A Most Vexing Problem

Written by Steven Barto, B.S., Psy., M.A. Theology

FOR THE FOURTH TIME this newscast I grabbed for the remote and muted yet another 90-second commercial touting the glorious new activity of gambling online. Sexy young voluptuous blondes and brunettes with plunging necklines smile seductively and splay decks of cards, gesturing. These TV ads bear the names of so-called “trustworthy” gambling institutions, and promise a risk-free day of odds-laying up to $500, failing to remind that the house always wins in the end or such games of chance would shrivel up and blow away. One TV spot says “…now you can have the name of MGM Grand Casino in your pocket.” Never has a more ironic statement been made!

Steve Rose, PhD, a certified gambling counselor and problem-gambling prevention specialist, writes, “Since the pandemic began, there has been an explosion of online gambling.” With experts warning of this ticking time bomb, responsible gambling safeguards are sparse. Admittedly, online gambling is not new. However, the pandemic accelerated demand, leading to higher rates of riskier gambling. According to a report published by the Responsible Gambling Council (RGC) of Canada, one out of three online gamblers admit to being influenced by pandemic lockdowns (1).

Due to ease of access, online platforms make it easier to use gambling as a way to cope with underlying issues such as anxiety and depression. In fact, the RGC survey found that anxiety and depression are major factors contributing to high-risk gambling. Individuals with severe depression are almost five times more likely to engage in high-risk gambling. Typical depression symptoms such as low mood, apathy, and social isolation are a barrier to people traveling to live venues to gamble. With online gambling, anxious and depressed people can engage in round-the-clock gambling while distracting themselves from their circumstances from the ease of their living room.

A Prolific Online Presence

I did an Internet search with the words the perils of impulsive online gambling. The site listed at the top of my search results was an AD, which said Pennsylvania Online Casino – Real Cash Payouts in 24 Hours! The second result listed said Best Online Casinos in PA 2021 – Get $1,500 Welcome Bonus! Internet gambling is reeling in college students and young children along with adults. The COVID-19 crisis, and the confinement and other restrictions associated with it, represent a unique situation that carries financial consequences for the population. People worrying about the future, possibly spending more time than usual online, are at risk for falling hard for distraction or “easy solutions” to their woes.

Sports gambling in particular has soared during the pandemic and continues to climb. CBS News reports that gamblers placed $4.3 billion in bets on Super Bowl LV, marking “the largest single-event legal handle in American sports betting history.” In sports betting, a “handle” refers to the total amount of money wagered by bettors. About 7.6 million people placed bets on the game through platforms like FanDuel and DraftKings, marking a 63% increase from bets place on the 2020 Super Bowl. Additionally, more than 47 million Americans placed bets on March Madness games (2). Casey Clark, a senior vice president at the gaming association, said “You weren’t going to in-person sporting events and you weren’t going to brick-and-mortar sportsbooks [where gamblers can wager on various competitions].” He said more than 100 million people live in a state where gambling is now legal. Not long ago, that was only in Nevada (3).

Salerno and Pallanti write, “The COVID-19 pandemic has exerted a dramatic impact on everyday life globally. In this context, it has been reported that the lockdown and social distancing may have exerted an impact even on gambling behavior, not only by increasing gambling behavior in those affected by this disorder but even contributing to the occurrence of new cases” (4). According to their peer-reviewed paper, studies performed in different countries around the world have reported psychological and mental health problems due to the changes caused by the pandemic, including stress, anxiety, and depressive symptoms. Moreover, the lockdown and social distancing exerted an impact on gambling behavior, not only by increasing gambling incidents in those affected, but even contributing to the occurrence of new cases of problematic gambling.

Hodgins and Stevens write, “…the impacts of the COVID-19 pandemic on gambling and problematic gambling are diverse – possibly causing a reduction in current or future problems in some, but also promoting increased problematic gambling in others” (5). The study says, “At the same time that land-based gambling accessibility decreased during the pandemic, online gambling sites continued to operate. Some media reports indicated that online gambling business flourished during this time, and that the pandemic served to promote this increasingly popular gambling format” (6). Online gambling sites typically include the full range of types of gambling, including lottery ticket sales, casino table games such a roulette, blackjack and craps, slot machines, online poker and sports betting.

Like a Drug

Gambling, a leisure pursuit for most individuals, has the potential to cause harm to the gambler, their family and the community (7, 8). It is considered to be a potentially addictive behavior, which for some individuals can lead to gambling disorder (GD). GD is found in the DSM-5 under Unspecified Other (or Unknown) Substance-Related Disorder. This category applies to presentations in which symptoms characteristic of an other (or unknown) substance-related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate, but do not meet the full criteria for, any specific substance-related disorder or any of the disorders in the substance-related disorders diagnostic class (9). It is critical to note that, according to clinical studies, gambling addiction activates the same brain pathways as drug and alcohol cravings. Online gambling is considered to be a particularly problematic gambling format given the relative lack of constraints on how and when it can be accessed, its solitary nature, and the wide variety of types of gambling available.

David Zendle says a variety of practices have recently emerged which relate to both video games and gambling. He writes, “These range from opening loot boxes, to e-sports betting, real-money video gaming, token wagering, and social casino spending” (10). A blurring of the lines has occurred between video games and gambling activities. The most widely-discussed example of this convergence are loot boxes: Items in video games that may be bought for real-world money, but which contain randomized contents. In other words, your expenditure may lead to a “goose egg,” but the risk becomes tantalizing. Loot boxes share several formal features with gambling, and there has been widespread interest in the idea that engaging with loot boxes may lead to problem gambling. The more frequently gamers use loot boxes, the more severe their gambling problems tend to be (11). Certainly, you can see how this phenomenon places chronic gamers (especially younger players) at great risk for developing a gambling addiction.

Gamblers Anonymous (GA) was founded in 1957. It is an international fellowship of people who have a compulsive gambling problem whose approach is based upon the 12-step method of recovery from addiction initially established by Alcoholics Anonymous. Related programs include Narcotics Anonymous, Cocaine Anonymous, and Over-eaters Anonymous. GA believes gambling disorder involves repeated problematic gambling behavior that causes significant problems or distress. It is also called gambling addiction or compulsive gambling. Though Gamblers Anonymous is not associated with any religious group or political affiliation, some people find the 12-step principle of surrendering your problems to a higher power to have distinctly religious overtones. However, Gamblers Anonymous is welcoming of people of all ages, religions, and racial backgrounds—you just need to want to end your gambling addiction.

Gamblers Anonymous is a community of people who want the same goal: freedom from gambling addiction. Many Gamblers Anonymous members may also be struggling with other mental health or behavioral addictions. As a group, Gamblers Anonymous members share their wisdom, experiences, ideas for maintaining recovery, and healthy habits so that others may benefit. Members offer each other support, understanding, compassion, and solace when times are tough. Often, Gamblers Anonymous members will serve as sponsors to newer members who need more intensive support or a person to call when urges hit.

Are You Addicted to Gambling?

According to the DSM-5, persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress is indicated by the individual exhibiting four (or more) of the following in a 12-month period (12):

  1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
  2. Is restless or irritable when attempting to cut down or stop gambling.
  3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
  4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
  5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
  6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
  7. Lies to conceal the extent of involvement with gambling.
  8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
  9. Relies on others to provide money to relieve desperate financial situations caused by gambling

Concluding Remarks

Television advertisements for gambling sites is a huge issue with me. I am sensitive to addiction issues because of my 40-year-plus struggles with alcohol and drug addiction. Looking over the nine criteria listed above for gambling addiction, I can honestly say I exhibited much of the same obsessive behaviors as they pertained to drinking and getting high. Addiction messes with the brain chemistry of the addict by taking hostage the chemicals associated with pleasure. The “computer chips” of the brain are neurons: billions of cells that are organized into circuits and networks. Each neuron acts as a switch controlling the flow of information. If a neuron receives enough signals from other neurons that it is connected to, it fires, sending its own signal on to other neurons in the circuit. To send a message, a neuron releases a neurotransmitter into the gap (or synapse) between it and the next cell. The neurotransmitter crosses the synapse and attaches to receptors on the receiving neuron, like a key into a lock. This causes changes in the receiving cell. Other molecules called transporters recycle neurotransmitters (that is, bring them back into the neuron that released them), thereby limiting or shutting off the signal between neurons.

Drugs interfere with the way neurons send, receive, and process signals via neurotransmitters. Some drugs, such as marijuana, opioid pain medications, and heroin, can activate neurons because their chemical structure mimics that of natural neurotransmitters in the body. These chemicals are dopamine, oxytocin, serotonin, and endorphins (abbreviated DOSE). Because heroin and other substances are extremely potent compared to these naturally-occurring brain chemicals, the brain is incapable of producing them at a level that can reproduce the intensity, leading the addict to develop a craving for his or her drug of choice.

Gambling addiction works by hijacking the brain’s neurochemicals and learned behaviors that activate the brain’s reward center. Remarkably, gambling behavior in such individuals has the same capacity to stimulate the brain as does dopamine, oxytocin, serotonin, and endorphins. In addition, the gambling addict feels rewarded by the intermittent thrill of winning. When the need to win outweighs the risk of losing, the gambling addict begins to exhibit many of the criteria noted in the DSM-5 listed above. At this point, gambling is no longer a form of entertainment. Gambling, as with drug or alcohol addiction, becomes both the problem and the solution. In other words, the addict is now locked into a pattern of behavior where he or she continuously expects to replicate the early “high” of gambling or abusing addictive substances. The brain is hijacked by the randomness of reward.

Addiction can rewire the chemical circuitry of the brain to the point that it seems impossible to quit the addictive behavior. Even though gambling does not involve ingesting chemical substances, it produces the same response as any drug. Gambling addiction is not about money or greed. As the harms outweigh the entertainment value, the gambler looses control and becomes fixated on winning back losses. Because compulsive gambling is a progressive illness, the will to gamble becomes irresistible. Adolescents and teens are at risk for developing a gambling addiction at a time when social and emotional growth is most vulnerable to change. Adolescence is characterized by increased risk-taking, novelty seeking, and locomotor activity, all of which suggest a heightened appetitive drive.

Although teens can gamble casually, the pressure to “fit it” or establish “street cred,” and times of stress or depression, can trigger overwhelming urges to gamble. Widespread neurobiological changes such as shifts in brain matter composition can complicate addiction in teens. Finally, adolescents appear especially sensitive to rewarding cues, as evidenced by exaggerated neural responses when exposed to dopamine. During adolescence, brain cells continue to bloom, with notable changes in the prefrontal cortex, which is involved in decision making and cognitive control, as well as other higher cognitive functions. Accordingly, I believe additional study is indicated regarding teen risk for developing a gambling addiction.

Help is Available Right Now!
National Problem Gambling Helpline

1 (800) 522-4700
SAMSHA National Helpline
1 (800) 662-HELP

References

(1) “The Emerging Impact of Covid-19 on Gambling in Ontario,” Centre for the Advancement of Best Practices, Responsible Gambling Council (July 2020). URL: https://www.responsiblegambling.org/wp-content/uploads/RGC-COVID-and-Online-Gambling-Report_Jul.AP_-1.pdf
(2) Kristopher Brooks, “Sports Gambling Has Soared During the Pandemic and Continues to Climb,” (March 29, 2021). URL: https://www.cbsnews.com/news/sports-gambling-betting-draft-kings-fanduel-american-gaming-association/
(3) Ibid.
(4) Luana Salerno and Steffano Pallanti, “COVID-19 Related Distress in Gambling Disorder,” (Feb. 25, 2021), Frontiers in Psychiatry. URL: https://doi.org/10.3389/fpsyt.2021.620661
(5) David C. Hodgins and Rhys M.G. Stevens, “The Impact of COVID-19 on Gambling and Gambling Disorder: Emerging Data,” (April 19, 2021). URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183251/
(6) Ibid.
(7) “Spain orders ‘social shield’ to fast track gambling advertising window,” SBC News (2020). ULR: https://sbcnews.co.uk/europe/2020/04/01/spain-orders-social-shield-to-fast-track-gambling-advertising-window/
(8) “Coronavirus: Gambling firms urged to impose betting cap of 50 pound a day,” The Guardian (2020. URL: https://www.theguardian.com/sport/2020/mar/22/coronavirus-gambling-firms-urged-to-impose-betting-cap-of-50-a-day
(9) American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) (Arlington, VA: American Psychiatric Association, 2013), 585.
(10) David Zendle, “Beyond Loot Boxes: A Variety of Gambling-like Practices in Video Games are Linked to Both Problem Gambling and Disordered Gaming,” PeerJ (July 14, 2020). URL: https://peerj.com/articles/9466/
(11) In Addictive Behaviors, Vol. 96 (Sept. 2019), 26-34. URL: https://doi.org/10.1016/j.addbeh.2019.04.009
(12) American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), Ibid., 585.

Mental Health and Addiction

The first section of this post is taken from the blog of Sophia Majlessi,
National Council for Behavioral Health
Released January 8, 2020

Voters More Likely to Support a Candidate Who Promises to Address Mental Health and Addiction, According to New Polling from the National Council for Behavioral Health Released Ahead of December 16 New Hampshire 2020 Presidential Candidate Forum

WASHINGTON, D.C. (December 11, 2019)—New polling released today by the National Council for Behavioral Health shows strong bipartisan agreement among registered voters in New Hampshire that the federal government is not doing enough to address mental health (84% of Democrats and 72% of Republicans) and addiction (77% of Democrats and 53% of Republicans) in America. The National Council released the new polling in advance of the Unite for Mental Health: New Hampshire Town Hall, a public forum for 2020 presidential candidates to discuss mental health and addiction policies. The National Council for Behavioral Health, Mental Health for US and the NH Community Behavioral Health Association will host Unite for Mental Health: New Hampshire Town Hall on December 16 at the Dana Center at Saint Anselm College in Manchester, N.H.

“The message is clear: candidates who want to win New Hampshire need to tell voters they have a plan to address the mental health and addiction crisis, one of the most important health issues facing the nation,” said Chuck Ingoglia, president and CEO of the National Council for Behavioral Health. “The Unite for Mental Health: New Hampshire Town Hall will provide an important opportunity for presidential candidates to engage with New Hampshire families, mental health professionals and local policymakers to discuss the issues and share solutions voters—and the nationare eager to support.”

This statewide poll comes on the heels of new national data from the U.S. Centers for Disease Control and Prevention (CDC) confirming that suicide is the second leading cause of death among teenagers in the U.S. The suicide rate among people ages 10 to 24 years old climbed 56% from 2007 to 2017, according to the CDC report. These findings, compared with high rates of death nationwide from drug overdose, are leading to calls for the 2020 presidential candidates to engage communities across the country in order to better meet the needs of millions of Americans.

“Mental health and addiction continuously poll as key issues for many Americans, yet our leaders rarely prioritize prevention, treatment, and recovery strategies,” said former U.S. Rep. Patrick J. Kennedy, founder of The Kennedy Forum and Mental Health for US co-chair. “This new polling data from New Hampshire is the catalyst we need for change. The Mental Health for US coalition is proud to stand with the National Council and the NH Community Behavioral Health Association as we call on policymakers and candidates to walk the walk for the those with mental health and addiction challenges.” “The results of this poll are compelling. The need to invest in caring for those with mental illness is clear, and the voters want to see candidates for public office at all levels address these important issues,” said Roland Lamy, executive director of the NH Community Behavioral Health Association.

Results from the full survey have a margin of error of +/-6%. Click here for full polling results.

My Thoughts

The struggle to break free from active addiction is among the hardest undertakings a person can face in his or her lifetime. Putting the drug down is more difficult depending on the substance, amount used, and duration of use. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, has sequestered substance abuse under the new heading Substance Use Disorder (SUD). The substance-related disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; cocaine (powder or rock); opioids; sedatives and hypnotics; stimulants (amphetamine-type, cocaine, and other stimulants; tobacco; and other (or unknown) substances. It is important to note that all drugs (when taken in excess) have a common direct activation of the brain reward system, typically leading to dependency and addiction.

Mental health issues can become a complicating factor; this is often referred to as dual-diagnosis, or, in the vernacular, “double-trouble.” Moreover, individuals with poor self-control may be particularly vulnerable to substance abuse. Accordingly, the roots of substance abuse for some individuals can be seen in behaviors long before the onset of actual substance use itself. It is also important to note that substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. These secondary issues can include intoxication, withdrawal, psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders.

Features of substance use disorders include a rather important element: change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral results of such changes may manifest in repeated relapses and intense craving for the individual’s favorite drug. This craving is often set in motion through a mere drug-related stimuli, which is referred to in the addictions field as a trigger. Typically, the longer an addict remains clean the easier it is to recognize and defeat such cravings. A craving is likely rooted in classical conditioning, and is associated with activation of specific reward structures in the brain. These structures are rather individualized; not every addict is triggered by the same thought or stimulus. Instead, triggers are established by what the individual is agitated or distressed by, and inversely related to the ability to properly handle such stimuli.

Not surprisingly, treating co-occurring substance abuse and mental illness calls for simultaneously addressing two critical and sometimes confounding problems. In fact, double-trouble can often complicate differential diagnosis—the comparison of symptoms from multiple likely mental or physical conditions. From a personal perspective, it was quite difficult for me to clearly determine what was “wrong” with me. Severe anxiety, constant ruminations, insomia, and underlying depression crippled me for decades. In addition, I felt powerless and helpless, unable to relax or sleep. This is likely what initially led to my substance abuse. I started drinking alcohol and smoking marijuana the summer following my high school graduation. My use was extensive from the beginning, but I was able to calm down, stop my thoughts from racing, and finally get some sleep. Unfortunately, I was not “sleeping” as much as I was passing out. It did not take long for my substance use to become excessive, leading to a decades-long season of poor choices and serious consequences.

Reasons for drug and alcohol abuse by individuals with mental illness varies by individual. Substance abuse could be primary or secondary to psychiatric issues, or may even in some cases be independent of mental illness. The association between mental disorders and substance abuse is complex. The relationship of substance abuse to onset, course, and severity of mental issues, and problems in the evaluation of dual-diagnosis patients, is often complex. Adding to this difficulty is the likelihood that the individual often engages in self-medication to alleviate troublesome symptoms for which they have no explanation. This psychodynamic perspective must also include neurochemical considerations. Affective disorders (those impacting mood, often including depression, bipolar disorder, anxiety disorder) are particularly difficult to manage. I found welcome relief through drug and alcohol us—albeit only temporarily.

Unfortunately, chronic substance abuse can also lead to the development of organic conditions, such as psychosis, mania, and mental confusion. Other disorders can include chronic apathy and dysphoria, and personality disorders such as Antisocial Personality Disorder and Borderline Personality Disorder. Again, there is often confusion regarding co-morbity. For example, addicts quite frequently use, abuse, manipulate, and disrespect friends, family, and other acquaintances in order to get what they need, whether it be money, shelter, or (at times) the drug itself. These traits are also typical of several key personality disorders.

As these traits become routine, the addict often slides down the slippery slope to criminal behavior—theft, embezzlement, forgery, kiting checks, burglary, armed robbery. A serious, unfortunate end-result for the dually-diagnosed addict can lead to suicide. I have personally considered taking my own life on many occasions during active addiction. I would become remorseful for the way I treated family and friends. The disconnect between my Christian worldview and my behavior haunted me. It seemed suicide was the only option. As my uncle once told me, I was unable to see the horizon. Truly, I have not faced a more difficult situation in my life than suffering from mental illness while in active addiction.

In my review of the diagnostic criteria for Borderline Personality Disorder, I determined I’ve displayed eight of the nine criteria for making such a diagnosis. I’ve demonstrated a pervasive pattern of instability in my interpersonal relationships, self-image, affect (mood swings), impulsivity (sexual behavior, drug and alcohol abuse, risk-taking, excessive impulse spending, reckless driving), recurring thoughts of suicide, chronic feelings of emptiness, and recurrent anger. Thankfully, I have seen a vast improvement in the lion’s share of these symptoms. However, I still deal with poor self-image at times, tend to “sanitize” the truth, occasionally manipulate others, and remain rather impulsive in areas such as impulsive spending.

Given the pervasive nature of dual-diagnosis, it is critical to identify when you are suffering from mental or emotional symptoms, and more importantly to recognize if you are using or abusing drugs or alcohol to dampen or defeat uncomfortable thoughts or feelings. Depression, anxiety, and insomnia tend to “respond” initially to substance use. However, the need for one’s drug of choice to “treat” these types of symptoms increases as use leads to abuse; abuse leads to tolerance; and tolerance leads to dependency. Consequently, self-medication of emotional or psychiatric difficulties by consuming drugs or alcohol is doomed to fail—often with quite devastating results. If you, or someone you know, is caught in the vicious cycle of addiction (with or without a co- occurring mental condition), it is vitally important to seek professional intervention.

It is impossible to “go it alone” and achieve anything like helpful results. In fact, it is likely your situation will deteriorate. I was told years ago by an addictions counselor that because I had an underlying mental illness, treating my addiction without addressing my psychiatric problem is like having two broken legs but only putting a cast on one of them.

If you or someone you know is struggling with substance use disorder and want more information or help quitting, please contact your local AA or NA chapter, or click here to visit the National Institute on Drug Abuse official website. You can also scroll back to the top of this post and click on the COMMENT bar to open an dialog with me. I will be glad to speak with you any time.

References

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th edition (Washington, DC: American Psychiatric Publishing), 2013.

 

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.

nida-banner-science-of-abuse-and-addiction

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.

girl-overdose.jpg

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.

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