unconscious negative feelings are laid bare. The drinker becomes truly self-destructive. All this drinking and emotional distress may lead to a vague but poignant feeling, I just might have a drinking problem. There is a general malaise so strong felt that desperate measures to escape are actually attempted. Geographical cure, a new job, divorce.

The Pathology of Alcohol Dependence

The final stages of alcoholism are close at hand. Continued excessive drinking and accompanying behavior bring on chronic suicidal feelings. I remember thinking many times, I should just go jump in the Susquehanna River! If the course of the disease is not interrupted, the end of all this is suicide—either slowly by continued drinking or in a direct manner. This is because as emotional distress mounts, and deterioration of the personality accelerates, these negative feelings are not clearly discernible. Quite the opposite is true: They are more effectively hidden.

A pathological use of alcohol can be measured by how the individual answers the following questions:

  • Have you ever drank early or first thing in the morning?
  • Have you ever drank alone?
  • Have you ever drank an entire fifth of alcohol in a day?
  • Have you ever felt remorse after drinking?
  • Is there a growing anticipation of the welcome effects of alcohol?
  • Has the anticipation moved into the realm of preoccupation?
  • Do you hide your booze in unusual places?
  • Are you unable to be honest about how much alcohol you consume?
  • Do you suffer blackouts or experience an inability to remember chunks of time?
  • Are you having difficulty with personal relationships, work, or the law due to drinking?

Counselors gather a history of the behavior patterns by questioning those who spend meaningful or extended time around the alcoholic. Here, the basic goal is to discover whether there has been a changing lifestyle secondary to the use of alcohol, which would indicate a growing dependence.

Drug and alcohol counselors often explore this changing lifestyle by asking probing questions. Has there been a growing tolerance to alcohol? Does it take more booze for the drinker to get the desired effect? Does the alcoholic start drinking in the kitchen before bringing drinks for guests into the living room? (I often drank secretly before drinking in front of guests or family.) To what lengths is the alcoholic willing to go to get the amount of alcohol needed? The degree of ingenuity used to get more booze becomes the scale for determining how far dependency has progressed. All instances of harmful dependency that show up in alcoholic behavior patterns indicate a maladaptation of the lifestyle to (a) growing anticipation of the welcome effects of drinking, (b) an increasingly rigid expected time of use, and (c) a progressive cunning in obtaining larger amounts of alcohol.

Rational defenses and projection take hold. Why is it that the alcoholic cannot see what is happening? Simple. They have lost the ability to see it at all. The reason alcoholics are unable to perceive what is happening to them is actually understandable. As the condition develops, self-image continues to deteriorate. Ego strength grows increasingly weaker. For many reasons, they are progressively unable to keep track of their own behavior and begin to lose contact with their emotions. Their defense systems continue to grow, so that they can survive in the face of their mounting problems. The greater the pain, the higher and more rigid the defenses become—and this whole process is unconscious. Alcoholics do not comprehend what is happening. Quite literally, they are victims of their own stinkin’ thinkin’.

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As the emotional turmoil grows in chemically-dependent people, rational defense activity turns into real mental mismanagement. The drinker erects a wall around him or her. The end result is that the alcoholic is cut off from increasingly negative feelings about themselves. They are unaware of the presence of such destructive emotions.

Not only is the drinker unaware of the powerful, highly developed defense systems, they are also unaware of the intense feelings of self-hate buried inside them. Moreover, the problem is being compounded by the fact that these defenses have now created a mass of free-floating anxiety, guilt, shame and remorse, which becomes chronic. In other words, the alcoholic no longer drinks from a “normal” point, experiencing an upswing in mood to feeling great or euphoric; rather, they must start from where they feel depressed or pained and drink to feel normal again.

Drink Takes a Man

Alcoholics drink because they drink. A Chinese proverb says, “First the man takes a drink, then the drink takes a drink, then the drink takes the man.” The drinking pattern becomes thoroughly unpredictable or compulsive. The alcoholic quits, then resumes, and does not know why he or she is drinking again. And whenever they do start again, the resumption is at the level of chronic emotional deterioration. Conditions worsen with each new episode, trapping the drinker in a deadly downward spiral.

Depression and low self-esteem become so great, the alcoholic begins to employ projection—a defense mechanism in which unwanted feelings are displaced onto another person, where they then appear as a threat from the external world rather than from within. The alcoholic does not know this is happening. The more hateful alcoholics see themselves, the more they will come to find themselves surrounded by hateful people. Depending on the personality of the drinker, such projection can present itself in ways ranging from gentle complaining to outright aggression. It is obvious the easier targets are those people typically spending time with the alcoholic, including the most meaningful. Although alcoholics tend to hate themselves, their projection works so well that they actually believe they are attacking hateful people.

People who live and exist around the active alcoholic have predictable experiences that are also psychologically damaging. As they meet failure after failure, their feelings of fear, shame, frustration, inadequacy, guilt, resentment, self-pity and anger mount. So also do their defense mechanisms. They too use rationalization as a defense against these feelings. The chemically-dependent—and those around them—all have impaired judgment; they differ only in the degree of impairment.

People who are chemically-dependent on alcohol have such a highly-developed defense system that they become seriously self-deluded. The rigid defenses that have risen spontaneously around their negative feelings about themselves, and therefore around their behaviors that caused these feelings, would be quite enough, were they the only deluding factors, to draw these people progressively and thoroughly out of touch with reality. Not only do these defense mechanisms become more rigid, but such individuals develop a growing rigidity in their very lifestyle. They are less able to adapt to unexpected change. They eventually reach a point where even schedules are burdensome. This is primarily because, paradoxically, they are less likely to plan ahead. Or, when they do plan something, they tend to feel trapped as the moment closes in.

To Make Matters Worse

Chemically-dependent people have two factors progressively working together to draw them out of touch with reality: Their defense mechanisms and distortions of memory. Consider euphoric recall, which is the tendency for an alcoholic to remember their drinking escapades euphorically or happily—in only the best light—with gross distortion of the truth. They believe they remember everything in vivid and accurate detail, thinking that all was “just fine.” Of course, this will only serve to bury the drinker’s antisocial or destructive behavior. There is a destructive distortion of perception itself. There is a lack of ability to see and appreciate reality. No recognition or acceptance that they are on a downward spiral, fast approaching rock bottom.

Rock Bottom Became the Foundation

Either of these defense mechanisms seriously impair judgment. The time inevitably comes when it is plain that alcoholics cannot see they are sick. Yet they are acutely ill with a condition that will ultimately lead to death and destruction, and which will seriously impair their constitution emotionally, mentally, and spiritually during the final months of year of their active addiction. Accordingly, treatment for acute alcoholism cannot concern itself merely with putting the drink down. It also has to do with restoration of adequate ego strength to enable the alcoholic once again to cope with life.

The Best Approach

Therapy for acute alcoholics must address the whole person. The alcoholic suffers emotionally, mentally, physically, and spiritually. Treatment often involves physicians, psychiatrists, sociologists, psychologists, pathologists, and clergy. If the whole person is not treated simultaneously, relapse is simply… inevitable. If, for example, the emotional disorder alone is addressed, the alcoholic may believe he or she feels “so good” now that they can handle the drink. When treatment is short-sighted or limited, friends and family of the alcoholic may be heard commenting, “He was easier to live with when he was drinking!” This is akin to being a dry drunk. As this “dry” condition worsens, mental gains erode away and the alcoholic inevitably reverts to drinking to feel normal.

A description of despair by Søren Kierkegaard found in his book The Sickness Unto Death. Human despair is found at three distinct levels. First is the despair that expresses itself in sentences such as, “Oh what a miserable wretch I am! Oh, how unbearable it is to be me!” Second is the despair  that expresses itself by crying out, “Oh, if only I were not what I am. If only I could be like that person!” This is deeper despair because it considers self to be so worthless as to want to abandon it completely. But the third, deepest, despair of all is despair that does not believe one is a self at all. In other words, “I used to be… but not I am not.”

Physical complications, mental mismanagement, and emotional disorder are accompanied by a similarly progressive spiritual deterioration. Guilt, shame, and remorse exact their inevitable and immobilizing toll as time goes on. Feelings of self-worth begin to decline. As meaningful relationships wither on the vine, the growing estrangements lead to spiritual collapse. At the end, these feelings produce suicidal moods, ideation, and, unfortunately, suicidal attempt and/or death. If asked, “Can’t you see you’re drinking yourself to death?” the alcoholic replies, “So what? Who cares?”

Concluding Remarks

When asked how alcoholism is treated, people commonly think of either the 12-step program of Alcoholics Anonymous (AA) or inpatient drug and alcohol rehabilitation. There are, however, a variety of treatment modalities currently available. Today’s treatment for alcoholism naturally rests upon decades of research. AA was founded by Bill Wilson (“Bill W.”) and Bob Smith (“Dr. Bob”) in Akron, Ohio in 1935. AA’s program of spiritual and character development is based on the premise that turning one’s life and will over to a “personally meaningful higher power” is the key to recovery. It is, in fact, referred to as the key of willingness. Another central idea is that sobriety or recovery depends on the admission of powerlessness with respect to alcohol or other substances.

Treatment for alcoholism has made significant advances in the last 20 years. Researchers are constantly seeking novel approaches for improving the effectiveness, accessibility, quality, and cost-effectiveness of treatment. Alcoholism is a treatable disease. Regardless of how someone is diagnosed as alcohol-dependent, or how they came to realize they have a drinking problem, the first step to treatment is a sincere desire to get help. Overcoming an alcohol problem is an ongoing process that sadly might involve relapse. Granted, relapse is not a “requirement” for recovery—you don’t have to change your sobriety anniversary!—but it is merely a setback and not an indication that you will fail in your attempt to get sober.

 

Supporting Our Physicians in Addressing the Opioid Crisis

From the blog of Dr. Lora Volkow dated August 31, 2018

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A recurring theme among addiction researchers and professionals is the so-called treatment gap: under-utilization of effective treatments that could make a serious dent in the opioid crisis and overdose epidemic. Ample evidence shows that when used according to guidelines, the agonist medications methadone and buprenorphine reduce overdose deaths, prevent the spread of diseases like HIV, and enable people to take back their lives. Evidence supporting the effectiveness of extended-release naltrexone is also growing; but whereas naltrexone, an opioid antagonist, can be prescribed by any provider, there are restrictions on who can prescribe methadone and buprenorphine.

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A series of editorials in the July 5, 2018 issue of the New England Journal of Medicine made a strong case for lessening these restrictions on opioid agonists and thereby widening access to treatment with these medications. For historical reasons, methadone can only be obtained in licensed opioid treatment programs, but experimental U.S. programs delivering it through primary care docs have been quite successful, as have other countries’ experiences doing the same thing. Although buprenorphine can be prescribed by primary care physicians, they must first take 8 hours of training and obtain a DEA waiver, and are then only allowed to treat a limited number of patients. Some physicians argue that these restrictions are out of proportion to the real risks of buprenorphine and should be lessened so more people can benefit from this medication.

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Stigma contributes to reluctance to use evidence-supported treatment—both stigma against addicted individuals and stigma against agonist medications, due to the persistent myth that they just substitute a new addiction for an old. This idea reflects a poor understanding of dependence and addiction. Dependence is the body’s normal adaptive response to long-term exposure to a drug. Although people on maintenance treatment are dependent on their medication, so are patients with other chronic illnesses being managed medically, from diabetes to depression to pain to asthma. Addiction, in contrast, involves additional brain changes contributing to the loss of control that causes people to lose their most valued relationships and accomplishments. Opioid-dependent individuals do not get high on therapeutic doses of methadone or buprenorphine, but they are able to function without experiencing debilitating withdrawal symptoms and cravings while the imbalances in their brain circuits gradually normalize.

Treating patients with addiction may be uniquely complex and demanding for several reasons. Patients may have co-morbid medical conditions, including mental illness; thus they may need more time than doctors are reimbursed for by insurers. They may also have pain, and while pain management guidelines have changed to respond to the opioid crisis, those changes have not necessarily made a doctor’s job any easier, since there are currently no alternative medications to treat severe pain that are devoid of dangerous side effects.

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Because of the complexity of Opioid Use Disorder (OUD), providers may find that it is not sufficient to simply dispense a new prescription after a quick consultation. These patients often need ancillary services provided by nurses or other treatment specialists; and in the absence of these extra layers of support, treatment is less likely to be successful, reinforcing physicians’ reluctance to treat these patients at all. In short, physicians are being blamed for causing the opioid epidemic, but thus far they have not been aided in becoming part of the solution.

Medical schools are starting to respond to the opioid crisis by increasing their training in both addiction and pain. For example, as part of its training in adolescent medicine, the University of Massachusetts Medical School has begun providing pediatric residents with the 8-hour training required to obtain a buprenorphine waiver—an idea that is winning increasingly wide support. Physicians in some emergency departments are also initiating overdose survivors on buprenorphine instead of just referring them to treatment. And through its NIDA MedPortal, NIDA provides access to science-based information and resources on OUD and pain to enable physicians to better address these conditions and their interactions, including easy-to-use screening tools to help physicians identify substance misuse or those at risk.

But if physicians are going to assume a bigger role in solving the opioid crisis, healthcare systems must also support them in delivering the kind of care and attention that patients need. Physicians need the tools to treat addiction effectively as well as the added resources (and time) for patients who need more than just a quick consultation and a prescription.

The Opioid Issue: Part 6

Part 6: Hope, Not Handcuffs

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In a growing number of towns, police aren’t arresting people facing addiction. Instead, they’re providing a doorway to treatment.

Judge Linda Davis hasn’t only seen the toll opioids take from the bench. She’s also seen it at home—with one of her daughters. “I thought our family would be the last family on earth this would happen to,” she says. “I was a judge and a former prosecutor who’d run the drug unit. We talked about these issues constantly.”

Then one of her daughters—a fine student and athlete—got hurt at age 17 and needed knee surgery. Pills were prescribed. That led to heroin. And later, a four a.m. confession: “Mom, I’m a heroin addict. I need help.”

That was 12 years ago: Davis’ daughter has been clean since then. “I’m just one of many parents with a story like that,” Davis says. “It amazes me that every time I share it, someone says, ‘I have a son or daughter or grandson or nephew or mother or grandmother with a problem like that.’ It’s that widespread.” Davis hasn’t stopped at telling her story. She volunteers her lunch hours to serve on drug court on top of her normal docket as a judge in Clinton Township, Mich. She co-founded a group, Families Against Narcotics (FAN), which has spread across the state. And that group is taking a leading role in promoting a new approach to fighting opioid addiction.

Angels Among Us

In May 2015, Gloucester, Mass. Police Chief Leonard Campanello posted a Facebook announcement: Anyone could come to the police department, report an opioid addiction, and police would get them into treatment. No arrests, no punishment. Just help. In the first year, 376 people showed up. Almost 95 percent got direct referrals for treatment. Today, that’s grown into a national program: the Police-Assisted Addiction and Recovery Initiative (PAARI), with nearly 400 participating police departments in approximately 30 states. Some 12,000 people have been ushered into treatment so far.

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The largest of those partners is Macomb County, Mich., comprised mostly of 860,000 Detroit suburbanites—FAN’s home base—where an important new element was added. FAN’s idea, successfully pitched to police and community leaders: Rather than burden police in such a populous area with getting people into treatment, specially-trained community volunteers—known as “angles”—would help with the load.

Under the Macomb County program—called “Hope, Not Handcuffs,” an angel is called to the police station to give one-on-one attention to the person reporting an addiction. The volunteer sits with him or her, helps fill out forms and makes the calls to get into a treatment center right away. The angel is there after treatment too—helping, if needed, to find housing or support services, among other things.

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It’s an approach which has captured a lot of hearts and minds. Some 250 people have stepped up to the angel role. Three emergency-service ambulance companies agreed to provide free transportation to treatment centers. Hope Not Handcuffs already is operating in eight Michigan counties, and spreading. “The program started a little over a year ago, and already we’ve placed almost 1,300 people in treatment,” Davis says. “We’re working with up to 90 police departments on implementing this in the state of Michigan. “We get calls from all over the U.S. wanting to initiate the program. But as an all-volunteer group, we don’t have the resources to coordinate with them. We can’t grow that fast.”

After decades as a judge and prosecutor, Davis is struck by the change in law enforcement’s approach. “Police officers are leading the charge for reforms,” she says. “We’ve had a big shift from the ‘lock ’em up’ mentality they were taught in the academies. “Now you’ll hear officers say it all the time: ‘We can’t arrest our way out of this. This is a disease, and locking up people with a disease won’t work.’ For them to say that is really changing the stigma of addiction and opening up new possibilities.”

Living Testimonies

Signs of that changing mentality in law enforcement are popping up all over. There are more than 3,100 drug courts in the country, the U.S. Department of Justice reports—specialized docket programs focusing mostly on treatment and rehabilitation. Roughly half of them deal with juveniles; the other half, with adults.

In Macomb County, a lot of people are grateful. And some are giving back. Micki Dodson’s mom was an addict. Micki, now 30, eventually followed in her footsteps, spending the better part of a decade on pills, heroin, and crack cocaine. Only after her mother died of an overdose last year did she turn the corner. Dodson has been clean since May 2017, and she’s scheduled to graduate from the drug court program in October. “I’m a huge fan of Hope Not Handcuffs,” she says. “Drug court has been my saving grace. I can’t thank them enough: They worked wonders for me. I couldn’t stay clean on my own.”

Now Dodson plans to undergo angel training, so she can do for others what someone did for her. “I have to give back,” she says. “It helps me. I want to let them know there’s hope. If I help one person today, I’ve done my job for that day.”

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Anthony Mattarella is giving back too. Much like Davis’s daughter, he was injured in his youth and went from prescription opioids to heroin and other drugs. That lasted eight years, with numerous fruitless stints in jail or rehab. Three years ago, when his case was bounded over to Davis’ drug court, things changed. “Before I got into the program, I wanted to die,” Mattarella says. “When I got in, I was willing to do anything they asked of me. I knew I was either going to kill myself or I was going to get sober.”

Now he’s a peer-recovery coach for 41B Drug Court in Clinton Township, Mich.—the same court where Davis serves. He’s helping lost people find their way, using his experience to connect with them and guide them. “It’s so rewarding,” he says. “I see them go through the [recovery] process; I see the smiles on their faces when they start to understand.”

Looking back, Mattarella marvels at the change in his life.

“It’s absolutely unbelievable to me,” he says. “I never thought I’d be here. I never thought I’d be someone who helps people.”

FOR MORE INFORMATION: To learn more about Hope, Not Handcuffs, go to familiesagainstnarcotics.org/hopenothandcuffs. For more information on the Police-Assisted Addiction and Recovery Initiative, visit paariusa.org.

The Opioid Issue: Part 5

Part Five: Troubling Vital Signs

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The opioid epidemic is straining America’s health care and treatment resources, while opening the door for unscrupulous fraudsters to make money off those struggling to overcome addiction. How much more can emergency rooms handle? The most recent numbers from the U.S. Centers for Disease Control and Prevention (CDC), spanning 45 states, show nearly 143,000 ER visits for opioid overdoses over a 15-month period. That period ended in the third quarter of 2017 and represented a 30-percent jump from the same time span a year earlier.

“The staff isn’t sure what to do with [opioid overdose patients],” says Karl Benzio, M.D., a Christian psychiatrist and member of Focus on the Family’s Physicians Resource Council (PRC). “You don’t feel comfortable just discharging the person. The staff doesn’t know how dangerous the person is when they leave the doors, whether they will overdose—or worse—when they leave, how to find a responsible party to transfer the care and responsibility to.” Fellow PRC member W. David, Hager, M.D., agrees. “We’re seeing a lot of frustration among our providers with ‘frequent fliers,” says Hager, a practicing physician with Baptist Health Medical Group in Lexington, Kentucky. Both physicians point to different problems connected to the opioid crisis.

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Benzio notes that many overdose cases are complicated because ER staffs aren’t generally equipped to deal with mental or behavioral health. Many of those patients  should ideally be in a residential rehabilitation program, but are unable to secure health care insurance coverage. This leaves the medical personnel on the front lines of care facing a dilemma for which there are no simple answers. Between the rapid rise in overdose cases and the moral gray area of providing narcotics to so-called “frequent fliers,” America’s emergency rooms are in a precarious position when it comes to the opioid issue. The crisis threatens to break the backs of overworked ER staffs, whose efforts to help those in pain with long-term prescriptions may only be fueling the crisis.

FAKE TREATMENT CENTERS

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The overwhelming strain the opioid epidemic has placed on legitimate health care providers has also opened the doors for unscrupulous con artists looking for easy money. These fraudsters—and it’s not clear just how many there are across the country—run fake treatment centers preying on those seeking a way out of their opioid struggles.

“Several factors came together—so many people in need of addiction treatment and managed care to reduce their length of stay in the hospital—that there became a huge need for more addiction rehabs,” Benzio explains. “Certain states that had a high level of drug use made it very easy to open a rehab; not many restrictions, licensing issues or hoops to go through. Also, insurance plans needed a place to put someone who was in danger of overdosing but needed one-on-one monitoring, so entities put together minimally-trained people with a schedule and sold it to the insurance as a rehab.” With the potential to make big money and only vague criteria for what a “quality” treatment facility includes, many unqualified providers jumped into the rehab industry.

Cash from Treatment Centers

“A lot of people going through addiction thought, ‘Wow, I could put together a better program than that,’ so they developed their own after getting clean for 20 minutes,” says Benzio. Though he believes some who entered the rehab industry in this way truly wanted to help, others are outright shams and just billing insurance large sums. Some bill for services they don’t even provide. Some will encourage their patients to use drugs or supply them so they can continue to bill insurance. Many cannot get doctors or licensed therapists [on staff], which would make them accountable to higher state and national licensing standards.

UNSCRUPULOUS REHAB CENTER OPERATORS

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Somehow, even with all our laws pertaining to drug possession and use, we still find ourselves in a largely unregulated addiction treatment field. And even worse, the biggest driving force seems to be well-meaning legislation—like the Affordable Care and Parity Acts—which made treatment more accessible for more people, but unfortunately also opened the door for predators and frauds to get in on the action. They are unconscionably attempting to make a profit off our nation’s current drug epidemic with unethical and shocking practices like patient brokering, identity theft, kickbacks, and insurance fraud.

A behavioral healthcare survey on ethical concerns in the drug rehab industry identified patient brokering tactics in the form of money and gifts that some treatment centers are using to entice patients. Need sober living but can’t afford it? Some programs address this by offering free room and board and other amenities, then bill insurance excessively for unnecessary drug testing and other services to make up the cost. Sadly, many unregulated sober living homes have become unsafe and overcrowded “flophouses” where crimes like theft, human trafficking, prostitution, and illegal drug use are commonplace.

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We’re also seeing patients-turned-recruiters, people just out of treatment with very little time in recovery who can suddenly start making big money selling people they know to rehab centers, checking themselves into competitor programs to lure clients away, and collecting “finder’s fees” of $500 to $1,000 per patient or more. And if that doesn’t work, people are getting paid to relapse so that treatment centers can collect more insurance money. Shockingly, some of these practices are not per se illegal. And in situations where they are, states do not have the resources to regulate.

A Palm Beach Post investigation of the county’s $1 billion drug treatment industry found that testing the urine of recovering addicts is so lucrative that treatment centers are paying sober living homes for patients. Urine drug screen costs may be $6 once a week, but centers test every 48 hours and bill insurance companies $1,200 each time. You may have heard about treatment center owner Kenneth Chatman. A federal investigation targeted sober living homes and rehab centers founded by Chatman and others. Chatman appeared before a U.S. magistrate in West Palm Beach, Florida. The recovery businesses founded by Chatman provided illegal kickbacks, coerced residents into prostitution, threatened violence against patients, and submitted urine and saliva for screening even when no medical need existed.

It’s an exploitation of some of our nation’s most vulnerable individuals and it needs to stop!

FINDING REAL HELP

Amid a sea of get-rich-quick frauds, how can those struggling to overcome opioid addiction find genuine help? How can they—and their families—be sure they’re not scammed by fraudsters? Benzio says quality facilities have several standout features. He advises looking for those that are Christian-owned, apply the Bible to daily living, and emphasize the importance of growing in a relationship with God. Some of the other key elements include:

  • One of the owners is an accomplished clinician, such as a psychiatrist, counselor, or therapist. Clinicians with ownership stakes usually have professional reputations to maintain, an understanding of what great care looks like, and a desire to make clinical excellence a primary focus.
  • A psychiatrist sees the patient early in the admission process for detox purposes and to help diagnose underlying issues that contribute to the patient’s opioid use.
  • The treatment and residential facilities are located on the same campus, allowing for a higher level of accreditation and insurance approval.
  • Individual therapy is provided by masters-level and/or licensed therapists. Each patient receives several individual sessions per week.

A FAMILY AFFAIR

Between the overloaded hospitals, risky prescribing practices and minefield of rehab programs, the opioid epidemic is stretching and straining America’s health care resources like nothing we’ve ever seen. Tackling those (and many other) massive opioid-related issues will require innovative solutions.

Cece and Bobby Brown of Charleston, WV had a son who died four years ago at age 27. His parents describe him as being “just like the kid next door,” stating he was a trouble-free child who loved sports, music, skateboarding, and God. His mother said, “I sent him to college to get a degree, and he came home with an addiction.” Ryan struggled with opioids for seven years, surviving three overdoses along the way. But in April 2014, he had another—at the local mall. The Browns believe their son ran into an acquaintance there who gave him the heroin that snuffed out his life.

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The couple spent thousands on detox and rehabilitation programs for Ryan. What he really needed, they say, was a long-term facility where he could get clean for good. Instead, a typical cycle for Ryan would consist of seven days of detox and regular participation in outpatient programs, therapy groups and Narcotics Anonymous. That combination would keep him clean for about six weeks.

But he needed more.

Ryan was on waiting lists for two long-term treatment centers when he died. Having aged out of his parents’ insurance plan at 26, he had just received Medicaid benefits three days before his death. Most heartbreaking, his parents learned after his passing that a treatment facility that could have accepted Ryan was only three miles away. Now his parents can’t help but wonder, What if the wait times had been shorter, the coverage had come a bit earlier, and we had known about the facility nearby?

“That would’ve given opportunity. I can’t say that would have changed things, but opportunity is everything,” Cece says. Over the last four years, the Browns have made it their mission to make sure others with similar struggles in West Virginia have the opportunities Ryan didn’t.

INNOVATE FOR THE STATE

After a two-year effort led by Bobby and Cece, last year West Virginia lawmakers passed legislation creating the Ryan Brown Addiction Prevention and Recovery Fund. The Fund aims to expand the state’s capacity to help those struggling with opioids but lacking private insurance, Medicaid or Medicare coverage by blending public grants and private dollars. People can contribute charitable gifts.

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So far, the model has yielded promising results: The West Virginia Department of Health and Human Services has awarded $20.8 million through the Fund to nine long-term treatment facilities statewide. That’s already translated to 300 more West Virginians getting treatment than would’ve been the case otherwise. The Browns explain it’s just reality that many struggling with opioids have low-wage jobs that don’t offer insurance. Some, they say, have felonies that prevent them from securing jobs with better wages and benefits. But that doesn’t mean they should be left behind. Bobby said, “If they don’t want help, there’s nothing we can do. But if they do want help, we need to get them help.”

The Browns are also grateful West Virginia has addressed another problem: In September 2015, the state launched a resource hotline to help those combating opioid addiction.  “We didn’t have a number to call to talk to anyone; didn’t know where to get help,” Bobby recalls. “Now that number has come out.” Those needing help can simply call 1-800-HELP-4WV—and thousands have.

Bobby and Cece say they feel honored to play a role in easing the burden the opioid epidemic has placed on the health care system, and to help families struggling with the weight of it all find solid answers. They’ve been part of several White House events aimed at finding solutions, and say they’ll continue to engage the Trump administration in the hopes of keeping the heat on. As a reminder of the epidemic’s devastating toll, Cece displayed a picture of Ryan at a round table discussion with First Lady Melania Trump earlier this year.

This needs to be about people, not politics.

The Opioid Issue: Part 4

Part Four: Taking It to the Streets

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The opioid epidemic doesn’t stay behind closed doors. It’s spilling into public life, spurring crime and homelessness.

The opioid crisis has hit hard in Macomb County, Michigan. Composed of 27 Detroit suburbs, the county has the state’s second-highest opioid-related overdose death rate, more than double the national average. District Court Judge Linda Davis has been on the bench 17 years. She sees the consequences pretty much every day. “When I look at the docket I handle, I’d say 70 percent is addiction-related,” she says, not counting low-level traffic offenses like driving on a suspended license. “We’ve definitely seen a rise in thefts with this opioid surge.”

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Although opioid addiction often starts out legally, recent years have seen a shift toward illegal opioids. It’s an all-to-familiar story: People get hooked on prescription painkillers, often moving on to heroin, which can be cheaper on the street. Since 2011, as prescription opioid overdose deaths leveled off, heroin overdoses started rising. Starting in 2014, illicit fentanyl deaths began spiking upward. Whatever the substance, the cost mounts up fast. So many users resort to theft. They’ll steal from family, friends, acquaintances or strangers. They’ll shoplift, commit fraud, rob pharmacies, break into homes or cars. Even commit armed robbery. And whether or not they’re committing those crimes themselves, their desperate dependency can feed some even worse ones.

Lethal Combination

In 2015, the nation’s homicide rate rose sharply (11 percent) after decades of decline. The uptrend continued in 2016, climbing another 8 percent. Some observers looked for racial reasons for it. There could be one, says Richard Rosenfeld, an emeritus professor of criminology and criminal justice at the University of Missouri-St. Louis. But he thinks there’s more to the story. When Rosenfeld looked into the data, he quickly saw homicides had jumped among several ethnicities—and it was very pronounced among whites.

“The increase is quite abrupt, quite recent and quite large, at levels we hadn’t seen since the early 1990s outside of 9/11,” Rosenfeld says. “The ‘Ferguson Effect’ doesn’t explain that. So what might explain it? The opioid epidemic, for one thing—which crosses racial lines, but is most concentrated among whites. Drug-related homicides rose more than 21 percent in 2015, a rate far higher than other common categories of homicide, which rose between 3 and 5 percent. Rosenfeld said it stands to reason that there’d be a connection between the spikes in opioid use and lethal violence.

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“It’s not opioid use per se that sparks violence, but the markets,” Rosenfeld says. “When disputes arise between sellers or buyers, they can’t be settled by police or courts or the Better Business Bureau. As the number of buyers expands, so does the number of disputes that turn deadly will also go up.”

Just how big a role do opioids play in driving the rise in homicides? That calls for more research, Rosenfeld says. But he sees ample evidence to sound the warning and to call for addressing the root causes. “Policymakers and law enforcement are framing this as a public-health crisis more than as a criminal-justice crisis, and I’m very much in favor of that,” he says. “The bottom line is: If we reduce demand, we reduce crime.”

“We Don’t Want Those People Here!”

Reducing demand for opioids would likely reduce other social pathologies too. Like homelessness. “For those of us who’ve been providing health care to people who are homeless, this is not a new problem,” says Barbara DiPietro, senior policy director for the National Health Care for the Homeless Council. “We’ve been seeing opioid addiction and overdoses for decades.

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“When people are in a spiral and aren’t getting the help they need, oftentimes they lose their jobs and their ability to pay rent. Before you know it, you cycle through family and friends, and you’re in a shelter or on the street.” Of course, not all people who are homeless have addiction issues, but those that do have a harder time getting into treatment once the stability of housing is gone. Living on the street could easily drive anyone to substance abuse. Maybe you started with alcohol, but once you were on the street, you found other things. It’s very hard to get well when you’re homeless.

Federally-qualified health centers provide care to 1.2 million people a year, and the Council provides technical assistance to help improve quality and access. DiPietro says homeless service providers often see clients who never expected to be in this situation. “We see a lot of clients who come from construction work or other hard-physical-labor jobs, who got hurt and got prescriptions for legitimate reasons,” she says. “We see a lot of people who’ve experienced trauma in their lives—child abuse, domestic violence, sexual assault. So they self-medicate to deal with the pain.” And on the street, their problems are much more visible than those of people who engage in their addictive behavior behind closed doors.

“They’re living their private lives in a public space,” DiPietro says. “They’re subject to public scrutiny, arrest and incarceration at a much higher rate. And once you have an incarceration history, it’s hard to get housing assistance or a job again.”

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While more medical facilities and first responders are being equipped with opioid-overdose medications like naloxone (Narcan), that’s just an emergency measure, not a solution. DiPietro says what people struggling with addiction and homelessness need most is stable housing where they can get effective treatment. Health care providers the Council works with can help, but not enough to meet the scale of the problem.

Right now, communities don’t have the capacity desperately needed to get people into treatment. Another big obstacle is the attitude known as NIMBY—Not in My Back Yard. “Everyone believes treatment is important, but no one wants the services near them,” DiPietro says. “When that’s proposed, they rise up in community meetings and say, “We don’t want those people here.”

We’ve simply got to get beyond that attitude.

A Parting Thought

I spent forty years in active addiction. It started simple enough: A case of beer and an ounce of Colombian Gold. Eighteen months later I was serving 3 to 10 in state prison. Drug and alcohol abuse continued throughout parole and into my thirties, forties and early fifties. My drug use ran the gamut, from weed to cocaine to crack to opiates. When I couldn’t get enough oxycodone through doctors, I began stealing it from friends and family. My addiction cost me plenty, yes, but it also cost my children, my two ex wives, my brothers, my sister, and my parents. I lost jobs, cars, apartments, friends and family. I blew every penny I made, bounced checks, embezzeled, fenced stolen goods. I was enslaved to addiction. Not only did my family disown me for nearly two years, my youngest son didn’t talk to me for five years.

It’s not only the family of addicts that can become fed up and turn their backs on their loved ones struggling with addiction; society has become rather fed up and impatient. One of our local television stations airs a nightly feature called “Talkback 16,” where viewers call to voice their grievances, pet peeves, and, yes, an occasional compliment. Several days after a news story aired about plans to build a drug and alcohol treatment center in the Pocono Mountains (Pennsylvania), a viewer called to complain about the plan, adding, “Not in my neighborhood. [Addicts and alcoholics] can’t be trusted. Besides, they did it to themselves.”

Truly, this attitude must change.