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

 

 

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.