Local Opioid Abuse: A Piece of the Nation’s Newest Health Crisis

By Steven Barto

I am no stranger to addiction. I started drinking and getting high the summer after high school graduation. It was 1977 and pot and southern rock went hand-in-hand. I found my answer to all the anger, anxiety, depression, insomnia, and feelings of not belonging. Of course, I had no idea where it would lead, or that it would take me nearly four decades to get clean. I’ve said it before: No one wakes up one day and says, “I think I want to be a full-blown alcoholic or drug addict when I grow up. I want to loose all self-respect, most of my teeth, two wives, four jobs, three cars, and my sense of ambition. I’d love to be estranged from family and friends. It’ll be great. Just me and my drugs!” Anyone whose not an addict or alcoholic and thinks it is a moral or deliberate choice doesn’t understand addiction.

Opiate Use Map (2)

Map shows areas of opiate use, with the most prevalence noted in dark pink.

Nationally

The “perfect storm” that got us to a nationwide opiate epidemic is intertwined with influences you’d never expect. Heroin used to be limited to the beatniks, poets, jazz musicians, wild-and-crazy rock stars of the 1950s, 60s and early 70s. But things were about to break loose. Congressmen Robert Steele (R-CT) and Morgan Murphy (D-IL) released an explosive report in 1971 covering the growing heroin epidemic among U.S. servicemen in Vietnam. America saw thousands of military personnel coming home from Southeast Asia addicted to heroin. As a result, President Richard Nixon declared a “war on drugs.” In fact, Nixon called drug abuse “public enemy number one.” Initially, the lion’s share of monies thrown at the drug problem went for treatment, which was a good thing. Unfortunately, this did not remain so in subsequent years. Politicians saw the opportunity to “take back the streets” of America from hippies, druggies, liberals, love children, people of color, and other “subversives” who did not seem to be conforming to the American lifestyle. Emphasis changed to criminalizing addicts and locking them up.

Admittedly, cocaine and crack became a serious concern before America fell face-first into the current opiate epidemic. Interestingly, one of the major factors contributing to increased cocaine trafficking was the North Atlantic Free Trade Agreement (NAFTA) signed into law under President Bill Clinton. Goods began to flow into the United States from Mexico at such an increase that border patrol was unable to adequately assure drugs were not coming over the border. There simply were not enough agents to keep up with inspection and enforcement. Prior to the climate of unrestrained trade, President Nixon had ordered that every vehicle returning from Mexico must be searched for drugs. Long lines ensued, and there was no appreciable reduction in drug trafficking.

Heroin and a Handgun

In 1995, The Food and Drug Administration (FDA) approved OxyContin for prescription use. Its active ingredient, oxycodone, was believed since the 1960s to be highly addictive. Purdue Pharma, the inventor of OxyContin, claimed their formula of delayed-release oxycodone would all but eliminate the “rush” experienced by taking the drug in its original form. Purdue launched an extremely aggressive marketing progam, sending drug reps to virtually every family practitioner and pain management specialist, armed with what was eventually deemed a falsified report that less than 1% of OxyContin patients became addicted. Doctors were offered outrageous incentives to prescribe the drug. Purdue Pharma began the practice of sponsoring trade shows and symposiums, often plying physicians with lavish meals and “entertainment.” On the heels of this marketing blitz, the American Pain Society began arguing for medical providers to view pain as the “fifth vital sign.” This is precisely the basis for the How would you rate your pain on a scale of 0-10? question that is asked in every emergency department in America today. Well-intentioned doctors believed it was unconscionable to let patents suffer through severe pain. They didn’t believe Oxy would do more harm than good.

By 1996, Purdue Pharma reported $45 million in sales of OxyContin. As of 2000, the number jumped to over $1 billion. That’s a two-thousand fold increase. Misuse and abuse of opiate painkillers (OxyContin, Vicodin, Lortab, oxycodone) increased significantly beginning in 2000. In 2002, 6.2 million Americans were abusing prescription drugs, and emergency room visits resulting from the abuse of narcotic pain relievers had increased dramatically. By 2009, the total number of visits to ERs for overdose on opiates was 730,000, which was double the number of five years before. More than 50,000 Americans died of a drug overdose in 2016. Heroin accounted for 12,898 of those deaths that year. Synthetic opioids (such as Fentanyl) killed 5,880. Prescription painkillers like OxyContin and Vicodin claimed 17,536 lives.

Companies like Purdue Pharma have restructured the formula of opiate medications in order to make them even harder to abuse. No doubt this had a lot to do with the $635.5 million fine levied against Purdue for intentionally misleading the medical community regarding the potential to become addicted to OxyContin. Typically, addicts crush and snort the drug, or cook it down and inject it. What’s disheartening today is that most people who started out taking and then abusing OxyContin and other opiate pain medication are now using heroin because it’s cheaper – $5 to $7 dollars for enough to be high most of the day versus $10 to $80 for one Oxy, depending on its strength. Heroin is readily accessible virtually everywhere you go, and it is easily converted to a form that can be smoked or injected.

Locally

Front page news in my hometown paper, The Sunday Item, indicates that drug overdoses in Pennsylvania killed nearly 11,000 people in the last three years, fueled largely by heroin and prescription painkillers. The number of deaths has steadily increased year after year. As fatal overdoses have increased, so has public awareness, access to addiction treatment, and legislative initiatives against an epidemic the U.S. Department of Justice describes as the leading cause of death of Americans under the age of 50. It is important to note that this is a disease that affects everybody. Let’s stop playing the New Jim Crow game and stigmatizing, criminalizing, and institutionalizing drug addicts based upon skin color. Heroin and opiate drug addiction is rampant today in all socioeconomic classes, to be sure, but surprisingly it is most prevalent in white males age 18 to 25.

heroin-graph_1185px

The Sunday Item interviewed a man named Steven C., 27 years old, who is a recovering heroin addict attempting sobriety after fifteen years of opioid abuse. When he heard the news of an overdose outbreak in the Williamsport (Pennsylvania) area that sent 51 patients to the hospital in 48 hours, with three patients now dead, Steven couldn’t help but realize, “That could have been me.” Steven was brought back to consciousness from a heroin overdose on August 9th of last year. EMTs adminstered naloxone, which is used in the field to reverse the effects of an overdose, but it didn’t work. His heart had stopped. Thankfully, CPR eventually restarted his heart.

The Official Response

Federal and state funding for the opioid and heroin problem in Pennsylvania has been increased 19% to $76 million for the current fiscal year. The funds include $5 million for grant money to provide naloxone for emergency responders, which is proven to reverse the effects of narcotic overdose in most cases, and $2.3 million to establish specialty courts for handling drug-related criminal cases. Great strides have already been taken in fighting this epidemic. Pennsylvania restricts opioid prescriptions to seven days for minors and those discharged from hospital ERs. Emergency room physicians are not allowed to see patients for follow-up visits or refills. Each instance where an opioid prescription is filled is recorded on a state-wide database in order to stop “doctor shopping” or getting refills “too early.” According to the Sunday Item article, the prescription database has been accessed by doctors 8 million times since it was launched.

An estimated 2 million Americans are addicted to painkillers, and another 591,000 are addicted to heroin. Although we’re beginning to made headway regarding opioid prescriptions, much remains to be done regarding heroin addiction. It is noteworthy that taking opioid pain medication for longer than three months makes patients up to forty times more likely to become addicted to heroin. Senator Gene Yaw (R-23) of Williamsport told reporters, “I have said many times that I don’t expect to see positive results for at least ten years. It took a long time to get into the situation we find ourselves and we can’t expect a change to happen overnight. We are addressing many issues and eventually together they will make a difference.” It is abundantly clear that there is a risk of progression from alcohol and other drugs (especially opioid painkillers) to heroin.

heroin-use_1185px

Concluding Remarks

What can you do? Most importantly, as public service announcements state on TV in Pennsylvania, “Mind your meds.” Please don’t react to this suggestion by simply saying drug addicts should be able to be trusted, otherwise they’re just thieves. Or, that they should have better impulse control. Addiction is not about willpower, nor is it a matter of a moral deficiency. Virtually anyone who uses opiates for pain for longer than three months can become addicted. That is the very nature of the morphine molecule found in these medications. It is extremely difficult for an opiate addict to “just say no” to the screaming of their mu-opioid receptors in the brain and spinal cord once the morphine molecule has latched “lock-and-key” into place. Opiates are far more potent than naturally occurring endorphins.

I really had no idea how difficult it can be to quit drinking or taking opiates once your body gets used to the chemical reaction and the euphoria. I have not had a drop of alcohol, a line of cocaine, or a joint since 2008. It was not so easy for me to give up opioid painkillers. It’s a two-edged sword. First, there’s the initial legitimate need for pain relief. Doctors recognized this in the 90s when they decided to not let their patients suffer in chronic agony. Although I was in recovery for other substances, I thought I could use pain medication safely. I’d abused it in the past, sure, but now I was “sober” and I needed help with severe back pain. I didn’t want the drug in order to “party.” The other edge of the sword is the neuropsychology of the addiction itself. These types of medications actually restructure the brain. Sometimes the effects are permanent, as when memory or IQ or motor skills are compromised. Thankfully, this is not the case for me.

If you or someone you know is struggling with a drug or alcohol problem, please consult your physician for a phone number to the nearest help line. You will also find AA and NA phone lines in the phone book or online. If you are a Christian facing addiction, consider Celebrate Recovery. Facebook has numerous groups you can join. You call also email me at stevebarto1959@gmail.com and I will reply as soon as I can.

References

The Sunday Item. (Sunday, July 9, 2017) Sunbury, PA http://dailyitem.com

Karlman, J. (February 16, 2017). Timeline: How Prescription Drugs Became a National Crisis. Retrieved from: http://fox5sandiego.com/2017/02/16/timeline-of-how-prescription-drugs-became-national-crisis/

Moghe, S. (October 14, 2016). Opioid History: From Wonder Drug to Abuse Epidemic. CNN Online. Retrieved from: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html

Sandino, J. (May 13, 2015). A Timeline of the Heroin Problem in the U.S. Addictionblog.org Retrieved from: http://drug.addictionblog.org/a-timeline-of-the-heroin-problem-in-the-u-s/

Tribune News Services. (December 8, 2016). More than 50,000 Overdose Deaths. Chicagotribune.com. Retrieved from: http://www.chicagotribune.com/news/nationworld/ct-us-overdose-deaths-20161208-story.html

America’s Fentanyl Crisis

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

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

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

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

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

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

A Review of “Tweak: Growing Up on Methamphetamines” by Nic Sheff

“Raw, powerful, and honest.” – The Bookseller

“A raw and sad account, vivid in its depiction of the pleasures and tunnel vision of addiction and the challenges of sobriety.” – Bulletin of the Center of Children’s Books

Nic Sheff writes a memoir that is searingly honest, detailing a downward spiral that seems to have no bottom. He was drunk for the first time at age eleven. In the following years, he would smoke pot regularly, do cocaine and Ecstasy, and develop addictions to crystal meth and heroin. Yet he always felt he could quit and put his life together whenever he needed to. It took a violent relapse one summer in California to convince him otherwise. Nic’s story takes you through the wild twists and turns in the life of a recovering addict. He is a kind soul. Creative, impulsive, curious. He is ever aware of the the pain and destruction he is causing those around him, but his addiction is too strong to just quit, as his family would have liked him to.

When he’s clean and sober, Nic is a sensitive, caring, loving person who is deeply insecure, and just wants to do things right. It is easy to root for him in spite of his insane return to crystal meth, heroin and cocaine over and over. Although I have never shot drugs into my arm, I completely understand being so obsessed with getting high that you will do nearly anything to score. When Nic began shooting dope, he changed from a youthful contender for the prizes of life, such as a promising career as a writer, a hint of leadership, and a quiet kindness that everyone noticed when he was a child, to a street scavenger with no future at all. He robbed his family and prostituted himself to men for drugs.

The exhausting cycle of rob, score, get high, rob, score, get high is finally broken when Nic gets caught breaking into his mother’s property. His father gives him a choice: Treatment or jail. He chooses treatment. This time it works. Nic does not suggest that he has now chosen a better way of life. He simply says, “Using just has no place in my life now, and I can’t see that ever changing.” I’ve been that far down, so I can appreciate this statement; however, it is always advisable in recovery to quit just for today. When and addict says they will never use again, he or she places themselves under such tremendous pressure that it can become overwhelming.

One thing I found particularly positive about this book is that Nic refuses to glamorize drug use. He lets us in to each of his battles, revealing every pain that comes with a life of addiction, with simple straightforward words. He vividly describes infected wounds in his arms from IV drug abuse, severe emaciation, and hallucinations caused by extended, unbroken meth use. Educators, counselors and parents would be well-advised to recommend this book to today’s young adult.

I have no idea what love is to most people. I have no idea what love is supposed to be. I have no idea what a healthy relationship should look like. I have no idea what society considers “normal” in terms of falling in love, being in love, and acting on that. Through group therapy, one-on-one therapy, supportive friends, writing, living, reflection, I’ve begun to find out who I am underneath all the protective coverings and drawn curtains and stained, twisted sheets. I’ve started to see myself, my true self, hiding somewhere behind my lungs maybe. Some unreachable center in me. I have an intensity inside of me that can be destructive as hell, but can also cut me wide open so that I feel sadness and joy and freedom and empathy and love like stars burning out and the sun captured inside every living thing. [Excerpt from a blog post at http://nicsheff.blogspot.com.]

Why Do Addicts Take a Drug That No Longer Gives Pleasure?

People who have used cocaine for a long time report a paradoxical-seeming experience: The pleasure they get from taking the drug decreases even as the drug intensifies its hold over their behavior.

A recent NIDA-supported study sheds light on why this might be. Researchers shows that, in mice, a cocaine-induced imbalance in the activity of two key populations of neurons in the reward system persists for a longer period after repeated exposure to the drug. For long-term users, the researchers suggest, this change could both weaken the cocaine “high” and strengthen the compulsion to seek the drug.

A Distorted Ratio

Drs. Congwu Du and Yingtian Pan and colleagues at Stony Brook University in New York and at NIDA injected two groups of mice with a single dose of cocaine (8 milligrams per kilogram of body weight). One group of mice had already been exposed to the drug daily for 2 weeks, and the other, a control group, was receiving the drug for the first time. Using a novel dual-imaging and measurement technique*, the researchers tracked the drug’s impact on activity levels of two populations of medium spiny neurons (MSNs) in the striatum of the two groups of mice.

One of two MSN populations observed by the researchers interacts with dopamine via receptors called D1R. When activated by dopamine, striatal D1R MSNs give rise to pleasurable feelings, motivate an animal or a person to repeat the experience that yielded these feelings, and promote the conversion of such motivation into action by stimulation neurons in the brain’s motor cortex. The other MSN population interacts with dopamine via a different receptor, called D2R. When activated, D2R MSNs counter the effects of the D1R MSNs. They attenuate euphoria and drug seeking and inhibit the motor cortex.

In the experiment, Drs. Du and Pan found that immediately after the cocaine injection, D1R MSN activation increased and D2R MSN activated decreased, both in the mice that had been exposed daily to the drug and in those being exposed for the first time. As a result, in both groups, the ratio of D1R MSN to D2R MSN activation shifted sharply in favor of the D1R MSNs and their reward- and motivation-promoting effects.

At 5 to 7 minutes post-injection, however, the D1R to D2R activity ratios diverged between the two groups of mice. In the control mice, D1R activation rapidly fell back to its baseline level, causing the D1R to D2R ratio to also return to near baseline. In the mice that had been exposed daily to cocaine, in contrast, the cocaine-induced D1R activation increased steadily over the entire 30 minutes that the animals were observed. As a result, D1R to D2R rose higher and remained elevated longer in the daily-exposed mice holds in people as well, it could help explain why long-term users of cocaine report less euphoria from taking the drug.

The researchers propose that the drawn-out time course of cocaine-induced D1R to D2R MSN activation following repeated exposure will also enhance an animal’s or a person’s drive to seek the drug. Dr. Pan explains, “Dopamine both activates and inhibits brain circuits, and normally this dual action produces healthy behavioral outcomes. Cocaine upsets this balance. It enhances the D1R MSN signaling that normally puts a brake on those behaviors. In our experiment, we showed that this imbalance is short lived in mice when they are exposed to the drug for the first time, but long lasting in mice that have already been repeatedly exposed.”

More Research is Needed

“The research field had not put much effort into separating how these two dopamine receptor systems are involved in rewiring the brain exposed to chronic cocaine use, or their effects on compulsive intake of the drug,” says Dr. Nora D. Volkow, NIDA Director and a collaborator on the study. “This work highlights the importance of the relative participation of D1R versus D2R signaling.”

Drs. Du and Pan have more work to do to show that their observations account for long-term cocaine users’ reduced enjoyment and increased compulsion to use the drug. As a first step, they plan to examine whether increasing the D1R to D2R MSN activity ratio indeed increases animals’ drug-seeking behavior. This will be very challenging, says Dr. Du, because it will require adapting their imaging technique to monitor MSNs in awake and moving animals. To date, they have used it only with anesthetized and restrained animals.

Another outstanding question is whether long-term cocaine use actually changes the time course of D1R MSN activation in people as it does in mice. Dr. Pan notes that although research has not yet addressed this question, imaging studies conducted in Dr. Volkow’s laboratory have shown that cocaine dampens D2R signaling in people as well as mice. If further investigations confirm the researchers’ hypotheses, says Dr. Volkow, “treatments that strengthen D2R signaling could help people stop using cocaine.”

Source

Park, K.; Volkow, N.D.; Pain, Y.; Du, C. Chronic cocaine use dampens dopamine signaling during cocaine intoxication and unbalances D1 over D2 receptor signaling. The Journal of Neuroscience, 33(40):15827-15836, 2013.

*To achieve their observations, Drs. Du and Pan developed a dual-imaging technique based on a novel microprobe that was used for visualizing individual neurons deep within the brain. The technique enabled them to distinguish the populations of D1R and D2R MSNs, and to track moment-to-moment changes in each one’s calcium levels. Calcium levels directly reflect a neuron’s level of activation.