Stigma and the Toll of Addiction

By Nora D. Volkow, M.D.
Executive Director, National Institute on Drug Addiction

Original Post April 20, 2020

Each day in 2018, an average of 185 people in the United States died from a drug overdose (1). In fact, recent declines in U.S. life expectancy are being attributed to direct and indirect effects of alcohol and drug use disorders. Expanding the number of people receiving evidence-based addiction treatment is crucial for reversing these trends. But among the many challenges in delivering appropriate care to the nearly 20 million people in the United States with substance use disorders is the chilling effect of stigma. Stigma not only impedes access to treatment and care delivery; it also contributes to the disorder on the individual level. Stigma associated with many mental health conditions is a well-recognized problem. But whereas considerable progress has been made in recent decades in reducing the stigma associated with some psychiatric disorders such as depression, such change has been much slower in relation to substance use disorders (2). One obstacle is that this stigma has causes beyond those that apply to most other conditions. People who are addicted to drugs sometimes lie or steal and can behave aggressively, especially when experiencing withdrawal or intoxication-triggered paranoia. These behaviors are transgressions of social norms that make it hard even for their loved ones to show them compassion, so it is easy to see why strangers or health care workers may be rejecting or unsympathetic.

Tacit beliefs or assumptions about personal responsibility — and the false belief that willpower should be sufficient to stop drug use — are never entirely absent from most people’s thoughts when they interact with someone with a drug problem. Health care professionals are not immune to these assumptions. Indeed, they may hold stigmatizing views of people with addictions (3) that may even lead them to withhold care. In emergency departments, for instance, health care professionals may be dismissive of someone with an alcohol or drug problem because they don’t view it as a medical condition and therefore don’t see its treatment as part of their job. People who inject drugs are sometimes denied care in emergency departments and other hospital settings because they are believed to be drug-seeking. In part, the difficulty reflects continued resistance to the idea that addiction is a disease. Drug use alters brain circuitry that is involved in self-regulation and reward processing, as well as brain circuits that process mood and stress. For a person with a serious substance use disorder, taking drugs is no longer pleasurable or volitional, for the most part, but is instead a means of diminishing excruciating distress and satisfying powerful cravings — despite often devastating consequences. Some people are more vulnerable than others to developing a substance use disorder because of a genetic predisposition, adverse social environmental exposures, traumatic life experiences, or other factors. To recover, they often need external help and support — evidence-based treatment, with medication when possible. Unfortunately, their encounters with health care providers may serve only to reinforce their disorder.

While visiting a makeshift heroin “shooting gallery” in San Juan, Puerto Rico, I urged a man who had what appeared to be a massive abscess in his leg to go to an emergency room to get it treated. He refused to even consider it, and told me that when he had previously sought medical help, he had been so badly mistreated that he was frightened of returning. He would rather jeopardize his life or risk a leg amputation than endure being dismissed as a “drug addict.” Stigma not only impedes care delivery, it also most likely causes us to underestimate the burden of substance use disorders in the population. But stigma plays an even larger role in this crisis, one that has been less discussed: when internalized, stigma and the painful isolation it produces encourage further drug taking, directly exacerbating the disease.

Ever since the “Rat Park” experiments of the 1970s, which showed that animals housed in enriched environments with access to other rats self-administered morphine much less frequently than those housed in isolation, social isolation has been known to play a crucial role in vulnerability to and difficulty of recovering from addiction. Research on social reinforcement and its neurobiologic mechanisms has illuminated the links between stigma and drug use. For one thing, there is substantial overlap between the neurologic underpinnings of drug rewards and those of social rewards. Research by Naomi Eisenberger at UCLA has found that social pain is processed in some of the same brain areas that process physical pain and is quelled by pain relievers (4).

Strikingly, a recent article by Venniro and colleagues reported that when given a choice between self-administering a drug and interacting with another animal, methamphetamine- or heroin-dependent rats chose the social interaction. However, when they were punished for the social choice with an electric shock before the interaction, the rats reverted to choosing the drug (5). In a sense, stigmatizing treatment of people who use drugs, such as ignoring or rejecting them, may be the equivalent of an electric shock in the cycle of drug addiction: it’s a powerful social penalty that spurs further drug taking. Stigma is not the only factor impeding adequate treatment of people with substance use disorders, but if we are to achieve the public health goal of getting and retaining many more people with substance use disorders in treatment, we have to ensure that the health care system will not penalize people who are addicted to drugs for their condition. Among other steps, improving treatment will require training physicians, nurses, nurse practitioners, physician assistants, and emergency department staff in providing compassionate care to patients who may display the difficult, sometimes frightening behaviors associated with drug addiction and withdrawal.

It is also necessary to promote awareness of addiction as a chronic relapsing (and treatable) brain disease. This effort should include promoting understanding of the disease’s behavioral consequences as well as of the factors that make certain people particularly vulnerable. Susceptibility to the brain changes leading to compulsive substance use is substantially modulated by genetic, developmental, psychiatric, and social factors, many of which are out of the person’s control. Given the gravity of the current overdose crisis, it is urgent that we conduct research aimed at overcoming stigma toward people with addiction. Yet even in the absence of research, common sense can guide us: respect and compassion are essential. People working in health care should be made aware that stigmatizing people who are addicted to opioids or other drugs inflicts social pain that not only impedes the practice of medicine but also further entrenches the disorder.

References

  1. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2018: NCHS data brief no 356. Hyattsville, MD: National Center for Health Statistics, January 2020 (https://www.cdc.gov/nchs/products/databriefs/db356.htm. opens in new tab).
  2. Corrigan PW, Nieweglowski K. Stigma and the public health agenda for the opioid crisis in America. Int J Drug Policy 2018;59:44-49.
  3. Kennedy-Hendricks A, Busch SH, McGinty EE, et al. Primary care physicians’ perspectives on the prescription opioid epidemic. Drug Alcohol Depend 2016;165:61-70.
  4. Dewall CN, Macdonald G, Webster GD, et al. Acetaminophen reduces social pain: behavioral and neural evidence. Psychol Sci 2010;21:931-937.
  5. Venniro M, Zhang M, Caprioli D, et al. Volitional social interaction prevents drug addiction in rat models. Nat Neurosci 2018;21:1520-1529.

Emergency Departments Can Help Prevent Opioid Overdoses

From the Blog of Dr. Nora Volkow
Executive Director, National Institute on Drug Abuse

Additional Writings by Steven Barto, B.S., Psych.

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Originally Posted at the NIDA Website on August 26, 2019

One of the biggest risk factors for overdose death from opioids is having had a previous overdose. Common sense and a growing body of research suggest that patients with Opioid Use Disorder who receive acute care in an emergency department will be at reduced risk for later overdose if they are initiated on medications to treat their Opioid Use Disorder. Unfortunately, too few Emergency Departments are making this a standard practice, and lives are being lost as a result.

According to a new report published by the Delaware Drug Overdose Fatality Review Commission, half of the people in the state of Delaware who died of an overdose in the second half of 2018 had suffered a previous nonfatal overdose, and more than half (52%) of the overdose deaths occurred within three months of a visit to the emergency room. Even when visits were not for overdose, signs of Opioid Use Disorder were apparent during the visit in most cases. The report thus recommended that patients who visit emergency rooms with obvious signs of Opioid Use Disorder should be immediately referred to rehabilitation treatment. Optimally, the initiation of medication for Opioid Use Disorder should be started before patients are discharged. This will improve their clinical outcomes.

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Even without a waiver, Emergency Department providers are permitted to administer Subcutex (buprenorphine) or methadone a limited number of times to patients under their care. In fact, several studies have now shown the benefit of initiating Subcutex in the Emergency Department rather than just referring the patient to drug treatment—it is called an “emergency” department for a reason! A recent NIDA-funded study by Yale researchers published in JAMA in 2015 showed that Subcutex treatment initiated by Emergency Department physicians was associated with decreased opioid use and improved treatment engagement in the 30-day period following discharge.

There is significant evidence that medications for Opioid Use Disorder prevent overdoses. For example, a prospective cohort study of 17,568 opioid overdose survivors in Massachusetts published last year in Annals of Internal Medicine found significant reductions in the risk of subsequent overdoses over the next 12 months in those who received treatment with methadone or Subcutex. Yet, only 30 percent of those who had overdosed received medication for Opioid Use Disorder. This statistic is extremely alarming, because the sample of patients was clearly at high risk for overdosing.

Bottles of Opiate Prescriptions

More alarmingly, 34 percent of those who had been treated for overdose received additional opioid pain prescriptions during the subsequent 12 months, despite their overdose history, and 26 percent received benzodiazepines, which as respiratory depressants further increase risk of overdose in those who misuse opioid drugs or who are being treated with high doses of opioid medications for pain management. [From my personal experience, benzodiazepines were hightly addictive and I tended to abuse them along with oxycodone. Family members noted my complete lack of sadness or empathy during my father’s funeral in December 2014. I stared at the floor and did not shed a tear. This is solely based on the fact that I was high on oxycodone and benzodiazepines at that time.]

It is crucial that acute care physicians, and the health care systems in which they practice, become aware of the importance of ensuring that patients be screened for Opioid Use Disorder and, if same is detected, that they receive treatment, ideally by initiating them on Subcutex before they are released.  Additionally, patients who visit an Emergency Department because of an overdose, or who otherwise show signs of Opioid Use Disorder, should be sent home with Narcan (naloxone)  and given instructions on how to use it to reverse an opioid-induced overdose. This was another recommendation of the Delaware report.

Naloxone kit

Four out of five fatal overdoses reviewed by the Delaware state commission occurred in a private residence were Narcan was unavailable in nearly 93% of the cases. Abundant research has shown the life-saving benefits of distributing Narcan not only to people who are addicted to opioids or misusing them but also to pain patients being treated with high doses of opioid medications and their families and friends. After all, patients taking opiates for severe chronic pain are at risk of becoming dependent on the narcotic, and could suffer an accidental opiate overdose. It is simply a matter of brain neurochemistry that has no true moral component, and can impact patients of any socioeconomic class.

Making Emergency Department physicians more responsive to the opioid epidemic often means educating colleagues and changing hospital culture. Many emergency physicians do not feel adequately prepared to treat with Subcutex—there are real or perceived logistical impediments like obtaining prior authorization from insurers. Emergency physicians should be encouraged to complete the training necessary to get a waiver to prescribe Subcutext, which greatly enhances their confidence and ability to respond to patients with Opioid Use Disorder.

The NIDA-MED website includes firsthand stories from physicians implementing emergency department overdose treatment with buphrenorphine and prescribed Suboxone to patients suffering from Opioid Use Disorder. Gail D’Onofrio, the lead researcher of the 2015 JAMA study, translated the study findings into practical videos for Emergency Room clinicians now posted on NIDA-MED. NIDA has also developed a companion, comprehensive set of resources to help emergency physicians initiate buprenorphine. In fact, initiating buprenorphine treatment in the emergency room includes step-by-step guidance on buprenorphine treatment, discharge instructions, instructional videos for clinicians on interacting with Opioid Use Disorder patients, and other useful materials.

[PLEASE NOTE: I have added the following sections to Dr. Volkow’s blog post.

Let’s Take a Look at Opioid Use Disorder

DSM 5

The American Psychiatric Association¹ included a comprehensive explanation of Opioid Use Disorder in their Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed. (DSM-5), beginning at page 541. Essentially, Opioid Use Disorder (OUD) is a problematic pattern of opioid use leading to clinically-significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. Opioids are often taken in larger amounts or over a longer period than was intended [by the prescribing physician].
  2. There is a persistent desire or unsuccessful effort to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  4. Craving or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of opioids to achieve intoxication or desired effect; (b) a markedly diminished effect with continued use of the same amount of an opioid. NOTE: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
  11. Withdrawal, as manifested by either of the following: (a) the characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdraw in the DMS-5, p. 547-548; (b) opioids (or a closely-related substance) are taken to relieve or avoid withdrawal symptoms. NOTE: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Healthcare is not yet doing enough to avail itself of an effective referral system in the opioid crisis: using visits to emergency rooms to get patients with Opioid Use Disrder on medication and provide them with Naloxone. Intervening in these simple ways would greatly help reduce the shocking numbers of deaths from opioids in this country.

Are You Struggling?

I was obsessed with alcohol and drugs for nearly four decades of my life, which caused horrific and lasting consequences. I ended up serving three years in a state prison around the time I turned 20 years old. My history of using had started in early summer of 1977 shortly after graduating high school. I enjoyed the escape these mind-altering (numbing?) substances provided. Admittedly, it was quite fun at first. Within months, I became dependent on drugs and alcohol in order to function and to feel any degree of release from the demons of my past and the obsessive thoughts in my brain. I couldn’t laugh, relax, enjoy sex or food, or sleep unless I first got high or drunk. Sadly, I struggled with active addiction from shortly after my 18th birthday in 1977 to June 8, 2019.

I had started smoking cannabis and popping oxycodone pills during early Spring of 2018 in an attempt to self-medicate my depression, anxiety, and severe back pain secondary to a construction-related injury several years ago. Looking at the above description of Opioid Use Disorder established by the DSM-5, when in active opiate addiction I exhibit ten out of eleven of the criteria needed for a definitive diagnosis! I am sixty years old now, and I am finally looking at who I am in Christ. I am clean from opiates and cannabis for nearly 120 days, and I no longer dwell on the decades of constant failure. I should mention that I nearly took my own life several times during  my long history of active addiction. My struggle with opiates is fairly recent, and has taken me to places that I did not wish to go. Thankfully, I am confronting this issue with confidence in the power of the Name of Jesus and my unmitigated committment to change, never to be the same.

I work extensively today with a drug and alcohol counselor who is a believer in Christ. The ability to focus on Christ in therapy sessions provides an opportunity to examine the “spiritual malady” of addiction. I am constantly in contact with several elders at my home church who have become mentors. I am “coachable” today. I have started speaking regularly with Duche Bradley on the phone. He has a nationwide ministry of speaking in prisons and high schools about addiction and who we are in Christ Jesus. You can hear his “white chair” testimony here. He has led me through renouncing pharmacia and all nature of flesh-bound habits and addictions, and has encouraged my growth in Christ in order to move forward with my own ministry. Duche said to me, “Brother, if you do these things, you will be blown away about the many permanent changes in your character and your life.”

Nowadays, after having submited to Jesus Christ as my “higher power”—indeed, as my Savior and my Lord and Teacher—the obsession to use chemicals is gone. Likewise, the physical compulsion or craving has been defeated. I could never accomplish this under my own power. The Big Book of Alcoholics Anonymous tells us that alcohol is cunning, baffling, and powerful! No human power can relieve our alcoholism, but God can and will if we seek Him. The same applies to drug addiction. After all, a drug is a drug whether you drink it, snort it, or shoot it into your veins.

It is only through admitting my weaknesses and deciding to work with those who have risen above the evil and failure in their lives that I can get on with my life: studying theology on the master’s degree level, teaching weekly Bible study lessons at a local homeless shelter, and reaching out to newcomers at 12-Step meetings that are presently on a rapid decent into the living hell of active addiction. By accepting God’s “call” on my life, I can move toward a ministry of evangelism, applied apologetics, and lecturing, writing about, and teaching about Christianity and the release we all can have through Jesus. This is my life (as it was always meant to be), and I am happy to finally get on with living it!

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Given the near impossibility of quitting a mind-altering substance on your own, I highly suggest you reach out to someone who’s been there. Check your local government phone number pages in the phone book or, better, yet, do a Google search for A.A. or N.A. If, however, you are in the middle of a psychological or physical life-threatening crisis secondary to substance abuse, Please Call 911.

With suicides on the rise, the federal government wants to make the National Crisis Hotline easier and quicker to use. A proposed three-digit number — 988 — could replace the National Suicide Prevention Lifeline, 1-800-273-TALK (8255). The FCC presented the idea to Congress in a report earlier this month and is expected to release more information and seek public comment about the proposal in the coming months. PLEASE REMEMBER: You are not alone.

______________________________
¹ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fifth ed. (DSM-5). Arlington, VA: American Psychiatric Publishing (2013), pp. 547-548.

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

Overdose Deaths In Susquehanna Valley, Pennsylvania

The following was published in The Sunday Item, April 3, 2016, Sunbury, Pennsylvania regarding the rash of overdose deaths in the Susquehanna Valley.

Jan. 6, Female, 39, Shamokin, mixed-drug toxicity/prescriptions
Jan. 10, Female, 45, Zerby Township, mixed-drug toxicity/prescriptions
Feb. 4, Male, 27, New Columbia, heroin
Feb. 5, Male, 63, Mount Carmel, mixed-drug toxicity/prescriptions
Feb. 6, Male, 56, Sunbury, mixed-drug toxicity/heroin
Feb. 7, Female, 48, Mifflinburg, mixed-drug toxicity/prescriptions
Feb. 17, Female, 40, Shamokin, mixed-drug toxicity/prescriptions
Feb. 26, Male, 35, McClure, mixed-drug toxicity/heroin
Mar. 10, Male, 60, Mount Carmel, meth
Mar. 11, Female, 27, Shamokin, heroin
Mar. 13, Female, 33, Allenwood, heroin
Mar. 15, Male, 21, Shamokin, heroin
Mar. 21, Male, 37, West Chillisquaque, heroin

-Source: County Commissioners

Drug Overdose Deaths Hit Record Numbers

The Centers for Disease Control and Prevention announced that drug overdose deaths hit record numbers in 2014, with more than 47,000 deaths nationwide. CDC has outlined steps for stopping the overdose death epidemic. Pennsylvania Department of Drug and Alcohol Programs Secretary Gary Tennis issued the following statement in response:

Like the rest of the nation, Pennsylvania is in the throes of the worst overdose death epidemic ever. In 2014, nearly 2,500 Pennsylvanians died from a drug overdose. With one in four families in the Commonwealth suffering with the disease of addiction, Pennsylvania, at the direction of Governor Tom Wolf, has made addressing this epidemic a priority. The Department of Drug and Alcohol Programs is working hard with its partners in the Department of Health and the Department of Human Services and other agencies to execute a plan to stem the rising tide of overdose deaths.

We have become a nation awash in prescription opioids due to the historic and ill-fated medical movement toward overprescribing for pain over the past two decades. Opioid prescribing has quadrupled, and today four out of five individuals with heroin addiction start out with prescription opioids. Our initiatives therefore focus largely on prescription opioids, as well as preventing overdose deaths and expanding access to clinically appropriate treatment.

“The record level of opioid overdose deaths around the country and here in Pennsylvania is tragic,” said Department of Health Secretary Dr. Karen Murphy. “My department is working expeditiously to address this crisis on all fronts. Our primary goal is to work at prevention as well as providing treatment for those in need.”

The Pennsylvania Department of Health is leading an effort to build upon the prescribing guidelines already created, including guidelines to address emergency department pain treatment with opioids, opioids in dental practice and opioids to treat chronic non-cancer pain. These guidelines give healthcare providers direction for safe and effective pain relief practices, with greater emphasis on non-opioid therapies and greater caution to prevent addiction and diversion.