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

 

 

The Worst Man-Made Epidemic in History

The following is comprised of excerpts from Sam Quinones’ Dreamland: The True Tale of America’s Opiate Epidemic. I want to praise Quinones for this seminal work. Personally, it has defined for me the very nightmare I, and countless others, have lived, each to his or her own level, after discovering the morphine molecule through seemingly acceptable pain medications like Vicodin, Percocet and OxyContin. You can purchase a copy of Dreamland here: Dreamland

AS HEROIN AND OXYCONTIN addiction consumed the children of America’s white middle class, parents hid the truth and fought alone. Quietly. Friends and neighbors who knew shunned them. “When your kid’s dying from a brain tumor or leukemia, the whole community shows up,” said a mother of two addicts. “They bring casseroles. They pray for you. They send you cards. When your kid’s on heroin, you don’t hear from anybody, until  they die. Then everybody comes and they don’t know what to say.”

These parents made avoidable mistakes, and when a son died or entered rehab for the fourth time, they again hid the truth, believing themselves alone, which they were as long as they kept silent. This pervasive lie was easily swallowed. It often lay buried beneath lush lawns, shiny SUVs, and the bedrooms of kids who lacked for nothing. It was easier to swallow, too, because some of these new addicts were high school athletes – the charismatic golden youth of these towns. Athletes opened the door for other students who figured that if cool jocks were using pills, how bad could it be?

One addict was Carter, from one of of California’s wealthiest communities, the son of a banker. Carter had been a high school star in football and baseball. With no break from sports during the year, he battled injuries that never healed. A doctor prescribed Vicodin for him, with no warning on what Vicodin contained, or suggestions for how it should be used. Sports were king in Carter’s town. It was a place of gleaming mansions, but he felt no sense that education was of value in providing choices in life, much less for the love of learning. These kids’ futures were assured. Sports were what mattered. Dads would brag to friends about their sons’ athletic exploits, then berate their boys for poor play, urging greater sacrifice. From the athletic director down to parents and teachers they heard, “You need grades so you can play. That was the vibe we got,” said Carter.

Many new athlete-addicts were not from poor towns where sports might be a ticket out for a lucky few. The places where opiate addiction settled hard were often middle- and upper-class. Parents were surgeons and developers and lawyers who provided their kids with everything. Yet sports were as much a narcotic for these communities as they were to any ghetto. Love of learning seemed absent, while their school weight rooms were palatial things, and in many of them pain pills were quietly commonplace. Just as opiates provided doctors with a solution to chronic-pain patients, Vicodin and Percocet provided coaches with the ultimate tool to get kids playing again.

Carter’s coach told him stories of players years before who were gulping down Vicodin before practices and games. “In my town, the stands were always filled. You wanted to be the hero. So you think, ‘I can’t look weak. I gotta push myself.’ I would get these small injuries. The coaches wouldn’t pay any attention. I taught myself to not pay attention to any injuries.” Most athletes on every team on which Carter played used pills, for injury or recreation. Soon Carter grew addicted to Vicodin, and then to OxyContin. From there, as a student athlete at a Division I university, he began using heroin.

Football players were seen as symbols of this American epidemic. Their elevated status on campus left some of them unaffected by consequences. Carter was caught selling pills and was told not to do it again. Above all, though, players were in constant pain and were expected to play with it. If opiates were now for chronic pain, well, football players endured more chronic pain than most. Necks, thighs, and ankles ached all season. Medicating injuries to get athletes playing through the pain was nothing new. But as oxycodone and hydrocodone became the go-to treatment for chronic pain, organized sports – and football in particular – opened as a virtual gateway to opiate addiction in many schools. Thus, with the epidemic emerged the figure of the heroin-addicted football player. Though, of course, few wanted to talk too much about that.

By 2008, when Jo Anna Krohn’s son died, these kinds of delusions had been accepted for almost a decade in places like Salt Lake, Albuquerque, Charlotte, Minneapolis, and other cities that had for that same decade been the drivers and beneficiaries of the greatest boom in the history of U.S. consumer spending. But it was in beat-down Portsmouth, Ohio, where one mother had the gumption to own the truth and say something about it.

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ACROSS PORTSMOUTH, AT THE Counseling Center, Ed Hughes thought silence was a huge part of the story. Opiates had exploded all those plans Hughes had in the mid-1990s to consolidate the Counseling Center’s operations and focus on improving its internal workings. The center opened years before in a small house. By 1992 it began residential treatment with 16 beds. This quickly increased to 150 beds, with a huge waiting list, and a staff of close to 200. It moved its outpatient center into an abandoned three-story school due entirely to the swarms of new opiate addicts.

“We’ve never seen anything move this fast,” said Hughes. A decade and a half in, Ed Hughes was still waiting for the arc of addicted clients to plateau and curve downward. Kids were coming to the center from across Ohio. Many, said Hughes, grew up coddled, bored, and unprepared for life’s hazards and difficulties. They’d grown up amid the consumerist boom that began in the mid 1990s. Hughes believed parenting was changing as well. “Spoiled rich kid” syndrome seeped into America’s middle class. Parents shielded their kids from complications and hardships, and praised them for minor accomplishments – all as they had less time for their kids.

“You only develop self-esteem one way, and that’s through accomplishment,” Hughes said. “You have a lot of kids who have everything and look good, but they don’t have any self-esteem. You see twenty-somethings: They have a nice car, money in their pocket, and they got a cell phone… a big-screen TV. I ask them, ‘Where the hell did all that stuff come from? You’re a student.’ ‘My mom and dad gave it to me.’ And you put opiate addiction in the middle of that?” Hughes added, “Then the third leg of the stool is the fifteen-year-old brain.”

Hughes saw this all the time: Adult drug users incapable of making mature choices. This happened because opiates stunted the part of their brain controlling rational action. ¹ “We’ve got twenty-five- to thirty-year-old, opiate-addicted people who are going on fifteen. Their behavior, the way their brain works, is like an adolescent,” said Hughes. “It’s like the drug came in there and overwhelmed that brain chemistry, and the front of the brain did not develop.” He added, “The front of the brain has to develop through mistakes. But the first reaction to the addicted person is to head back to the family: ‘Will you rescue me?’ Whatever the person’s rescued from, there’s no learning. There’s no experiences, no frontal brain development. They’re doing well and then some idea comes into their head and they’re off a cliff. It may not be a decision to use [drugs]. Most relapse comes not from the craving for the drug. It comes from this whole other level of unmanageability, putting myself in compromising situations, or being dishonest, being lazy – being a fifteen-year-old.”

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FIVE YEARS AFTER PORTSMOUTH found itself swept up in a national epidemic, the victims of America’s opiate scourge had emerged from the shadows and the silence. They were everywhere now. Heroin had traveled a long way from the back alleys of New York City and William Burrough’s Junky. The town of Simi Valley agonized over a spate of opiate overdose deaths – eleven in a single year. Simi Valley, conservative and religious, has long been an enclave for cops. Many LAPD officers live in the town. Simi’s vice mayor at the time was a Los Angeles police officer. So for years Simi was one of America’s safest towns. According to the crime statistics, it still is. But with pills everywhere and heroin sold in high schools, its kids were now also dying of dope. Simi youths clogged the methadone clinic. Nearby, Thousand Oaks, Moorpark, and Santa Clarita told similar stories. Low crime and high fatal overdoses was the new American paradigm.

Susan Klimuski, whose son Austin died from a heroin overdose, formed a coalition to fight back. It was called Not One More. It received support from city council and the town’s retail core. Yet these were times when heroin was still invisible, conveniently hidden away, at least to anyone who wasn’t a junkie, or a parent of one. Then, on Super Bowl Sunday 2014, America awoke to the news that one of its finest actors was dead. Philip Seymour Hoffman, forty-six, was found that morning in his Greenwich Village apartment, a syringe in his arm and powder heroin in packets branded with the Ace of Spades near his corpse. Blood tests showed he had heroin in his system, combined with cocaine, amphetamine, and benzodiazepine. The Oscar-winning actor – a father of three- had checked into rehab the previous May for ten days, and then, pronouncing himself sober again, left to resume a hectic film schedule. This death hit me right between the eyes. I was a die-hard fan of Hoffman’s acting. He had a heroin habit in college (twenty years ago), but managed to get clean. At least for two decades. Hoffman’s death awoke America to the opiate epidemic.

Within days of covering the story of Hoffman’s death, media outlets from coast to coast discovered that thousands of people were dying. Heroin abuse, the news reports insisted, was surging. Almost all the new heroin addicts were hooked first on prescription painkillers. It was not just the pain, however. This scourge was connected to the conflation of bigger forces: of economics, of aggressive prescription drug marketing, of poverty and prosperity. But this was tough to articulate in four-minute interviews, and a lot of it got lost in the media’s rush to discover and report the new plague. Attorney General Eric Holder described an “urgent and growing public health crisis,” and called on police and paramedics to carry naloxone, an effective antidote to opiate overdose. The problem also prompted Surgeon General Vivek H. Murthy, M.D., M.B.A. to issue a report in November 2016 on alcohol, drugs and health. This is the most comprehensive health crisis report issued by a surgeon general since cigarette smoking. You can read a PDF of the entire report here.

Two decades since the evolving pain revolution,² a consensus emerged that opiates are not helpful for some varieties of chronic pain, including back pain, migraines, and fibromyalgia. In fact, it was finally decided that opiate use is risky. Many clinics and physicians developed policies against using opiates for chronic non-cancer pain. One 2007 survey of studies of back pain and opiates found that “use disorders” were common among patients, and “aberrant” use behavior occurred in up to 24 percent of the cases. It was unclear whether opiates had a positive effect on back pain in the long term. Personally, I have found that opiates do nothing more than create a euphoria that tends to distract me from the pain for a few hours, only to ebb, thus requiring more opiates. By the end of the 2000s, it was already common for people to go from abusing opiate painkillers to a heroin habit. Purdue Pharma, the inventor of OxyContin (who paid a $635.5 million fine for falsely claiming their formulation of the drug oxycodone in time-released pills was far less addictive) recognized this, and in 2010 they reformulated OxyContin with an abuse deterrent, supposedly making the drug even harder to deconstruct and inject.

Unfortunately, by this time, heroin had spread to most corners of the country because the rising sea level of opiates flowed there first. “What started as an OxyContin and prescription drug addiction problem in Vermont as now grown into a full-blown heroin crisis,” said Governor Shumlin. What made New York City the dominant heroin market for much of the twentieth century – its vast number of addicts, and its immigrants from poppy-rich regions of the globe – was now true of most of America. Most of the country’s heroin was coming from Mexico, through the Southwest, trucked into New York. The entrepreneurial Xalisco brothers from Nayarit, Mexico, devised a system for selling heroin across the United States that resembles pizza delivery. An addict calls and places an order, and an operator directs him to an intersection or parking lot. The dealer carries balloons of heroin in his mouth. He simply spits out what the addict ordered. If the cops move on the dealer, he washes the balloons down his throat with a swig from a nearby bottle of water. No evidence, no arrest. The dealers have also been known to deliver to the door for “clients” that are home-bound due to illness or disability.

What started as a concern among physicians for a solution to chronic pain was hijacked by greedy Big Pharma, eventually morphing into nationwide heroin use and addiction resulting from the medical community and the government tightened the reins on prescriptions. Of course, whenever drugs are involved, there is always someone at the ready to provide a system of delivery to dope-sick addicts and chronic pain sufferers hankering for release.

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¹ Adolescence and young adulthood is a period of continued brain growth and change. The frontal lobes, key to executive functioning, such as planning, working memory, and impulse control, are among the last areas of the brain to mature. Age is a risk factor that is associated with the onset of drug use in adolescence and young adulthood. Adolescence is a developmental period associated with the highest risk for developing a substance use disorder.

² During the 1990s changes in attitudes and techniques in pain treatment were coming quickly. In 1996, the president of the American Pain Society, Dr. James Campbell, proposed that pain should be assessed in the same manner as other vital signs. They trademarked the slogan, “Pain: The Fifth Vital Sign.” This led to the 0-10 pain intensity scale now prevalent in every ER and doctor’s office in America. Essentially, doctors were finally given more power in prescribing opiates to patients suffering from chronic pain who were not cancer patients.

References

Quinones, Sam. (2015). Dreamland: The True Tale of America’s Opiate Epidemic. New York, NY: Bloomsbury Press

Winters, K. and Arria, K. (2011). “Adolescent Brain Development and Drugs.” The Prevention Researcher, 18(2), 21–24.