The Molecule

Andy Coop very nearly spent his career watching paint dry. The son of a machinist and school cafeteria worker, Coop hailed from Halifax in Northern England. He finished his undergraduate work in chemistry at Oxford University in 1991. He was given a choice of where to continue his studies. At Cardiff University was a professor whose specialty was the chemistry of paint. Industry at the time was aiming to find a new paint that dried at a certain temperature. At the University of Bristol was John Lewis, who studied the chemistry of drugs and addiction. In the 1960s, Lewis had discovered buprenorphine, an opiate that he later helped develop into a treatment for heroin addicts.

Coop didn’t remember giving the choice much thought. Drugs sounded more interesting than paint, so off to Bristol and John Lewis he went. It was there, in 1991, in a lab at Bristol, that Andy Coop encountered the morphine molecule – the essential element in all opiates. In time, Andy Coop got hooked on the morphine molecule – figuratively, of course, for he only once took a drug that contained it, and that was following surgery.

Like no other particle on Earth, the morphine molecule seemed to possess heaven and hell. It allowed for modern surgery, saving and improving too many lives to count. It stunted and ended too many lives to count with addiction and overdose. Discussing it, you could invoke some of humankind’s greatest cultural creations and deepest questions: Faust, Dr. Jekyll and Mr. Hyde, discussions on the fundamental nature of man and human behavior, of free will and slavery, of God and evolution. Studying the molecule, you naturally wandered into questions like, Can mankind achieve happiness without pain? Would that happiness even be worth it? Can we have it all?

In heroin addicts, there is a certain debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior. In fact, the United States achieved something like this state of affairs during the last decade of the twentieth century and the first decade of the twenty-first century. It was first observable in widespread obesity. It wasn’t just people. Everything seemed obese and excessive. Massive Hummers and SUVs were cars on steroids. In some of the Southern California suburbs, on plots laid out with three-bedroom houses in the 1950s, seven-thousand-square-foot mansions barely squeezed between the lot lines, leaving no place for yards in which to enjoy the California sun.

In Northern California’s Humbolt and Mendocino Counties, 1960s hippies became the last great American pioneers by escaping their parents’ artificial world. They lived in tepees without electricity and funded the venture by growing pot. Now their children and grandchildren, like mad scientists, were using chemicals and thousand-watt bulbs, in railroad cars buried to avoid detection, to forge hyperpotent strains of pot. Their weed rippled like the muscles of bodybuilders, and growing this stuff helped destroy the natural world that their parents once sought. Today, great new numbers of these same kids – most of them well-off and white – began consuming huge quantities of the morphine molecule, doping up and tuning out.

What gave the morphine molecule its immense power was that it evolved somehow to fit, key-in-lock, into the receptors that all mammals, especially humans, have in their brains and spines. The so-called mu-opioid receptors – designed to create pleasure sensations when they receive endorphins the body naturally produces – were especially welcoming to the morphine molecule. The receptor combines with endorphins to give us those glowing feelings at, say, the sight of an infant or the feel of a furry puppy. The morphine molecule overwhelms the receptor, creating a far more intense euphoria than anything we come by internally. It also produces drowsiness, constipation, and an end to physical pain. Aspirin had a limit to the amount of pain it could calm. But the more morphine you took, Coop said, the more pain was dulled.

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For this reason, no plant has been more studied for its medicinal properties than the opium poppy. As the mature poppy’s petals fall away, a golf-ball-sized bulb emerges atop the stem. The bulb houses a goo that contains opium. From opium, humans have derived laudanum, codeine, thebaine, hydrocodone, oxymorphone, and heroin, as well as almost two hundred other drugs – all containing the morphine molecule, or variations of it. Etorphine, derived from thebaine, is used in dart guns to tranquilize rhinoceroses and elephants. [Amazingly, Etorphine has hit the streets of America as an opiate which teens and young adults are taking to get high, only to be dropping dead due to its potency.]

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Tobacco, coca leaves, and other plants had evolved to be pleasurable and addictive to humans out of the gate. But the morphine molecule surpassed them in euphoric intensity. Then it exacted a mighty vengeance when a human dared to stop using it. In withdrawal from the drug, an addict left narcotized numbness and returned to life and to feeling. Numbed addicts were notoriously impotent; in withdrawal they had frequent orgasms as they began to feel again. Humans with the temerity to attempt to withdraw from the morphine molecule were tormented first with excruciating pain that lasted for days. If an addict was always constipated and nodding off, his withdrawals brought ferocious diarrhea and a week of sleeplessness.

The morphine molecule resembled a spoiled lover, throwing a tantrum as it left. Junkies say they often have an almost constipated tingling when trying to urinate during the end of withdrawal, as if the last of the molecule, now holed up in the kidneys, was fighting like hell to keep from being expelled. Like a lover, no other molecule in nature provided such merciful pain relief, then hooked humans so completely, and punished them so mercilessly for wanting their freedom from it.

Certain parasites in nature exert the kind of control that makes a host act contrary to its own interests. One protozoan, Toxoplasma gondii, reproduces inside the belly of a cat, and is then excreted by the feline. One way it begins the cycle again is to infect a rat passing near the excrement. Toxoplasma gondii reprograms the infected rat to love cat urine, which to healthy rats is a predator warning. An infected rat wallows in cat urine, offering itself up as an easy meal to a nearby cat. This way, the parasite again enters the cat’s stomach, reproduces, and is expelled in the cat’s excrement – and the cycle continues.

The morphine molecule exerts an analogous brainwashing on humans, pushing them to act contrary to their self-interest in pursuit of the molecule. Addicts betray loved ones, steal, live under freeways in harsh weather, and run similarly horrific risks to use the molecule.

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It became the poster molecule for an age of excess. No amount of it was ever enough. The molecule created ever-higher tolerance. Plus, it had a way of railing on when the body gathered the courage to throw it out. This wasn’t only during withdrawals. Most drugs are easily reduced to water-soluble glucose in the human body, which then expels them. Alone in nature, the morphine molecule rebelled. It resisted being turned into glucose and it stayed in the body.

“We still can’t explain why this happens. It just doesn’t follow the rules. Every other drug in the world – thousands of them – follows this rule. Morphine doesn’t,” Coop said. “It really is almost like someone designed it that way – diabolically so.”

The above is taken from Sam Quinones’ best-selling nonfiction book “Dreamland: The True Tale of America’s Opiate Epidemic.” ©2015, New York, NY: Bloomsbury Publishing.

Predictable

He’s about as predictable as a wasp on speed!

There is a commercial running on broadcast television that defines predictable as the comfort in knowing where things are headed. That’s a very lovely yet very narrow definition. Generally, it is defined as “able to be predicted.” If you’re talking about trading on the open market, the comment typically is “the market is volatile and never predictable.” A derogatory definition is “behaving or occurring in a way that’s expected.” Unfortunately, this is a definition I am personally familiar with. A predictable person is one for whom it is easy to anticipate actions; easy to foresee or anticipate what he or she will do. An example of a predictable person is someone who always shows up drunk.

In fiction, we find the predictable boring. In real life, we find the unpredictable terrifying. I’ve heard it said that an artist should paint from the heart, and not always what people expect. Predictability often leads to the dullest work. In comparison, in The Art of War Sun Tzu said, Engage people with what they expect; it is what they are able to discern and confirms their projections. It settles them into predictable patterns of response, occupying their minds while you wait for the extraordinary moment — that which they cannot anticipate.”

When Predictability equals Immutable Truth

Unlike us, God is totally unchangeable, and has revealed to us many things about His immutable character. He is ultimately and fundamentally predictable. I can predict, for instance, that God will never leave me, nor forsake me; that He will work all things out to good for those who love Him; that He will hear and save all those call on His name. To doubt these things or fail to depend on them would be a great insult. Hebrews 13:8 says, “Jesus Christ is the same yesterday and today and forever.” 

The naturalist believes naturalism is a logical conclusion for atheists. Naturalism maintains that all things in the universe are the byproducts of natural laws, behave according to natural laws, and that such laws cannot be violated. Accordingly, atheists believe theism grants power to an omnipotent being who, by definition of being “all powerful,” could cause the universe to operate in any manner they choose. Here’s an interesting thought: What if any laws we might think we observe are merely the coincidental result of God’s choice to make things happen that way at the exact moment when we’re looking?

Routine versus Schedule

Predictability isn’t something you could say I’ve aspired to embody. It sounds sort of boring, doesn’t it? Not something the Cool Kids are into. I’ve never sought it out. That is, not until after a decade of stumbling around the chaotic territory of bipolar disorder, and, before that, nearly thirty years of active addiction. And when the two met, it was the “perfect storm.” As I struggled to manage my mental illness, and get clean and sober, my father told me I was addicted to chaos. That I needed to live on the edge. I think he was right.

I found it helpful to create routines rather than schedules. (Besides, there would be plenty of time for schedules and punching a clock once I got well and was able to return to full-time gainful employment.) Routine smacks of lifestyle, and I was certainly in need of changing that. For me, stability comes from routine.  I did find benefit, however, in ritual, no matter how contradictory that might sound. For example, morning meditation and regular time in my “war room” like in the movie of the same name. Prayer seemed almost meaningless to me for a long time. I realize now that this was rooted in poor self-image and thinking I deserved nothing of value from God or anyone.

What You Can Do to Help Yourself

Take some time to think about a few concepts, such as what the term predictable means to you. Where do you think this definition or concept originated for you? What do you think the difference is between schedule and routine? Can routines be healthy? What are your daily Dos and Don’ts? What are some of the meaningful or constructive rituals you use daily? What new habits might you be able to cultivate to help you reach your goals?

An example of high predictability would be a mouse who was trained to push a lever after it sees a light. It receives food after it pushes the lever. After the mouse has been trained and repeated this task hundreds of times there will be a high predictability that the mouse will hit the lever once it sees the light again. Do you have a high level of predictability in a particular area that is bad for you? Something that might be sabotaging your goals? Remember, there is absolutely no shame in seeking help for those serious, dangerous or predictable behaviors you just can’t seem to quit on your own.

A Fundamental Orientation of the Heart

Perhaps one of the hardest things we face is taking stock of whether our actions match what we claim to believe. Our worldview – that is, how we see the world and our place in it, or, if you prefer, our “philosophy of life” – should be obvious from our behavior. A worldview is not just a set of basic concepts but a fundamental orientation of the heart.

Since the events of 9/11, the term worldview is often used as a very general label for how people view the cultures with which their culture clashes. This is very important to note, as a worldview is a set of presuppositions (assumptions which may be true, partially true, or entirely false) which we hold (consciously or unconsciously, consistently or inconsistently) about the basic makeup of our world. A worldview is sometimes considered to be the fundamental perspective from which we address every issue of life.

From a Human Perspective

Imagine someone who thinks life has no true purpose. For that person, events are random. “I live, then I die.” A meaningless existence requires nothing from anyone. There is no need to check our bearings along the way to see of we’re “on track.” There is no need to justify our choices, values, or goals. There is a quiet desperation that drives humanity to think about the question, “Does life have meaning?” Even non-religious people understand that man has a burning desire to make sense of his life. Humanist Deane Starr writes, “Humans find their most complete fulfillment, whether real or imaginary, in some sort of intimacy with the Ultimate.” Our greatest and most difficult achievement is to find meaning in life. It is well known that many people lose their will to live because such meaning evades them.

What happens when someone fails to find a reason for living? Often they experience a spectrum of emotional and behavioral aberrations. Jay Asher published a book in 2007 titled Thirteen Reasons Why. Netflix has produced a mini-series based on Asher’s book, which has caused quite an uproar across the country. The story begins when Clay Jensen returns home from school to find a strange package with his name on it lying on his porch. Inside he discovers several cassette tapes recorded by Hannah Baker—his classmate and crush—who committed suicide two weeks earlier. Hannah’s voice tells him that there are thirteen reasons why she decided to end her life. Clay is one of them. If he listens, he’ll find out why.

Suicide is the third leading cause of death in the age group of 10 to 24 years. It is a critical problem in America. Educators and mental health professionals have mixed feelings about Thirteen Reasons Why. Dr. Nicole Quinlan, a pediatric psychologist at Geisinger Medical Center in Danville, PA, objects to the show’s graphic, gratuitous portrayal of Hanna Baker’s suicide. I watched the mini-series, and I was shocked and upset by the final scene. I didn’t expect to see Hanna Baker drag a razor blade up both of her arms while sitting in a bathtub of warm water. It was, indeed, horrific.

Hanna Baker is a fictional character, but her plight is far from pretend. She was hounded by classmates, bullied online, and was labeled a “slut” after a football jock posted a random shot of her dress flying up when she came down a sliding board during her date with him. He intimated in his online post that Hanna was “easy.” Hanna’s problems worsened when she was raped by another member of the football team. On each side of the cassette tapes, she exposed one person (one “reason”) why she decided to end her life. Her thirteen excuses. Teenage angst is a very real and difficult emotion. Hanna, as are many teens, was trying to find meaning in what she felt was an already meaningless existence. Her worldview was that life was without purpose. The fault of the story depicted in Thirteen Reasons Why is its lack of providing meaning, hope, or the option of seeking treatment.

From a Biblical Perspective

Developing a biblical worldview involves both a mindset and a willset. First, how does the Bible explain and interpret my life and the world around me? Once this question is answered and accepted, the next aspect of a biblical worldview presents the challenge of putting this view into practice. A worldview is the framework of our most basic beliefs that shapes our view of and for the world, and is the basis for our decisions and actions. Worldview leads to values, which lead to actions. Beliefs clearly shape our behavior.

Man’s attempts to explain his existence are just that: man’s attempts. Within the world, man’s experience and perceptions of the infinite universe are limited and inadequate. We need help from the “outside.” This is what a biblical worldview is. Help from the outside. More fundamental than any worldview that can be delineated by ideas and propositions is the religious or faith orientation of the heart. There are only two basic commitments, leading to two basic conditions of life: “man converted to God,” and “man averted from God.” The commitment one makes is decisive for all life and thoughts. From a Christian perspective,  worldview is not so much a matter of theoretical thought expressed in propositions, but is a deeply rooted commitment of the heart. Theory and practice are a product of the will, not the intellect; of the heart, not the head.

How Would My Life be Different if I Lived Out my Convictions?

I have spent most of my life manipulating others. For reasons best understood by reading my testimony, https://theaccidentalpoet.net/about/, I felt the need to hide, run away, or escape. I had a difficult time telling the truth, and, because of a victim mentality, I was able to rationalize my behavior. I became a born-again Christian at age 13, but never fully developed a relationship with, nor the mind of, Christ. When I began escaping through drugs and alcohol, I set off down a road that ultimately took me until August of last year to get off of and head in the right direction.

How could I act in such a callous and selfish manner if I was a Christian? I now understand the reason. One of my sponsors in Alcoholics Anonymous kept saying, “I hope you get God out of your head and into your heart.” Each time I heard that, I became defensive. Who are you to tell me I don’t have God in my heart? My former pastor said the same thing when he commented, “You don’t seem to have a heart for God.” What? I continued becoming defensive.  Several things happened over the past year that finally got through to me

First, I returned to the church of my youth where I accepted Christ. Within a few months, our church got a new pastor from New Jersey. Pastor Mike is exactly what I needed. He has a wealth of experience counseling Christians struggling with addiction. In our several one-on-one meetings, he has been able to help me restructure how I see my addiction and the many excuses I was holding on to as justification. He has also helped me take a different approach to my chronic back pain. He made an amazing statement: “Have you ever considered that your chronic pain gives you the opportunity to share in the sufferings of Christ?” Whoa!

Last August I made the ridiculous decision to “help myself” to some of my mother’s oxycodone. Unfortunately, this was not the first (or second, or third) time I’ve done so. The result was serious damage to my relationship with her and the rest of my family. Interestingly, this is something I feared would happen if I did not stop using drugs. Especially using mom’s medication! I remain estranged from the family, and can only continue on my road to recovery, turning my relationship with the family over to Christ. I know I am delivered from the bondage of addiction. I have to live that freedom all over again each day. One day at a time.

Luke 6:45 is a Scripture I meditate on daily. It is very convincing, and seems to confirm what my former pastor and a former sponsor said regarding my lack of having God in my heart. The verse states, “A good man out of the good treasure of his heart bringeth forth that which is good; and an evil man out of the evil treasure of his heart bringeth forth that which is evil: for of the abundance of the heart his mouth speaketh.” Proverbs 23:7 says, “As a man thinketh in his heart, so is he.” God is concerned about the hidden man of the heart, which is our inner life. Our inner life is what we think about. And like the Scriptures above indicate, how we live and who we are.

A Change of Behavior Requires a Change of Heart

It says in Jeremiah 17:9, “The heart is deceitful above all things, and desperately wicked: who can know it?” Why do we sin, do bad things, and make mistakes? Because of our heart, which the Bible says is desperately wicked. Why do so many people struggle with drugs and pornography, returning again and again to these sins and vices even though they know their lives are being ruined by them? Because our heart often leads us astray. We cannot live perfect lives, and we cannot save ourselves from the punishment that we deserve. Moreover, it is impossible to deny the flesh, resist temptation, and stop living a self-centered and sinful life without a true change of heart.

Can this explain my constant relapsing over nearly forty years? Can it account for my selfishness? The disrespect and dishonor I’ve shown toward my parents and siblings? Does it help explain how I can “believe” and “speak” about Christ and recovery while secretly using drugs? Worldview, as I mentioned at the beginning of this post, is how we think about the world and our place in it. This basic belief establishes our values, which directly control our actions.

O Lord, how heartily sorry I am for failing to establish the proper Christian worldview, and to hide your Word in my heart that I might not sin against Thee.

It is only through my embracing a true Christian perspective and asking Christ to take away my heart of stone and give me a heart of flesh that I can hope to act from a position of love and respect.

Opioid Use Disorders and Suicide

The following is a guest blog taken verbatim from the monthly blog post of Dr. Nora Volkow, director, National Institute of Drug Abuse published April 20, 2017.

“At a Congressional briefing on April 6, the President of the American Psychiatric Association, Dr. Maria Oquendo, presented startling data about the opioid overdose epidemic and the role suicide is playing in many of these deaths. I invited her to write a blog on this important topic. More research needs to be done on this hidden aspect of the crisis, including whether there may be a link between pain and suicide.” – Nora

In 2015, over 33,000 Americans died from opioids—either prescription drugs or heroin or, in many cases, more powerful synthetic opioids like Fentanyl. Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides. Let me share with you some chilling data from three recent studies that have investigated the issue.

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In a study of nearly 5 million veterans recently published in Addiction, scientists reported that presence of a diagnosis of any substance use disorder and specifically diagnoses of opioid use disorders (OUD) led to increased risk of suicide for both males and females.  The risk for suicide death was over 2-fold for men with OUD.  For women, it was more than 8-fold.  Interestingly, when the researchers controlled the statistical analyses for other factors, including co-morbid psychiatric diagnoses, greater suicide risk for females with opioid use disorder remained quite elevated, still more than two times greater than that for unaffected women.  For men, it was 30 percent greater.  The researchers also calculated that the suicide rate among those with OUD was 86.9/100,000.  Compare that with already alarming rate of 14/100,000 in the general US population.

You may be tempted to think that these shocking findings about the effects of OUD on suicide risk are true for this very special population.  But that turns out not to be the case. 

Another US study, published last month in the Journal of Psychiatric Research, focused on 41,053 participants from the 2014 National Survey of Drug Use and Health.  This survey uses a sample specifically designed to be representative of the entire US population.  After controlling for overall health and psychiatric conditions, the researchers found that prescription opioid misuse was associated with anywhere between a 40 and 60 percent increased risk for suicidal ideation (thoughts of suicide).  Those reporting at least weekly opioid misuse were at much greater risk for suicide planning and attempts than those who used less often.  They were about 75 percent more likely to make plans for a suicide, and made suicide attempts at a rate 200 percent greater than those unaffected.

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Using a different strategy, a review of the literature in the journal Drug and Alcohol Dependence estimated standardized mortality ratios for suicide.  This is a way of comparing the risk of death in individuals with a given condition compared to individuals from the general population.  The researchers found that for people with OUD, the standardized mortality ratio was 1,351 and for injection drug use it was 1,373.  This means that compared to the general population, OUD and injection drug use are both associated with a more than 13-fold increased risk for suicide death. These are stunning numbers and should be a strong call to action.

Persons who suffer from OUD are highly stigmatized. They often talk about their experience that others view them as “not deserving” treatment or “not deserving” to be rescued if they overdose because they are perceived as a scourge on society.  The devastating impact of this brain disorder needs to be addressed.  People who could be productive members of society and contribute to their families, their communities, and the general economy deserve treatment and attention.

As a country, we desperately need to overcome stigmatizing attitudes and confront the problem. We need to understand what causes some individuals to become addicted when exposed to opioids and thus study the biological basis of the disease of opioid addiction. We desperately need to know what the best treatments are for a given individual, and for that too, we need research to identify biomarkers for treatment response. Given the fact that effective medications exist but are drastically underutilized, we need to overcome institutional and attitudinal barriers to these treatments and deliver them to the 24 million people who could benefit. It can prevent not only the suffering of addiction and the danger of unintentional overdose but also help prevent the tragic outcome of opioid-related suicide.

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America’s Fentanyl Crisis

Every day 91 Americans fatally overdose on an opioid drug. It may be a prescription analgesic or heroin–4 to 8 percent of people who misuse painkillers transition to heroin–but increasingly it is likely to be heroin’s much more potent synthetic cousin fentanyl. In the space of only two years, fentanyl has tragically escalated the opioid crisis. This drug is 50 to 100 times more potent than morphine and able to enter the brain especially quickly because of its high fat solubility; just 2 milligrams can kill a person, and emergency personnel who touch or breathe it may even be put in danger. Unfortunately, many people addicted to opioids as well as other drugs like cocaine are accidentally being poisoned by fentanyl-laced products.

Although fentanyl is a medicine prescribed for post-surgical pain and palliative care, most of the fentanyl responsible for this surge of deaths is made illicitly in China and imported to the United States via the mail or Mexican drug cartels. Its high potency and ease of manufacture make it enormously profitable to produce and sell. According to the Drug Enforcement Agency (DEA), one kilogram of fentanyl can be purchased in China for $3,000 to $5,000 and then generate over $1.5 million in revenue through illicit sales in America. Thus, distributors of illicit drugs are eager to adulterate heroin or cocaine powder with fentanyl or put it in counterfeit prescription drugs, such as pills made to look like prescription pain relievers or sedatives. Last month, for example, a wave of deaths in Florida was linked to fake Xanax pills containing fentanyl.

Deaths from fentanyl and a handful of other synthetic opioids tripled from 3,105 in 2013 to 9,580 in 2015, and those numbers are likely underestimates; some medical examiners do not test for fentanyl and many overdose death certificates do not list specific drugs involved. Thus far, New Hampshire has recorded the most fentanyl overdoses per capita; an NIDA-funded study found that in 2015, almost two-thirds of the 439 drug deaths in that state involved fentanyl. Although most who fatally overdose on fentanyl are unaware of what they have taken, news of such fatalities has unbelievably driven some people with severe opioid addictions to seek it out. Part of the cycle of an opioid use disorder is increased tolerance, causing diminished response to the drug, which leads users to seek products with higher potency so they can experience the euphoria they initially felt. Roughly one-third of opioid users interviewed as part of the study in New Hampshire knowingly sought fentanyl.

The fentanyl problem is already a high priority for policymakers. Last month, NIDA’s Deputy Director Wilson Compton testified before Congress on the science of fentanyl, accompanied by representatives from the DEA, the Office of National Drug Control Policy (ONDCP), the CDC, and other agencies. Diplomatic and law enforcement efforts to cut off the supply of illicit fentanyl and the chemicals needed to manufacture it will be important, but the emergence of very high potency opioids–which can be transported in smaller volumes–will make addressing supply increasingly difficult. Thus, a public health strategy to address the opioid crisis and overdose epidemic is more important than ever.

First, we must improve pain management and minimize our reliance on existing opioid pain medications. Second, treatment centers and healthcare systems must make much wider use of available, effective medications for opioid addiction (Buprenorphine, Methadone, and extended-release Vivitrol). Third, the opioid-overdose reversing drug naloxone needs to be made as widely available as possible, both to emergency first responders as well as to opioid users and other laypeople who may find themselves in a position to save a life. In cases of fentanyl overdose, multiple doses of naloxone may be needed to reverse an overdose, and additional hospital care may be needed. All individuals who overdose on opioids need to be linked to a treatment program to prevent it from happening again.

From the blog of Dr. Nora Volkow, Dir., National Institute on Drug Abuse
April 6, 2017

NIDA to Undertake Research on Adolescents, Drug Use and Development

From the blog of Dr. Lora Volkow, National Institute of Drug Abuse, posted  September 13, 2016.

Adolescence is a time of many physical, behavioral, and social transitions, not to mention changes in the brain. As part of their normal maturation, people in their second decade of life are beginning to become independent in the world, which means seeking new experiences and taking risks to determine what they are capable of. The state of the adolescent brain reflects this: The structure and circuits governing reward and emotion are more fully developed and tend to win out in the tug-of-war with the still-maturing prefrontal circuits governing judgment and impulse control. The behaviors that arise as a result of this imbalance can be wide-ranging, both positive and negative, including potentially harmful behaviors like substance use. Such behaviors can in turn affect how the brain develops, often in ways that remain poorly understood.

The phrase “more longitudinal research needed” is the bottom-line message in many studies of substance use and other behaviors during this period of life and their long-term impacts—such as whether using drugs increases risk of mental illness (or vice versa), whether smoking marijuana causes lower IQ (or vice versa), or whether vaping leads to increased or decreased cigarette use. This is why NIDA is excited to announce that recruitment is now underway for the largest longitudinal study ever conducted on adolescent behavior, brain development, and related health outcomes.

The Adolescent Brain Cognitive Development (ABCD) study, which has been in the planning phase for just under a year, is now recruiting more than 10,000 9- and 10-year-olds at 19 research sites across the United States, and will follow these young people for a decade, through their early adulthood. Recruitment will be conducted over a two-year period through partnerships with public and private schools near the research sites, as well as through twin registries.

The study will collect an enormous amount of behavioral, genetic, and health data on the participants, including MRI scans every other year, so that brain development can be tracked and correlated with a vast range of factors including participation in extracurricular activities like music and athletics; video games and screen time; sleep habits; head injuries from sports; and experimentation with or regular use of alcohol, tobacco, marijuana or other substances, as well as socioeconomic and other environmental variables.

Besides enabling researchers to draw stronger conclusions about the developmental impacts of adolescent behaviors and environments, it will also create, for the first time, a baseline standard of normative brain development. Today, when parents take their child to the doctor, their physical development can be plotted and compared to established norms for measures like height and weight, but nothing of this kind has ever existed for brain maturation. The ABCD study data will clarify the normal trajectory of brain development and its developmental benchmarks. At the end of this study, pediatricians will potentially have new brain-imaging biomarkers to determine if a patient’s development is off course, so that they can possibly intervene.

To me, this is the only way to win the “war on drugs.”

For more information about ABCD, please visit its website at www.ABCDStudy.org.

Overcoming the Stronghold of Addiction

The following is from Chapter 7, “Overcoming Addiction,” from Beth Moore’s book Praying God’s Word: Breaking Free from Spiritual Strongholds.

Addiction is one of the cruelest of all yokes because it deceives us unmercifully and ruthlessly. It comes to us like a friend, promising to bring comfort. It kisses us on the cheek like Judas, stealing from our treasury, then rents us for a cheap fee to the opposition. Addiction is a yoke that convinces us we must wear it to survive. Nothing makes us feel more powerless. No ungodly master is a more unyielding dictator. Countless people, even those in the Christian faith, have concluded that they are hopeless to overcome this relentless beast. After more failures than they can bear to count, many believers accept earthly defeat as compulsory and await a freedom that will only come in heaven. Satan, the accuser of the brethren, chides them constantly with his tally of failures, and convinces them that they are unable to derail the miserable cycle of self-loathing.

No matter whether your addictions are to substances or behaviors, God can set you free. What He requires from you is time, trust, and cooperation. The immense power of an addiction is rarely broken in a day. You see, God has as much to teach us as He has to show us. He could show us His power by instantaneously setting us free from all desire for our stronghold. Often, however, God chooses the process of teaching us to walk with Him and depend on Him daily. Few things (beyond our salvation) are “once and for all.” If He delivered us instantly, we would see His greatness once, but we would soon forget, and we’d risk going back to our addiction. On the other hand, if God teaches us victory in Christ Jesus day by day, we live in the constant awareness of His greatness and His sufficiency. Hard lessons are often long-lasting lessons. Never forget that God is far more interested in our getting to know the Deliverer than simply being delivered.

Realize that God’s unquestionable will is your freedom from this yoke, but also trust that He has written a personalized prescription for your release. Remember when King Saul offered young David his armor to wear as he opposed Goliath?  David was not able to walk around in Saul’s armor, so he took it off. Then he took his own staff in his hand, chose five smooth stones from the stream, put them in the pouch of his shepherd’s bag and, with his sling, approached the giant Philistine. (See 1 Samuel 17:38-40) God may have used a method to set someone else free that doesn’t work as effectively for you. Perhaps the success of others has done little more than increase your discouragement and self-hatred. Don’t let the enemy play mind games with you. God’s strength is tailor-made for weakness.

We are never stronger than the moment we admit we are weak. Seek God diligently and ask Him to show you the way to victory. Use Scripture-prayers in conjunction with any plan He sets forth for you. Ask Him how He wants you to use Scriptures in your journey to freedom. How God chooses to apply His truth is His call. Becoming legalistic and reciting a bunch of prayers as penitence, or as a magic elixir, will not work. Without a doubt, some of the people respected most in the faith are those who have allowed God to set them free from the strangling stronghold of addiction. That’s the key: Allowing God to work within you.

Anxiety, Depression, and the American Adolsecent

The cover story for Time magazine, November 7, 2016, by Susanna Schrobsdorff, tells of American teens who are anxious, depressed and overwhelmed. Experts are struggling over how to help them. Schrobsdorff’s article is strikingly titled “The Kids Are Not All Right.” The article begins with the story of Faith-Ann Bishop, who was in eighth grade the first time she cut herself. She took a piece of metal from a pen and sliced into the soft skin near her ribs. There was blood and a sense of deep relief. “It makes the world very quiet for a few seconds,” she said. “For a while, I didn’t want to stop, because it was my only coping mechanism. I hadn’t learned any other way.”

Faith-Ann indicated that pain from the superficial wound was a momentary escape from the anxiety she was fighting constantly, about grades, about her future, about relationships, about everything. For Faith-Ann, cutting was a secret, compulsive manifestation of the depression and anxiety that she and millions of teenagers in the U.S. are struggling with. Some experts say self-harm among adolescents is on the rise. Self-Harm Increasing Among Youth.

As Schrobsdorff indicates in her article, adolescents today have a reputation for being more fragile, less resilient and more overwhelmed than their parents were when they were growing up. Sometimes they are called spoiled or cuddled or “helicoptered.” But a closer look paints a far more heartbreaking portrait of why young people are suffering. According to the Time article, anxiety and depression in high school kids have been on the rise since 2012 after several years of stability. This is a problem that cuts across all demographics – suburban, urban and rural; those who are college-bound and those who aren’t.

It is very alarming to learn from Schrobsdorff’s article that in 2015 about 3 million teens aged 12 to 17 had at least one major depressive episode in the past year. (U.S. Dept. of Health and Human Services.) More than 2 million reported experiencing depression that impaired their daily function. According to the National Institute of Mental Health, about 30% of girls and 20% of boys – totaling 6.3 million teens – have had an anxiety disorder. Even more alarming, Schrobsdorff reports that only about 20% of young people with a diagnosable anxiety disorder get treatment.

These adolescents are, according to Schrobsdorff, “…the post-9/11 generation, raised in an era of economic and national insecurity. They’ve never known a time when terrorism and school shootings weren’t the norm. They grew up watching their parents weather a severe recession, and, perhaps most important, they hit puberty at a time when technology and social media were transforming society.” Schrobsdorff also reminds us that “…every fight or slight is documented online for hours or days after the incident.” Faith-Ann Bishop told Schrobsdorff, “We’re the first generation that cannot escape our problems at all. We’re all like little volcanoes. We’re getting this constant pressure, from our phones, from our relationships, from the way things are today.”

Other Concerns Not Discussed in the Time Article

From a distance, depression can seem like no big deal. After all, who doesn’t feel a little down in the dumps now and then? But depression in America is a big deal, and, according to the CDC, it is projected to become an even bigger and more serious issue in the next four years. CDC Mental Health Report. Mental illness is defined as “all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.” Approximately 1 in 5 adults in the U.S. (43.8 million, or 18.5%) experiences mental illness in a given year. Approximately 1 in 5 youth aged 13 to 18 (21.4%) experiences a severe mental disorder at some point during their life. For children aged 8 to 15, the estimate is 13%.3. Mental Health By the Numbers, National Alliance of Mental Health.

Although adolescent depression may not differ significantly from adult depression, the adolescent brain is different, and it seems possible that these differences may affect teenagers and their responses to depression. Teenage propensity for risk-taking and poor decision making can turn untreated depression into a dangerous game. A study released by researchers at the White House Office of National Drug Control Policy suggests that depressed teenagers are more likely to self-medicate with marijuana and illicit drugs. Depressed teenagers are almost twice as likely as their non-depressed peers to become psychologically dependant on marijuana.

The White House study also suggested that use of drugs like marijuana can make depression worse. There was a higher percentage of youth with a major depressive episode in 2014 than in each year from 2004 and 2012 – similar to the 2013 estimate. Youth who experienced a major depressive episode in the past year were more likely than other youth to have used illicit drugs.

When adolescents are depressed, they have a tough time believing that their outlook can improve. But professional treatment can have a dramatic impact on their lives. It can put them back on track and bring them hope for the future.

If you or someone you know is contemplating suicide, call 1-800-273-TALK.

Christianity Today: How Good Church People Become Addicts – and How They Recover

Timothy King’s article Just Say No to Shame in the December 2016 issue of Christianity Today includes a very insightful comment: “My recovery from opioid addiction began when I realized my addiction had chosen me.” King fell to the disease of opioid addiction following suffering from acute necrotizing pancreatitis caused by a surgical procedure. He said, “I had known pain before: crutches, casts, and stitches. But until this moment, pain had always been experienced as something outside of myself. Now it was all that was left of me.”

An opioid, from the root word opium, is a class of pain-relieving drugs that can vary in intensity from fentanyl (extreme) to codeine (mild). According to the Department of Health and Human Services, more than 240 million prescriptions were written for legal opioids in 2014 – more than enough for every adult in the United States to have their own bottle. From 1999 to 2014, the period in which opioid overdose deaths quadrupled, so too did the sales of prescription opioids.

The widespread nature of the opioid epidemic that reaches across typical class, race and geographical stereotypes has challenged myths of who drug addicts are. It has also widened the lens, revealing more moral actors participating in the crisis beyond the addict. Years of distorted public policy, overworked and unrestrained doctors, intentionally misleading pharmaceutical marketing, and even watered-down theology that reduces people to disembodied moral characters instead of whole human persons created in the image and likeness of a good God, have all contributed through sins of both omission and commission.

Many opioid addicts began using these drugs for legitimate physical ailments, merely following their doctor’s orders. In fact, the American Society of Addiction Medicine reports that four out of five heroin addicts started with prescription opioid medications, with nearly all reporting that they eventually switched to heroin because of the price.

Our mental picture of an addict should include the high school honors student who breaks her arm skateboarding and is prescribed an opioid by her doctor. Or the middle-aged factory or construction worker who has permanent back pain from his job and is prescribed an opioid by an overworked doctor who misses the fact that his patient is severely depressed. Or a white, college-educated, employed, middle-class Christian (as in my case, and the case of Timothy King, the author of the article) from a good family who grew up in small-town America.

When King’s doctor informed him he had become addicted to pain medication, he told King, “That isn’t a judgment on you. I’m not saying you’ve done anything wrong or that you aren’t still in pain. But we’ve been giving you this pain medication for so long, your body is now dependent on it. It has gone from helping you to hurting you.” The doctor told King he was not going to just take the pain medication away when he needed it. But he asked King to commit to taking less whenever he could. The doctor said, “For a while you couldn’t have made it without the pain medicine. Now to fully heal, you need to eventually stop taking it.”

In July of this year, Congress passed legislation to address the opioid crisis and heroin epidemic. Even the language  of “crisis” and “epidemic” to describe the bill indicates a shift in mentality. The legislation acknowledges a growing medical consensus that the addict is subject to a disease – one with deep biological and psychological roots that often preclude individual choice. This landmark legislation marked an important step forward in reorienting public policy to reflect this new consensus. Framing addiction as a chronic disease does not remove the moral choices involved, but gives us a broader framework for understanding them. We can’t ignore the reality of our bodies, and when it comes to opioid addiction (as well as other addictions), part of the effect of those chemicals is to actually rewire the brain, making it more difficult, if not nearly impossible, to change patterns of thought and behavior.

King discusses one commonly used analogy helping us understand addiction: heart disease. Like all analogies, it doesn’t explain everything, but it has the virtue of pointing out how clogged arteries cannot be cleared up by giving a pep talk to the patient or urging him to stop breathing so hard after climbing a set of stairs. Its causes are found in a mix of hereditary, environmental, and lifestyle choices. It’s also helpful to think about how often our physical state and surroundings influence our actions.

But the sense that addiction is solely a moral problem is hard to eradicate. After I clearly understood my addiction as a disease (which took nearly four decades and several encounters with the criminal justice system), I still battle internally with my self-image to this day. I grew up with the “Just Say No” anti-drug campaigns aimed at warning youth about illegal drugs. In that model, those with moral fortitude say “no,” and moral degenerates say “yes.” Those who said “no” received praise, and those who said “yes” were shamed and punished.

King recalls how he began to back down from taking opioid painkillers. He writes, “I removed the fentanyl patch first and switched to taking only Dilaudid. Within a day I could again feel my body in ways I did not realize I had been missing. At the same time, it felt as if a thick protective comforter had been ripped off from around me while I lay shivering and naked on my bed. Pain that had been blunted refocused and pressed out from the inside. The doctor was right. I could handle the pain now without the same levels of opioids. But I couldn’t  have continued my recovery if it were all up to the strength of my will alone.” King added, “So much more powerful than saying ‘no’ to an opioid was the opportunity to say ‘yes’ to a slow return to a life of flourishing.”

King said goodbye to narcotic pain medication, but indicated it was not an easy goodbye. He said the feeling was like the tremor in your hand when your blood sugar drops. Desire spreads out to every cell of your body as if each one is making its own demand, aching and promising to be satisfied with “just a little more.” Feelings of withdrawal and the troubled sleep that often comes with them are typically intense for the first few days. They can flare up even months down the road as a reminder of what had been, and the perilously thin line between you and the mounting numbers of long-term addicts and overdose victims. For me, I always thought I could control my usage. I was convinced I would never “take too much” and overdose. And yet it happened. I don’t recall anything from the moment I became unresponsive in my parents’ living room, through the ambulance ride to the ER, and ripping out my IV, to being sedated with haldoperidol. I woke up the next morning in a hospital room.

King relates, “I’ve realized that the word ‘addict’ is a particularly useful descriptor for who I have always been. I always resonated with Paul’s lament: ‘I do not do the good I want to do, but the evil I do not want to do – this I keep doing.’ (Romans 7:19) Some who have never experienced the furious grip of chemical dependence are tempted to split the world into addicts and non-addicts…morally bad and morally good.” He added, “I did not realize how fully I had embraced this view until faced with my own opioid addiction.” For me personally, I will admit I didn’t know I could have an addiction problem and still be a good person.

While addiction science has made strides, there is still no silver bullet. Already there are stories of innovative addicts who have found new ways to abuse the medications intended to help them. Any approach that reduces addiction to a mere problem of brain chemistry and fails to acknowledge humans as moral actors will ultimately fail. But leading researchers and those discussing public initiatives have gone a long way to acknowledge the importance of a both/and methodology.

Churches can be cultural epicenters for shifts in societal norms. The longer that addiction is seen as a struggle for the “sinners out there” and not at the heart of the struggle of each and every one of us, the longer this problem will make headlines and remain in the shadows. Remember, sin takes its deepest root in the cover of darkness where it is never given a name.  King concludes, “When our affliction is named for what it is and brought into the light, that’s when darkness may be overcome.”

Preface to The Surgeon General’s Report on Alcohol, Drugs and Health

Before I assumed my position as U.S. Surgeon General, I stopped by the hospital where I had worked since my residency training to say goodbye to my colleagues. I wanted to thank them, especially the nurses, whose kindness and guidance had helped me on countless occasions. The nurses had one parting request for me. If you can only do one thing as Surgeon General, they said, “Please do something about the addiction crisis in America.”

I have not forgotten their words. As I have traveled across our extraordinary nation, meeting people struggling with substance use disorders and their families, I have come to appreciate even more deeply something I recognized through my own experience in patient care: that substance use disorders represent one of the most pressing public health crises of our time. Whether it is the rapid rise of prescription opioid addiction or the longstanding challenge of alcohol dependence, substance misuse and substance use disorders can—and do— prevent people from living healthy and productive lives. And, just as importantly, they have profound effects on families, friends, and entire communities.

I recognize there is no single solution. We need more policies and programs that increase access to proven treatment modalities. We need to invest more in expanding the scientific evidence base for prevention, treatment, and recovery. We also need a cultural shift in how we think about addiction. For far too long, too many in our country have viewed addiction as a moral failing. This unfortunate stigma has created an added burden of shame that has made people with substance use disorders less likely to come forward and seek help. It has also made it more challenging to marshal the necessary investments in prevention and treatment. We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.

I am proud to release The Surgeon General’s Report on Alcohol, Drugs, and Health. As the first ever Surgeon General’s Report on this important topic, this Report aims to shift the way our society thinks about substance misuse and substance use disorders while defining actions we can take to prevent and treat these conditions.

Over the past few decades, we have built a robust evidence base on this subject. We now know that there is a neurobiological basis for substance use disorders with potential for both recovery and recurrence. We have evidence-based interventions that prevent harmful substance use and related problems, particularly when started early. We also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support. Additionally, we have learned that recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual. As Surgeon General, I care deeply about the health and well-being of all who are affected by substance misuse and substance use disorders.

This Report offers a way forward through a public health approach that is firmly grounded in the best available science. Recognizing that we all have a role to play, the Report contains suggested actions that are intended for parents, families, educators, health care professionals, public policy makers, researchers, and all community members.

Above all, we can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves. Despite the significant work that remains ahead of us, there are reasons to be hopeful. I find hope in the people I have met in recovery all across America who are now helping others with substance use disorders find their way. I draw strength from the communities I have visited that are coming together to work on prevention initiatives and to connect more people to treatment. And I am inspired by the countless family members who have lost loved ones to addiction and who have transformed their pain into a passion for helping others. These individuals and communities are rays of hope. It is now our collective duty to bring such light to all corners of our country.

How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another?

Fifty years ago, the landmark Surgeon General’s report on the dangers of smoking began a half century of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General’s Report on Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can lead healthy and fulfilling lives.

Vivek H. Murthy, M.D., M.B.A., Vice Admiral, U.S. Public Health Service, Surgeon General

To read The Surgeon General’s Report on Alcohol, Drugs, and Health click on the following link: https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf