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.

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“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.

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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.

 

The Opioid Issue: Part 3

Part Three: A System on the Brink

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Already under tremendous strain from a lack of qualified homes and social support, the American foster care system is staring down its toughest opponent yet: the opioid epidemic. Typically, when a mother or father in active addiction has young dependent children, agencies such as Children and Youth or Child and Family Services will remove the children from their parents. Of course, family court judges nearly always focus on possibly reuniting the children and their parents after they become clean and sober.

Consider the mother of a child who was born addicted to opiates. The court removed the infant from the mother’s care and placed him in foster care. After the mother was able to stay clean for one year and put her life back together, the child was returned to her. Sadly, the mother ultimately relapsed, and the child’s health and welfare were put in jeopardy. He would need to reenter the foster care system, this time with the goal of being adopted permanently. Foster Care CollageAccording to the U.S. Department of Health and Human Services (HHS), nearly half a million children nationwide were living in foster care arrangements in 2016—and that number has been rising for the last four years. One could say the very heart of the nation’s foster system is aching for any sort of relief.

A Century-Old Practice

Since creating a Children’s Bureau in 1912, the U.S. government has played a critical role when parents can no longer care for their minor children due to illness, death, criminal activity and/or substance abuse. That care—provided mainly by individual foster families or relatives, but also through group homes and institutions—has at times extended to other nations, such as the more than 8,000 European refugee children who were fostered in American homes during World War II.

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Though it has successfully kept millions of children fed, clothed, educated, sheltered and safe over the last 106 years, the American foster system hasn’t been foolproof. In 1972, when President Richard Nixon declared a “National Action for Foster Children Week” to recruit more foster families, the system has been highlighted mostly for its deficits: Too few willing foster parents, too many kids, too little funding and support, too hard on the heart for everyone involved.

Margie Nielsen deals with those shortcomings daily. As the director of Foster Care & Adoption Ministries at Louisiana Baptist Children’s Home (LBCH)—a nonprofit ministry founded in 1899, more than a decade before official government foster care was created—Nielsen’s organization is an official partner of the Louisiana Department of Children & Family Services. Certified foster parents run residential “cottages” that each accommodate up to six children between the ages of 5 and 17. LBCH exists to educate, inform, encourage, support, and strengthen current and prospective foster parents.

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While there are many families who clearly are not called to foster, everyone can and should be involved in supporting the families who are. In James 1:27, God’s Word teaches, “Religion that God our Father accepts as pure and faultless is this: to look after orphans and widows in their distress and to keep oneself from being polluted by the world” (NIV). It is our duty as the Body of Christ to help foster families to understand the call God has placed on their lives and to help equip them to answer that call. A joy, yes—but the last few years have greatly expanded the need for people to answer that call.

With opioid addiction soaring to crisis level, it certainly calls for more information to be disseminated. And while drug addiction of any kind affects everyone, the nation’s opioid crisis has upped the ante. The necessity of developing preventive strategies is felt more than before.

Little Victims

While the connection between drug abuse and children needing foster care is nothing new—think heroin in the 1970s, cocaine in the 1980s, and meth in the 1990s—what has changed the game for today’s foster care system has been the sheer percentage of Americans struggling with opioid addiction across all demographics. The cold hard truth: That number staggers at more than two million, according to the American Society of Addiction Medicine, a 60-year-old professional society for treatment providers based in Maryland.

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According to the National Institute of Health, 21 to 29 percent of patients suffering from chronic pain misuse their prescription opioids, and that often puts them on the path to harder drugs; about 80 percent of people who use heroin first abused prescription opioids, Tragically, around 116 people in the United States die from an opioid overdose every day—that’s one death every seven minutestranslating into tens of thousands of dead Americans annually. In fact, the U.S. Centers for Disease Control and Prevention reports more than 200,000 people died from prescription opioid overdoses between 1999 and 2016.

It stands to reason that a significant portion of those people who died, as well as the millions living with addiction, were or are parents of minor children. Indeed, HHS reports 30,000 more children were living in foster homes nationwide in 2015 than in 2012, and substance abuse (including, but not limited to, opioids) was cited as a reason in about one-third of those placements. Drug addiction does not discriminate; sadly, it can hit any family at any time. And often, when it does, children of those struggling with addiction enter the already-pressed foster system.

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Simply put, there are not enough foster homes in the United States to accommodate the burgeoning number of kids needing short- and long-term care. In California, for example, the Los Angeles Times reports the number of available beds in qualified foster homes fell from 22,000 in 2000 to just 9,000 in 2016. Massachusetts had more than 6,100 foster children in 2016, but less than 4,800 foster homes, according to The Boston Globe. Such shortages have led to reports of foster children sleeping in government offices and even hotels around the nation while their social workers scramble to find willing families.

But it’s not just the dearth of available foster parents that concerns child welfare advocates. Though government reports show about one-quarter of all formal foster care placements are with relatives (sometimes called kinship care), the vast majority of foster families are strangers to foster children. According to the National Center for Missing & Exploited Children, 88 percent of the 25,000 children who reported ran away from home in 2017 were in foster care at the time. Many of those runaways become the victims of sex traffickers.

We need to pray that as each day passes these foster children (who have had their tiny world shattered by drug abuse) survive—indeed, thrive—and that they live with hearts full of love and hope. Sadly, the future is yet unclear regarding America’s opiate epidemic. Moreover, we don’t know the full scope of opioid crisis’ on the foster system still has yet to be revealed. These little victims never had the choice to be exposed to the drugs. They can’t Just Say No.

Thousands upon thousands of little Americans are waiting to be seen, helped and healed.

The Opioid Issue: Part 2

Part Two: Collateral Damage

As the nation grapples with opioid’s hold over millions, its smallest victims cry out to be heard, held, and healed. No Child Left Behind is a familiar battle cry. But to foster parents helping to care for children of parents addicted to drugs, those words have nothing to do with a political agenda or advertising campaign. One foster mom reported quietly watching another baby detox from opiates, its high-pitched wails unique with the sound of drug-induced anguish, and whispering, “A whole generation is being lost from the opioid epidemic. A whole generation.”

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That generation—with hundreds of thousands of America’s youngest feeling its physical, mental, and emotional impact, sometimes from the moment of conception—is staring down what doctors call Neonatal Abstinence Syndrome (NAS). The condition is not something that can be cured with a pill. There are so many children growing up without their parents that the long-term ramifications are still unforeseen. The United States has certainly faced its share of social and public health problems over the years, but when it comes to the opioid crisis, child advocates around the country warn, it’s a strange and scary new world.

Agony in the Womb

According to a study released by the University of Minnesota this spring, one baby struggling with NAS is born in America every 15 minutes. Furthermore, almost 90 percent of pregnancies among women struggling with opioid addiction are unintentional. When a woman takes opioids while pregnant—even exactly as a doctor might instruct, according to the March of Dimes—she runs the substantial risk of harming her unborn child.

One Baby Every Half Hour

Prescription painkillers like codeine, fentanyl, hydrocodone, morphine, and oxycodone (as well as the street drug heroin) are all classified as opioids and all negatively affect children in the womb. Common risks of opioid use during pregnancy, the March of Dimes says, include miscarriage, preterm labor, premature birth, birth defects, low birth weight (defined as weighing less than five pounds, eight ounces), and NAS. NAS is its own beast. The completely preventable condition can grip babies with tremors, fever, chills, weight loss, seizures, and even death. Dr. W. David Hager, member of Focus on the Family’s Physicians Resource Council (PRC), believes 55-94% of newborns delivered to women who used opioids in pregnancy suffer from NAS.

Clearly, it is nearly impossible for an unborn child to skate past the consequences of his or her mother’s opioid use, no matter how slight. Yet damage isn’t usually intentional. Instead, Hager says, addiction to opioids reaches far beyond the initial physical pleasure to something much deeper.

It All Adds Up

That’s a familiar story for J. Scott Moody and Wendy Warcholik, a married pair of economists. As the directors of Family Prosperity Institute (FPI), a New Hampshire-based think tank focused on measuring the health of the American family, Moody and Warcholik frequently hear about opioid-related crises—and have watched their own loved ones succumb to substance abuse along the way. Warcholik, for example, grew up in a family fragmented by her parents’ collective five divorces. Of all her siblings, she was the only one to have fully escaped the negative consequences. The others have experienced unemployment, substance abuse, government dependency, low educational attainment, unwed childbirth, and divorce.

FPI has created a family prosperity index—a formula-driven rankings list that measures the strength and prosperity of families and the nation by combining the most important economic and social data into a single number and then ranking those states based on which create the best environment for families to thrive. The index fills in the gaps around other measures like the gross domestic product, assembling all the pieces of the prosperity puzzle into a complete picture of the economy. No other measure takes into consideration both the economic and social choices of people in a state to create a holistic measure of human behavior in the States.

The latest FPI index ranked Utah first and New Mexico last. FPI’s formula calculates things like average welfare utilization, children in married households, religious attendance and infant mortality rate. That last category is most disconcerting because as opioid use has risen, so has infant mortality rate. (The U.S. Centers for Disease Control and Prevention defines that as the death of an infant before his or her first birthday), while the infant mortality rate is the number of infant deaths for every 1,000 live births.

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Between 2010 and 2015 twenty-one states saw an increase in their infant mortality rate. So many states, in fact, that while the national average dropped 16 percent between 2000 and 2015, the last five years only saw a decrease of 1.6 percent. Clearly, if trends continue, the country could see an increase in the infant mortality rate in the near future. Keep in mind that a rising infant mortality rate is typically only found in Third World countries. Besides the physical, emotional and mental cost to America’s children, opioid addiction doesn’t come fiscally cheap, either. For example, in 2015 Ohio paid more than $133 million to care for approximately 2,000 NAS babies born that year.

The True Cost

Interestingly, FPI’s research shows that devout beliefs and behaviors (consistent church attendance, daily prayer, Bible reading, etc.) reduce illicit drug use. The converse holds true as well. Moody says, “It is clear that people in despair who don’t turn to God for help will try to numb their pain some other way, whether it be with drugs or sex. Unfortunately, at least for the last decade, we’ve been seeing more and more people turning to drugs and sex than God. We have to reverse this trend.”

Ultimately, America truly has no idea what the long-term consequences of opioid addiction on our most innocent citizens will be. “We read horrifying stories in New England about parents shooting up their own children just to keep them quiet, or left in a freezing car with their parents passed out in the front seat,” Warcholik says. How far are we, as a society, willing to go in elevating adult desires over the health and well being of our children?

That is a question far beyond the scope of any research team—but one the Church must rise up to help answer.

 

 

The Opioid Issue: Part 1

Part One: Dangerous Prescriptions

The opioid crisis seems to hit everyone, everywhere, regardless of socioeconomic class, geography, age, profession, or religious affiliation. Overdosing on drugs, especially opiates and heroin, is now the most common cause of death for Americans under fifty years of age. I spent forty years embroiled in active addiction. It started innocently with a case of beer, but quickly led to marijuana, cocaine, and inhalants. The longer I struggled, the more hopeless I became. Friends stopped calling me or inviting me to parties. Family felt they could no longer trust me given the hundreds of broken promises and countless runs on their medicine cabinets for opiates. Although I was able to stop drinking and taking street drugs in 2008, I battled with benzodiazepines (Xanax, Ativan) and oxycodone for another eight years. I am blessed presently with nearly two years without taking narcotics.

Opiates in Pill Bottles

This epidemic has reached every corner of the United States. This is the first in a series of blog posts regarding opiate addiction in America. This series will address dangers of opiate prescriptions, collateral damage, impact on the nation’s foster care system, homelessness and addiction, troubling developments in drug rehabilitation, addiction and crime, and a Christian response to the crisis.

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Current medical opinion indicates the reason the U.S. is experiencing a disastrous epidemic of opioid abuse can be summed up in two words: pain avoidance. In the 1990s there was a proliferation of health care professionals trying to address the symptom [of pain] and not so much the underlying causes of the pain a person has. In 2015, opioid-related deaths stole the lives of over 33,000 Americans. To put this number into perspective, this outnumbers fatal car crashes and gun deaths during the same year. According to the federal government, in 2016 the nation mourned close to 64,000 deaths from drug overdoses. Two-thirds of those involved the misuse of opioids. Karl Benzio, M.D., a Christian psychiatrist and member of Focus on the Family’s Physicians Resource Council (PRC), fears the toll could reach 80,000 deaths in 2018.

We wouldn’t be here if opioids weren’t so effective. Americans want something for their pain—regardless of whether that pain is physical, mental, or emotional. We live in a psychologically compromised society that is impatient and entitled, whose citizens feel there should be no pain in life. Accordingly, greater demands have been made on providers to eliminate all pain with medication. The problem is—and I know this all too well firsthand—once a patient gets a taste of the relief, some develop a dependence that leads them down a dark path. Ironically, that path leads only to deeper struggles. For some, the exit will only come in the form of fatal overdoses as opioids shut down the body’s ability to breath.

It is time we start helping patients deal with life’s pain and its root causes head-on, rather than masking it through medication.

How it All Began

Chronic Pain The Silent Condition

The current crisis can be traced back nearly forty years. Medical researcher Hershel Jick and graduate student Jane Porter of Boston University Medical Center analyzed data from patients who had been hospitalized there. Close to 12,000 had received at least one dose of a narcotic pain medication during their stay. Of those, Jick and Porter’s analysis found only four had developed a well-documented addiction. Jick sent the findings to the New England Journal of Medicine, who published his analysis as a letter to the editor in 1980. “Despite widespread use of narcotics [sic] drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction,” Jick wrote. Unfortunately, this quote was given far more merit than it deserved. Moreover, the conclusion had not been subjected to peer review.

In 1990, Scientific American called the Jick/Porter research “an extensive study.” About a decade later, Time proclaimed it “a landmark study.” Most significantly, Purdue Pharmaceuticals, maker of the popular narcotic OxyContin, began a promotion asserting less than one percent of patients treated with their time-released opiate medication OxyContin would become addicted. In the 1990s, pain was correlated with a greater probability of a patient having ongoing health issues. So the medical community elevated it to the position of the fifth vital sign along with heart rate, blood pressure, body temperature, and respiratory rate. The medical community, thinking that reducing pain would help long-term patient satisfaction, health and outcomes, started to prescribe more pain meds.

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The ’90s also saw the development of stronger and more effective opioid painkillers. As the decade drew to a close, the opioid epidemic was ignited. It took some time for most of the country to realize the metaphorical fuse had been lit, but the numbers back up this concern. According to the U.S. Department of Health and Human Services (HHS), between 2000 and 2017 opioid prescriptions increased 400 percent. Between 2000 and 2010, misuse involving noncompliance with prescription instructions or using medications prescribed for another person doubled. Now, the results are playing out in heartbreaking fashion nationwide, which are impossible to ignore. Overdose deaths—116 per day, according to federal statistics—are shaking Americans of all incomes, ages, and ethnicity. From the rural back roads of Appalachia (Kentucky, West Virginia) to the urban sprawl of New York and Los Angeles, the epidemic is cutting a path that threatens to leave no family unscathed.

The Blame Game

It’s become quite popular (if not convenient) to lay the blame for the epidemic squarely at the feet of the big pharmaceutical companies. For example, according to an article in the Los Angeles Times in May of this year, more than 350 cities, counties, and states had filed lawsuits against makers and distributors of opioid painkillers. The LA civil action accuses drugmakers and distributors of deceptive marketing aimed at boosting sales, claiming the companies borrowed from the “tobacco industry playbook.” One of the companies most frequently put under scrutiny has been Purdue Pharma, maker of OxyContin.

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In May The New York Times called Purdue “the company that planted the seeds of the opioid epidemic through its aggressive marketing of OxyContin.” The Times article uncovered a disturbing report on OxyContin compiled by the U.S. Department of Justice, which found that Purdue Pharma knew about and concealed significant incidents of abuse of OxyContin in the first years after the drug hit the market in 1996. The article further noted that Purdue Pharma admitted in open court in 2007 that it misrepresented the data regarding OxyContin’s potential for abuse.

Overdose Deaths Not Just Related to Opiate Prescriptions

Government reports have recently stated that today’s increase of fatal opioid-related overdoses is being driven by abuse of heroin and illicit fentanyl. A study prepared by the National Institute on Drug Abuse last September found that overdose deaths from heroin and other drugs laced with fentanyl increased 600 percent between 2002 and 2015. Street dealers have increasingly been cutting their drugs with fentanyl—a particularly dangerous and relatively inexpensive substance 50 to 100 times more powerful than morphine—to boost their profit margins. In most cases, the users don’t even realize they’re buying fentanyl-laced products.

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It is important to note that although many people believe Big Pharma is complicit in fueling the epidemic and should shoulder the loin’s share of the blame, Dr. Benzio sees it differently. “Pharmaceutical companies only make the meds,” Benzio says. “Only about 6 to 8 percent of people who take an opioid will misuse or overuse it in a destructive way. It is the doctors who over-prescribe and a society that is looking for a quick fix and can’t tolerate any discomfort [that’s to blame].”

The Road Ahead

The opiate epidemic may have grown somewhat quietly, but the nation’s attention is riveted to it now and policymakers aren’t sitting still. In 2016, Massachusetts became the first state to limit the duration for painkiller prescriptions at seven days. Since then, more than two dozen other states have also established limits. In my home state of Pennsylvania, Governor Tom Wolf initiated a statewide prescription drug monitoring system to help prevent prescription drug abuse. Of concern is the practice of “doctor shopping,” which involves a patient visiting multiple doctors and emergency departments in search of opioids. Unfortunately, this is something I did quite often while in active addiction. This practice often necessitates filling prescriptions at multiple pharmacies. The governor’s new policy includes the monitoring program, a standing order for naloxone (Narcan, used to reverse the effects of an opiate overdose), a patient non-opioid directive (which allows patients to opt out of opioid pain medicine in advance) a “warm hand-off” where ER attending physicians and other providers can set up a face-to-face introduction between a patient and a substance abuse specialist, and revised prescribing guidelines relative to opiates.

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At the federal level, President Donald Trump declared the opioid crisis a public health emergency in 2017, and formed a commission to fight it. Meanwhile, HHS now has a multi-pronged strategy to get the crisis under control, including getting better data through research and improving prevention, treatment, pain management, and recovery services. The federal crackdown is estimated to cost $13 billion to $18 billion over the next two years. Dr. Benzio believes this is “a good start,” but said providers must resist the urge to automatically jump to the quick fix of narcotics for those in pain. “There are many ways to combat pain through physical therapy and fitness, relaxation, better sleep and nutrition,” says Benzio. It seems likely that we will not get a significant handle on opioid abuse until the core issues that lead people to the drugs are addressed.

The Christian Perspective

W. David Hager, M.D., a member of the PRC, notes three principle root issues in addiction: rejection, abandonment and abuse. Hager has been a facilitator for the Christian program Celebrate Recovery. He said, “Unless we enable [people] to identify their root issue and deal with it first, the rates of relapse are high. When they are able to deal with their root issues by offering forgiveness, making amends, and seeking a personal relationship with Jesus Christ, we find that large numbers are able to enter and maintain sobriety.” That is why the Church has the unique ability to make a difference in combating the opioid crisis.

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“We have to convince faith-based communities to get their hands dirty, to get involved and realize that this is an issue,” Benzio says. He suggests inviting laypeople to develop a working knowledge of dopamine, the brain chemical that provides the pleasure-inducing sensation many who use drugs are seeking. “There is only one [higher] power that can sever synapses in the brain that have been stimulated by a substance to achieve [a certain] dopamine level,” he adds, “and that’s the power of the Holy Spirit.”

Exactly how Christians appropriate the Spirit’s power to take on the opioid crisis will vary from case to case. The point, Benzio and Hager say, is that this needs to become a top-of-mind concern for the Church. But are North American churches up to the mission of addressing opioid use among their members? Pastors are in a unique position to proclaim and demonstrate the Gospel to individuals struggling with addiction. Many are too ashamed to confess an addiction to pain medication. As the opioid crisis deepens, so must the response of the local church. If the Christian church has anything to offer those hurting from drug addiction, it is hope and community. I was only able to break the bondage of addiction over my life through the Power in the Name of Jesus.

Power in the Name of Jesus

Programs such as Narcotics Anonymous and Celebrate Recovery have been extremely effective in changing lives, but it’s not always enough. Addressing the root of addiction is one of the most effective long-term solutions, which for Christians is about the heart. The church must be willing and capable of seeing those struggling with addiction as not merely a program of the church’s community outreach; these individuals are children of a God who loves them no matter their current condition. I believe America’s recovery can find its roots in the local church.

What does love look like? It has the hands to help others. It has the feet to hasten to the poor and needy. It has eyes to see misery and want. It has the ears to hear the sighs and sorrows of men. That’s what love looks like. -St. Augustine

 

 

Partnering With Dentists and Oral Surgeons to Fight Opiate Addiction

From the blog of Dr. Nora Volkow, Executive Director of NIDA, posted July 25, 2018

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Reducing the reliance of doctors on potentially addictive opioid pain relievers has been one of the pillars of federal efforts to reverse the opioid crisis. Because many dental procedures such as extractions and other types of oral surgery often produce severe acute pain, dentists are among the largest prescribers of opioids. Thankfully, the dental profession has made significant progress in reducing opioid prescriptions. Two decades ago, when the opioid crisis was just starting, dentists accounted for 15.5 percent of all immediate-release opioid prescriptions; by 2012, they only wrote 6.4 percent of such prescriptions. Still, those in the oral health professions can play a key role in further improving the treatment of acute pain and making it safer.

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In March of this year, the American Dental Association (ADA) released a new policy on opiods, supporting limits on dosage and duration of opioid prescriptions and mandatory continuing education on their use, as well as recommending that dentists make use of their regional prescription drug monitoring program (PDMP). This policy is an important step toward protecting patients and their families from the potential harms of opioids. Following a meeting between representatives of the National Institute on Drug Abuse (NIDA), the National Institute of Dental and Craniofacial Research (NIDCR), and the ADA, NIDCR director Martha Somerman and Dr. Volkow wrote an editorial in this month’s issue of the Journal of the American Dental Association about how a partnership between NIH and oral health practitioners can continue to alleviate the opioid overdose epidemic.

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Increased knowledge of opioid prescribing practices among dentists, as well as among emergency department physicians when managing acute dental pain, is an important research priority. While dentists have reduced their opioid prescriptions, recent studies suggest the same is not true of emergency department providers when patients have dental pain. A study of Medicaid recipients showed that physicians in the ER prescribed opioids for dental pain five times more often than dentists in their own practices, and nurse practitioners in the ER prescribed opioids three times as often. Understanding the ways opioids are prescribed and the decisions underlying opioid prescribing can inform new clinical guidelines and policies to reduce the risks of opioid misuse. 

Concluding Remarks

Dentists can play a role in minimizing opioid abuse through patient education, careful patient assessment and referral for substance abuse treatment when indicated, and using tools such as prescription monitoring programs. Research is needed to determine the optimal number of doses needed to treat dental-related pain. Besides reducing their prescribing of opioids, these practitioners can learn to screen for opioid misuse and opioid use disorders, ultimately referring patients to treatment when indicated. To this end, NIDCR plans to fund research studies of interventions in rural communities.

These practitioners cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. Dentists, along with other prescribers, take steps to identify problems and minimize prescription opioid abuse through greater prescriber and patient education; use of peer-reviewed recommendations for analgesia; and, when indicated, the tailoring of the appropriate and legitimate prescribing of opioids to adequately treat pain.

Ambitious Research Plan to Help Solve the Opioid Crisis

From the blog of Dr. Lora Volkow, National Institute on Drug Abuse Posted June 12, 2018

NIDA Banner Science of Abuse and Addiction

In spring 2018 Congress added an additional $500 million to the NIH budget to invest in the search for solutions to the opioid crisis. The Helping to End Addiction Long-term (HEAL) initiative is being kicked off June 12th with the announcement of several bold projects across NIH focusing on two main areas: improving opioid addiction treatments and enhancing pain management to prevent addiction and overdose. The funding NIDA is receiving will go toward the goal of addressing addiction in new ways, and creating better delivery systems for addictions counseling for those in need.

NIH will be developing new addiction treatments and overdose-reversal tools. Three medications are currently FDA-approved to treat opioid addiction. Lofexidine—a drug initially developed to treat high blood pressure—has just been approved to treat physical symptoms of opioid withdrawal. Narcan (naloxone) is available in injectable and intranasal formulations to reverse overdose. Regardless, more options are needed. One area of need involves new formulations of existing drugs, such as longer-acting formulations of opioid agonists and longer-acting naloxone formulations more suitable for reversing fentanyl overdoses. Compounds are also needed that target different receptor systems or immunotherapies for treating symptoms of withdrawal and craving in addition to the progression of opioid use disorders.

Much research already points to the benefits of increasing the availability of treatment options for Opioid Use Disorder (“OUD”), especially among populations currently embroiled in the justice system. Justice Community Opioid Innovation Network is working to create a network of researchers who can rapidly conduct studies aimed at improving access to high-quality, evidence-based addiction treatment in justice settings. It will involve implementing a national survey of addiction treatment delivery services in local and state justice systems; studying the effectiveness and adoption of medications, interventions, and technologies in those settings; and finding ways to use existing data sources as well as developing new research methods to ensure that interventions have the maximum impact.

The National Drug Abuse Treatment Clinical Trials Network (“CTN”) facilitates collaboration between NIDA, research scientists at universities, and a myriad of treatment providers in the community, with the aim of developing, testing, and implementing addiction treatments. As part of the HEAL initiative, the CTN Opioid Research Enhancement Project will greatly expand the CTN’s capacity to conduct trials by adding new sites and new investigators. The funds will also enable the expansion of existing studies and facilitate developing and implementing new studies to improve identification of opioid misuse and OUD. Further, it will enhance engagement and retention of patients in treatment in a variety of general medical settings, including primary care, emergency departments, ob/gyn, and pediatrics.

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A great tragedy of the opioid crisis is that there are a number of effective tools not being deployed effectively in communities in need. Only a fraction of people with OUD receive any treatment, and of those less than half receive medications that are universally acknowledged to be the standard of care. Moreover, patients often receive medications for too short a duration. As part of its HEAL efforts, NIDA will launch a multi-site implementation research study called the HEALing Communities Study in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA). The HEALing Communities Study will support research in up to three communities highly affected by the opioid crisis, which should help evaluate how the implementation of an integrated set of evidence-based interventions within healthcare, behavioral health, justice systems, and community organizations can work to decrease opioid overdoses and prevent and treat OUD. Lessons learned from this study will yield best practices that can then be applied to other communities across the nation.

The HEAL Initiative is a tremendous opportunity to focus taxpayer dollars effectively where they are needed the most: in applying science to find solutions to the worst drug crisis our country has ever seen.

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. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

Opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as Fentanyl, and pain relievers available by prescription such as codeine, oxycodone, Vicodin, morphine, and others.

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All opioids are chemically related and interact with opioid receptors on nerve cells in the brain and on the spinal column. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose, and death. 

An opioid overdose can be reversed with the drug naloxone (Narcan) when given right away. Improvements have been seen in some regions of the country in the form of decreasing availability of prescription opioid pain relievers and decreasing misuse among the Nation’s teens. However, since 2007, overdose deaths related to heroin have been increasing. Fortunately, effective medications exist to treat opioid use disorders including methadone, Buprenex and Vivitrol. 

A National Institute of Drug Abuse (NIDA) study found that once treatment is initiated, both a Buprenex/Vivitrol combination and an extended-release Vivitrol formulation are similarly effective in treating opioid addiction. However, Vivitrol requires full detoxification, so initiating treatment among active users is difficult. These medications help many people recover from opioid addiction.

What are Prescription Opioids?

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Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made by scientists in labs using the same chemical structure. Opioids are often used as medicines because they contain chemicals that relax the body and can relieve pain. Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can also make people feel very relaxed and high, which is why they are sometimes used for non-medical reasons. This can be dangerous because opioids can be highly addictive. Overdoses and death are common. Heroin is one of the world’s most dangerous opioids, and is never used as a medicine in the United States.

How Do People Misuse Opioids?

Prescription opioids used for pain relief are generally safe when taken for a short time and as directed by a doctor, but they can be misused. People misuse prescription opioids by:

  • taking the medicine in a way or dose other than prescribed
  • taking someone else’s prescription medicine
  • taking the medicine for the effect it causes—getting high

How Do Prescription Opioids Affect the Brain?

Opioids bind to and activate opioid receptors on cells located in many areas of the brain, spinal cord, and other organs in the body, especially those involved in feelings of pain and pleasure. When opioids attach to these receptors, they block pain signals sent from the brain to the body and release large amounts of dopamine throughout the body. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience.

Opioid misuse can cause slowed breathing, which can cause hypoxia, a condition that results when too little oxygen reaches the brain. Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, or death. Researchers are also investigating the long-term effects of opioid addiction on the brain, including whether damage can be reversed.

What are Other Health Effects of Opioid Medications?

Older adults are at higher risk of accidental misuse or abuse because they typically have multiple prescriptions and chronic diseases, increasing the risk of drug-drug and drug-disease interactions, as well as a slowed metabolism that affects the breakdown of drugs. Sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV.

Prescription Opioids and Heroin

Prescription opioids and heroin are chemically similar and can produce a similar high. Heroin is typically cheaper and easier to get than prescription opioids, so some people switch to using heroin instead. Nearly 80 percent of Americans using heroin (including those in treatment) reported misusing prescription opioids prior to using heroin. However, while prescription opioid misuse is a risk factor for starting heroin use, only a small fraction of people who misuse pain relievers switch to heroin. This suggests that prescription opioid misuse is just one factor leading to heroin use.

The Numbers

More than 64,000 Americans died from drug overdoses in 2016, including illicit drugs and prescription opioids. This number has nearly doubled over the past ten years. 2015 was the worst year for drug overdoses in U.S. history. Then 2016 came along. In that year alone, drug overdoses killed more people than the entire Vietnam War did.

A chart of US drug overdoses going back to 1999.

The Opioid Epidemic Explained

This latest drug epidemic is not solely about illegal drugs. It began, in fact, with a legal drug. Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About 100 million U. S. adults suffer from chronic pain, according to a report from the Institute of Medicine.

Chronic Pain The Silent Condition

Pharmaceutical companies took advantage of this concern. Through a big marketing campaign they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term non-cancer related chronic pain is very weak despite their effectiveness for severe short-term, acute pain—while the evidence that opioids cause harm in the long term is very strong. So painkillers inundated society, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.

As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (Xanax, Ativan, Valium) typically prescribed to relieve anxiety. By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths. The numbers have grown exponentially over the past three years.

What Can We Do?

Seeing the rise in opioid misuse and deaths, officials have cracked down on prescription painkillers. Law enforcement, for instance, now threaten doctors with incarceration and loss of their medical licenses if they prescribed the drugs unscrupulously. Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being instructed to give more thought to their prescriptions.

Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids bought off the street, such as heroin and Fentanyl. Not all painkiller users went this direction, and not all opioid users started with painkillers. But statistics suggest many did. A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention (CDC) found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

So other types of opioid overdoses, excluding painkillers, also rose. That doesn’t mean cracking down on painkillers was a mistake. It appears to have slowed the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders. But the likely solution is to get opioid users into treatment. According to a 2016 report by the Surgeon General of the United States, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options. Given the exorbitant cost of health care in America today, that is simply unacceptable. Federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and Buprenex.

Source: National Institute on Drug Abuse; National Institutes of Health; U. S. Department of Health and Human Services.

NIH Study Yields Important Insight Into Addiction and Pain

From the web blog of Dr. Lora Volkow, director of the National Institute of Drug Abuse dated May 6, 2018.

We are on the verge of a new era in medicine, one that truly treats the patient as an individual and as a participant in his or her own care. New data-gathering and analytic capabilities are enabling the kinds of massive, long-term studies needed to investigate genetic, environmental, and lifestyle factors that contribute to disease. Fine-grained insight into prevention and treatment is creating a truly precision, individualized form of medicine, the payoffs of which are already striking in such areas as cancer treatment.

Recently, the NIH Precision Medicine Initiative launched All of Us, a massive study set to gather data from a million Americans across all demographic, regional, and health/illness spectrums. It will use electronic health records to track the health and medical care received by participants for a decade or more, incorporating surveys, blood and urine samples, and even data from fitness trackers or other wearable devices. For the time being, recruitment is limited to those 18 or older, but future stages will include children as well. The data will be open-access for researchers—and of course, anonymous.

The All of Us study will benefit addiction science in many ways, such as yielding valuable data on the influence of substance use and substance use disorders on various medical conditions. Information on use of alcohol, tobacco, opioids, and perhaps other substances is liable to be captured in the electronic health records used for this study, and surveys will also capture lifestyle-related information including substance use and misuse. Gathering these records and survey data over time will provide important insight into how common forms of substance use impact treatment outcomes for a range of common diseases. It could yield valuable insights into genetic risk factors for substance use and substance use disorders as well as predictors of responsiveness to treatment using different medications. Links between substance use, substance use disorders, and other psychiatric problems such as depression and suicide can also be explored with such a large sample.

Factors affecting pain and its treatment are also directly relevant to addiction, especially in the context of the current opioid crisis. All of Us could provide valuable data on demographic variations in pain prescribing, telling us what groups (ethnic, age, and gender) are being prescribed opioids as opposed to other medications or non-pharmacological treatments. It will also tell researchers how these treatments affect patients’ lives. This data set will help answer questions about the role opioid treatments may play in the transition from acute to chronic pain, for instance, and what role opioid treatment plays in development of opioid use disorders or other substance use disorders. It will also help us understand what other factors, such as mental health or other co-morbidity, affects trajectories associated with pain.

Like the ABCD study currently underway to study adolescent brain development, the All of Us study is deliberately open-ended. It is understood that rapidly advancing technology will give us the ability not only to answer new questions but also ask questions that might not even occur to researchers currently. Consequently, All of Us is being designed to allow the ingenuity of the research community to explore how this dataset can be utilized and design new ways of making it address their specific research questions.

Why is Early Childhood Important to Substance Abuse Prevention?

Abundant research in psychology, human development, and other fields has shown that events and circumstances early in peoples’ lives influence future decisions, life events, and life circumstances—or what is called the life course trajectory. People who use drugs typically begin doing so during adolescence or young adulthood, but the ground may be prepared for drug use much earlier, by circumstances and events that affect the child during the first several years of life and even before birth.

Intervening early in childhood can alter the life course trajectory in a positive direction.

The first, overarching principle drawn from research is that intervening early in childhood can alter the life course trajectory of children in a positive direction. Early childhood includes prenatal through age 8, as delineated by the following developmental periods:

  • Prenatal Period (conception and birth)
  • Infancy and Toddler (birth to 3 years)
  • Preschool (ages 3 through 5)
  • Transition to School (ages 6 through 8 years)

The “transition to school” period is actually part of the middle childhood and early adolescence period (6 to 13 years), but is addressed separately here because it is a major and significant transition in the child’s development. The middle childhood period is followed by adolescence (ages 13 to 18). The age range for interventions that form the basis for the principles of prevention described in this resource is prenatal through 8 years.

Life course perspectives show risk for drug abuse; How Do We Prevent it?

The period of development discussed above is typically characterized by rapid orderly progressions of normal patterns of physical, cognitive, emotional, and social development. Such development is marked by important transitions between developmental periods and the achievement of successive developmental milestones. How successfully or unsuccessfully a child meets the demands and challenges arising from a given transition, and whether the child meets milestones on an appropriate schedule, most certainly has an affect on his or her future course of development, including an elevated risk for drug abuse or other mental, emotional, or behavioral problems during adolescence.

A number of risk factors can interrupt or interfere with unfolding developmental patterns in all of these periods and, especially, in the transitions between them. Prevention interventions designed specifically for early developmental periods can address these risk factors by building on existing strengths of the child and his or her parents (or other caregivers) and by providing skills (e.g., general parenting skills and specific skills like managing aggressive behavior), problem-solving strategies, and support in areas of the child’s life that are underdeveloped or lacking.

The child’s stages of life, aspects of his social and physical environments, and life events he experiences over time all contribute to his physical, psychological, emotional, and cognitive development.

Life events or transitions represent points during which the individual is in a period of fluidity, sometimes referred to as sensitive, critical, or vulnerable periods. Although vulnerability can occur at various stages throughout the life course, it tends to peak at critical life transitions, which present risks for substance abuse as well as opportunities for intervention. Thus transitions such as pregnancy, birth, or entering preschool or elementary school are prime opportunities to introduce skills, knowledge, and competencies to facilitate development during those transitions. Therefore, interventions are often designed to be implemented around periods of transition.

What are the major influences on a child’s early development?

The changes unfolding throughout a child’s development are influenced by a complex combination of factors. One of them is the genes the child inherits from his or her biological parents. Genetic factors play a substantial role in an individual’s development through the course of life, influencing a person’s abilities, personality, physical health, and vulnerability to risk factors for behavioral problems like substance abuse. But genes are only part of the story.

Another very important factor is the environment, or the contexts into which the child is born and in which the child grows up. The family/home environment is the context that most directly influences the young child’s early development and socialization. This includes quality of parenting and other parenting influences such as genetic factors and family functioning. Also, siblings, if present, can influence a child’s development and adjustment (e.g., internalizing and externalizing behaviors and substance use, as well as positive behaviors). These influences may result from shared environmental experiences and interactions with parenting and other family factors. But conditions at home are also influenced by wider physical, social, economic, and historical realities—such as the family’s socioeconomic status and the affluence and safety of the community in which the family lives. As the child grows older and enters school, these wider environmental contexts influence him or her more directly.

Throughout early childhood, even when the child enters preschool or attends day care, the family remains the most important context for development. Parents play a number of roles in the development of a young child’s social, emotional, and cognitive competence, including establishing the structure and routines for parent-child interactions; maintaining a sensitive, warm, and responsive relationship style; and providing instructional practices and experiences that help the child acquire necessary developmental skills.

When a nurturing, responsive relationship does not exist, elevated levels of stress hormones can impede a child’s healthy brain development. Moreover, when a caregiver cannot provide attention and nurturing because of a history of trauma, chronic stress, and/or mental health problems, the child is more likely to develop behavioral, social, emotional, or cognitive problems. Likewise, impaired judgment related to substance use can reduce a parent’s ability to create a warm, supportive environment for the child. Child abuse and neglect, social isolation due to illness or disability, and lack of constancy in the primary caregiver (as in the case of a child in institutionalized care) are also linked to growth (including brain growth and neuronal connectivity), cognitive, motor, social, and emotional problems. Many of the prevention interventions discussed in this guide are aimed at facilitating constant, nurturing, responsive caregiving to reduce risk and prevent child behavior problems.

Transition to School.

As the child grows older, new transitions and associated challenges occur. A major transition for young children is beginning elementary school. Even children who attended preschool or had been in day care can find the rules for behavior and academic requirements associated with elementary school difficult to adapt to and achieve. Readiness for school is something that occurs over time with experience and practice. Early intervention can help parents and schools assist children through this transition. Once in elementary school, teachers can help children to adjust by providing positive classroom management.

Intervene early in childhood.

Research over the past three decades has identified many factors that can help differentiate individuals who are more likely to abuse drugs from those who are less likely to do so. Risk factors are qualities of a child or his or her environment that can adversely affect the child’s developmental trajectory and put the child at risk for later substance abuse or other behavioral problems. Protective factors are qualities of children and their environments that promote successful coping and adaptation to life situations and change. Protective factors are not simply the absence of risk factors; rather, they may reduce or lessen the negative impact of risk factors.

All children will have some mix of risk and protective factors. An important goal of prevention is to change the balance between these so that the effects of protective factors outweigh those of risk factors. Both risk and protective factors may be internal to the child (such as genetic or personality traits or specific behaviors) or external (that is, arising from the child’s environment or context), or they may come from the interaction between internal and external influences.

Some important early childhood risk factors for later drug use.

Some factors that powerfully influence a child’s risk for later substance abuse and other problems have their strongest effects during specific periods of development. Important examples include:

Prenatal Period

  • Maternal smoking and drinking can affect a developing fetus and may result in altered growth and physical development and cognitive impairments in the child.

Infancy and Toddlerhood

  • Having a difficult temperament in infancy may set the stage for the child having trouble with self-regulation later, as well as create challenges for the parent-child relationship.
  • Insecure attachment during the child’s first year of life can cause a child to be aggressive or withdrawn, fail to master school.
  • Uncontrolled aggression when a child is a toddler (2 to 3 years) can lead to problems when he or she enters preschool, such as being rejected by peers, being punished by teachers, and failing academically.

Preschool

  • Lack of school readiness skills such as failure to have learned colors, numbers, and counting will put a child at a disadvantage in a classroom environment, setting the stage for poor academic achievement.

Transition to School

  • Poor self-regulation can lead to frustration and constant negative attention on the child by peers and teachers at school.
  • Lack of classroom structure in the school environment can lead to additional social and behavioral problems in children who have trouble switching from one activity to another.

Other risk factors can affect a child in any developmental period. Some important ones are:

  • Stress: All children experience stress at some point, and in fact a certain amount of stress helps young children develop skills for meeting challenges and coping with setbacks that inevitably occur in life. But chronic stressors like family poverty and stress that is intense or prolonged—such as a parent’s mental health problems or a lingering illness—can diminish a child’s ability to cope. These types of stress can even interfere with proper development, including brain development, and aspects of physical health like proper functioning of the immune system. This is particularly true of children who have experienced the extreme stress of maltreatment, such as abuse or neglect, by parents or caregivers. Some children who experience a lot of stress early in life, even during the prenatal period, are more susceptible to the effects of later stressful life circumstances than other people.
  • Parental substance use: Parental substance use—including smoking, drinking, illicit drug use, and prescription drug abuse—can affect children both directly and indirectly. Substances used by a mother during pregnancy can cross the placenta and directly expose the fetus to drugs, and substances can pass to a nursing infant through breast milk. When parents smoke in the home, it can also expose children to secondhand smoke, putting them at risk for health and behavioral problems, as well as increasing children’s likelihood of smoking when they grow older. Parental substance use can also impact the family environment by giving rise to family conflict and poor parenting, which could increase risk for child abuse and neglect and involvement with the child welfare system. Poor family functioning can increase the risk for multiple problem behaviors in children and adolescents, including risk for substance use and abuse. Children with a family history of drug abuse also may have increased genetic risk for substance use, often manifested in combination with family or other environmental risk factors. Children can learn about substance use from a very young age, especially if exposed to parental substance use and abuse. However, children are less likely to smoke, drink alcohol, or use other drugs when parents are clear that they do not want their children to do so, even if they use substances themselves.
  • Emergent mental illness. Many mental illnesses have symptoms that can emerge during childhood and can increase risk for later drug abuse and related problems. For example, anxiety disorders and impulse-control disorders (such as ADHD) begin their onset prior to 11 years of age, on average, but frequently symptoms may appear in early childhood. Symptoms associated with impulse-control disorders, such as aggressive disruptive behavior, as well as those associated with affective and psychotic disorders all increase the risk of substance use disorders and related problems in adolescence.

If not successfully addressed when they initially present themselves, early risk factors and associated negative behaviors can lead to greater risks later in childhood and in adolescence, such as academic failure and social and emotional difficulties, all of which put an individual at increased risk for substance abuse.

https://www.drugabuse.gov/publications/principles-substance-abuse-prevention-early-childhood