The Importance of Prevention in Addressing the Opioid Crisis

NIDA Banner Science of Abuse and Addiction

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

June 27, 2019

As our communities, healthcare systems, and government agencies join in the effort to reverse the epidemic of opioid overdoses and solve the opioid crisis, it is not enough to focus all our resources on treating people who are already addicted to opioids. Keeping people who do not have an opioid use disorder from becoming addicted is an equally important task [italics mine]. Addressing over-prescribing of pain medications through improved pain management and prescription monitoring has been one important prevention approach; and as illicit opioids like heroin and imported fentanyl become more prevalent, reducing the supply of those substances through law enforcement efforts is also crucial. But reducing the demand for opioids by addressing the reasons people turn to them and become addicted in the first place is just as vital and fundamental to ensuring that a new drug epidemic does not follow once the opioid crisis is contained.  

Research on preventing drug use by addressing vulnerability factors that increase the risk for substance use disorders is an important component of the National Institutes of Health (NIH) HEAL (Helping to End Addition Long-Term™) Initiative. Specifically, the HEALthy Brain and Child Development (HBCD) study being partially funded by HEAL will examine how the human brain develops in the transition from infancy into early adolescence. Evaluating the effects of fetal drug exposures, adverse environments, genetics, mental illness will provide knowledge to help us understand how these risk factors operate in conferring vulnerability for substance use disorders.

Abundant research by NIDA-funded investigators over the past few decades has shown that positively altering a child’s life trajectory by reducing various risk factors, strengthening protective factors, and increasing access to resources can reduce or delay later drug use as well as minimize other adverse outcomes like criminality or other mental illness. Risk factors addressed by early childhood interventions can include poor self-regulation, aggression, or insecure attachment to parents. Those addressed in family and school prevention interventions at all ages through the teen years include lack of parental supervision, exposure to drugs at home or at school, and stresses from poverty, neglect, or abuse.

Prevention programs can take many forms, but all in one way or another address these risk factors and/or bolster factors like self-control, peer relationships, or other age-appropriate skills. These forms of resilience may make all the difference in the young person’s life when faced with the opportunities and temptations to begin smoking, drinking, or using drugs when they are adolescents, despite whatever adversity they may have experienced when younger. Effective prevention can even begin as early as the prenatal period: For example, an intervention in which trained nurses visit and provide guidance to first-time mothers during their pregnancy and in the first two years of their child’s life was shown to be effective at improving various cognitive and behavioral outcomes into adolescence, including reduced substance use and involvement with the juvenile justice system.

The stresses of impoverished environments negatively impact brain development, but a striking finding from prevention research is that interventions can protect against or reverse some of these neurobiological impacts. For example, a family-focused intervention with poor families in rural Georgia protected against poverty-associated neurobiological changes to brain areas involved in learning and stress reactivity. And maltreated children in foster care who received a prevention intervention for preschoolers were better able to regulate stress, as measured by cortisol levels.

Because risk factors for drug use are common to other behavioral problems, most prevention interventions do not focus solely on preventing drug use or on preventing a single type of drug use. A wide range of problems can be addressed or averted by addressing core risk or protective factors. A few programs, however, such as a middle-school intervention called PROSPER, have shown specific benefits at preventing nonmedical use of prescription drugs.

An important research priority is finding out how to widen the adoption and effective implementation of evidence-supported prevention programs. The menu of such interventions is diverse, but few of the options are widely used. Part of the problem is that high-quality intervention programs are costly, and communities may be reluctant to invest the needed resources when the payoff may be years or more in the future. However, studies have strikingly shown that many programs more than pay for themselves. Like other investments—saving for retirement, for instance—primary prevention of substance use and addiction requires long-term thinking and balancing the short-term costs in money and time against the long-term benefits of a healthier society down the road.

The HEAL initiative will also prioritize research on developing interventions targeted towards the transition from late adolescence into adulthood, the age where there is the largest increase in initiating opioid use. NIDA will be funding research to create an evidence base for new strategies and interventions to prevent opioid initiation and opioid use disorder (OUD) in older adolescents and young adults in healthcare, justice, and other settings.

In a new Commentary, Targeting Youth to Prevent Later Substance Use Disorder: An Underutilized Response to the US Opioid Crisis, in the American Journal of Public Health, colleagues at NIDA, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control (CDC) highlight the importance of research on primary prevention for helping to address the opioid crisis. Such research will provide us not only with scientific solutions to address the current opioid crisis but will provide us with the knowledge and tools to protect us from future drug crises.

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

The Opioid Issue: Part 2

Part Two: Collateral Damage

As the nation grapples with opioid’s hold over millions, its smallest victims cry out to be heard, held, and healed. No Child Left Behind is a familiar battle cry. But to foster parents helping to care for children of parents addicted to drugs, those words have nothing to do with a political agenda or advertising campaign. One foster mom reported quietly watching another baby detox from opiates, its high-pitched wails unique with the sound of drug-induced anguish, and whispering, “A whole generation is being lost from the opioid epidemic. A whole generation.”

opioid-crisis-word-cloud

That generation—with hundreds of thousands of America’s youngest feeling its physical, mental, and emotional impact, sometimes from the moment of conception—is staring down what doctors call Neonatal Abstinence Syndrome (NAS). The condition is not something that can be cured with a pill. There are so many children growing up without their parents that the long-term ramifications are still unforeseen. The United States has certainly faced its share of social and public health problems over the years, but when it comes to the opioid crisis, child advocates around the country warn, it’s a strange and scary new world.

Agony in the Womb

According to a study released by the University of Minnesota this spring, one baby struggling with NAS is born in America every 15 minutes. Furthermore, almost 90 percent of pregnancies among women struggling with opioid addiction are unintentional. When a woman takes opioids while pregnant—even exactly as a doctor might instruct, according to the March of Dimes—she runs the substantial risk of harming her unborn child.

One Baby Every Half Hour

Prescription painkillers like codeine, fentanyl, hydrocodone, morphine, and oxycodone (as well as the street drug heroin) are all classified as opioids and all negatively affect children in the womb. Common risks of opioid use during pregnancy, the March of Dimes says, include miscarriage, preterm labor, premature birth, birth defects, low birth weight (defined as weighing less than five pounds, eight ounces), and NAS. NAS is its own beast. The completely preventable condition can grip babies with tremors, fever, chills, weight loss, seizures, and even death. Dr. W. David Hager, member of Focus on the Family’s Physicians Resource Council (PRC), believes 55-94% of newborns delivered to women who used opioids in pregnancy suffer from NAS.

Clearly, it is nearly impossible for an unborn child to skate past the consequences of his or her mother’s opioid use, no matter how slight. Yet damage isn’t usually intentional. Instead, Hager says, addiction to opioids reaches far beyond the initial physical pleasure to something much deeper.

It All Adds Up

That’s a familiar story for J. Scott Moody and Wendy Warcholik, a married pair of economists. As the directors of Family Prosperity Institute (FPI), a New Hampshire-based think tank focused on measuring the health of the American family, Moody and Warcholik frequently hear about opioid-related crises—and have watched their own loved ones succumb to substance abuse along the way. Warcholik, for example, grew up in a family fragmented by her parents’ collective five divorces. Of all her siblings, she was the only one to have fully escaped the negative consequences. The others have experienced unemployment, substance abuse, government dependency, low educational attainment, unwed childbirth, and divorce.

FPI has created a family prosperity index—a formula-driven rankings list that measures the strength and prosperity of families and the nation by combining the most important economic and social data into a single number and then ranking those states based on which create the best environment for families to thrive. The index fills in the gaps around other measures like the gross domestic product, assembling all the pieces of the prosperity puzzle into a complete picture of the economy. No other measure takes into consideration both the economic and social choices of people in a state to create a holistic measure of human behavior in the States.

The latest FPI index ranked Utah first and New Mexico last. FPI’s formula calculates things like average welfare utilization, children in married households, religious attendance and infant mortality rate. That last category is most disconcerting because as opioid use has risen, so has infant mortality rate. (The U.S. Centers for Disease Control and Prevention defines that as the death of an infant before his or her first birthday), while the infant mortality rate is the number of infant deaths for every 1,000 live births.

Drug Dependent Newborns.png

Between 2010 and 2015 twenty-one states saw an increase in their infant mortality rate. So many states, in fact, that while the national average dropped 16 percent between 2000 and 2015, the last five years only saw a decrease of 1.6 percent. Clearly, if trends continue, the country could see an increase in the infant mortality rate in the near future. Keep in mind that a rising infant mortality rate is typically only found in Third World countries. Besides the physical, emotional and mental cost to America’s children, opioid addiction doesn’t come fiscally cheap, either. For example, in 2015 Ohio paid more than $133 million to care for approximately 2,000 NAS babies born that year.

The True Cost

Interestingly, FPI’s research shows that devout beliefs and behaviors (consistent church attendance, daily prayer, Bible reading, etc.) reduce illicit drug use. The converse holds true as well. Moody says, “It is clear that people in despair who don’t turn to God for help will try to numb their pain some other way, whether it be with drugs or sex. Unfortunately, at least for the last decade, we’ve been seeing more and more people turning to drugs and sex than God. We have to reverse this trend.”

Ultimately, America truly has no idea what the long-term consequences of opioid addiction on our most innocent citizens will be. “We read horrifying stories in New England about parents shooting up their own children just to keep them quiet, or left in a freezing car with their parents passed out in the front seat,” Warcholik says. How far are we, as a society, willing to go in elevating adult desires over the health and well being of our children?

That is a question far beyond the scope of any research team—but one the Church must rise up to help answer.

 

 

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.

no-pain.jpg

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.

pain-management-word-cloud-e1453101800676

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.

oxycontin pills.jpg

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.

Heroin and Fentanyl in Bottles.jpg

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.

22SCI-NUMBER-articleLarge

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.

Celebrate-recovery.jpg

“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

 

 

Addressing the Opioid Crisis Means Confronting Socioeconomic Disparities

FROM THE BLOG OF DR. NORA VOLKOW, EXECUTIVE DIRECTOR
NATIONAL INSTITUTE ON DRUG ABUSE

October 25, 2017

crowd

The brain adapts and responds to the environments and conditions in which a person lives. When we speak of addiction as a chronic disorder of the brain, it thus includes an understanding that some individuals are more susceptible to drug use and addiction than others, not only because of genetic factors but also because of stress and a host of other environmental and social factors in their lives that have made them more vulnerable.

Opioid addiction is often described as an “equal opportunity” problem that can afflict people from all races and walks of life, but while true enough, this obscures the fact that the opioid crisis has particularly affected some of the poorest regions of the country, such as Appalachia, and that people living in poverty are especially at risk for addiction and its consequences like overdose or spread of HIV. The Centers for Disease Control (CDC) considers people on Medicaid and other people with low-income to be at high risk for prescription drug overdose.

Below is a pic of teens in Allegheny County, Pennsylvania, the heart of Appalachia.

Teens in Appalachia.jpg

Some of the reasons have to do with access and quality of health care received by people in economically disadvantaged regions. According to the U.S. Department of Health and Human Services, people on Medicaid are more likely to be prescribed opioids, at higher doses, and for longer durations – increasing their risk for addiction and its associated consequences. They are also less likely to have access to evidence-based addiction treatment. But psychological factors also play a role. Last year, economists Anne Case and Agnus Deaton attributed much of the increased mortality among middle-aged white Americans to direct and indirect health effects of substance use, especially among those with less education, who have faced increasing economic challenges and increased psychological stress as a result.

Environmental and social stressors are an important predictor of many mental disorders, and decades of research using animal models have told us a great deal about how such stressors increase risk for substance use, and even make the brain more prone to addiction. Among the best-known animal models of environmental stress and addiction risk are those involving social exclusion and isolation: Solitary animals show greater opioid self-administration than animals housed together, for example – a finding originally made famous by the “Rat Park” experiment of Bruce K. Alexander in the 1970s and replicated by other researchers over the subsequent decades.

Even more pertinent to the question of how low social status might affect addiction risk is research by Michael Nader, who showed that male monkeys who are dominant in their social group demonstrate less cocaine self-administration than lower-ranked (subordinate) animals or solitary ones. Some evidence points to brain circuitry in the insula – a region important in processing social emotions – that may link feelings of social exclusion to increased drug craving, as well as possibly altered dopamine-receptor availability in the striatum – part of the reward circuit – depending on social status. The relationship may be bi-directional. In other words, exclusion not only increases risk for using drugs, but increased drug use can increase social isolation further, creating a vicious cycle. Similarly, when people have strong family or community relationships, this often acts as a protective factor against the risk of becoming addicted, and can facilitate recovery among those striving to achieve it.

family-2611748__340

Another animal model of environmental stress is an environment without opportunities for play, exploration, and exercise. Rodents housed in non-enriched environments have been shown to be more sensitive to the rewarding effects of heroin compared to those in more enriched environments. A team of researchers at the University of Texas Medical Branch in Galveston recently explored the molecular mechanisms that mediate the protective effects of enriched environments. They analyzed the transcriptome – or the parts of the genome that are expressed – in the nucleus accumbens, which is part of the reward circuit, following cocaine exposure in animals raised in either enriched or dull environments. They identified a number of molecules and signaling pathways, including a pathway involving retinoic acid – a product of Vitamin A metabolism – that may underlie the effects of an enriched environment on the brain’s processing of reward. The researchers suggest that the mild stressors and surmountable challenges presented by an enriched environment act to “inoculate” against stress, making individuals in those environments more resilient.

Although highly simplified, animal models of social and environmental stress can tell us a great deal about how stressful human environments may act as risk factors for substance use and other adverse outcomes and, conversely, how socially supportive and rewarding environments may offer protection. Prevention efforts targeting some of the environmental determinants of substance use, especially in young people, have already shown great success by applying the principles of boosting social support and creating the human equivalent of “enriched environments.” For example, a primary prevention model implemented in Iceland drastically reduced teen substance use in that country by increasing parental involvement and youth participation in team sports.  

opiate painkillers

Blame for the opioid crisis now claiming 91 lives every day is often placed on the supply side: overprescription of opioid pain relievers and the influx of cheap, high-quality heroin and powerful synthetics like fentanyl, which undoubtedly have played a major role. But we cannot hope to abate the evolving crisis without also addressing the lost hope and opportunities that have intensified the demand for drugs among those who have faced loss of jobs and homes due to economic downturns. Reversing the opioid crisis and preventing future drug crises of this scope will require addressing the economic disparities, housing instability, poor education quality, and lack of access to quality health care (including evidence-based treatment) that currently plague many of America’s disadvantaged individuals, families, and communities.

References

Volkow, N. (October 25, 2017). “Addressing the Opioid Crisis Means Confronting Socioeconomic Disparities.” [Web blog comment.] Retrieved from:  https://www.drugabuse.gov/about-nida/noras-blog

 

High-Achieving and Religious Students At-Risk Youth For Substance Abuse?

New research shows high-achieving kids are more likely to drink and use drugs during their teen years and develop addictions by adulthood.

182417552

DO YOU ASSUME THAT since your kid gets good grades and goes to a good school that they’re not drinking or doing drugs? Think again. That’s the takeaway from two new studies suggesting that academically gifted youths are more likely to abuse substances, both as teens and adults. One surveyed 6,000 London students over nine years. Those with the highest test scores at age 11 were more likely to drink alcohol and smoke marijuana in adolescence – and were twice as likely to do so “persistently by age 20.”

Notably, a study taken by Arizona State University (ASU) study found that high school students who were more afraid their parents would punish them were less likely to drink or get high as adults. One professor, Luthar, said her guidance for parents is to start the conversation in middle school, and not to downplay the seriousness of underage or or excessive drinking. She says, “Tell them it only takes one arrest, and all the things they are working for so hard can be derailed.”

BETWEEN 23% AND 40% OF HIGH-ACHIEVING UPPER MIDDLE-CLASS BOYS ARE DIAGNOSED WITH DRUG OR ALCOHOL DEPENDENCE BY AGE 26 ACCORDING TO A STUDY OF NEW ENGLAND HIGH SCHOOL STUDENTS.

The ASU study followed 330 high-achieving high school students from suburban New England schools. It found that their frequency of drunkenness and use of marijuana, stimulants, cocaine, and other drugs was substantially higher than the norm for their peers. By age 26, they were two to three times more likely to have been diagnosed with an addiction.

“The assumption has always been that if there is a group of kids that are at greatest risk of addiction, it is those living in poverty. Our data shows there is another group at great risk here,” says Suniya Luthar, lead author and ASU psychology professor. Luthar suspects pressure to excel at AP courses and extracurricular activities and get into a good college may drive some to self-medicate. While not all students in her study came from wealthy families, the schools were in affluent neighborhoods where access to disposable income makes it easier to purchase fade IDs, alcohol, and drugs.

Parents with high cognitive ability and socioeconomic status also tend to drink more themselves, thereby modeling a relaxed disposition regarding alcohol consumption as a means of reward or a way to unwind after a hard day. Some of these parents take a laissez-faire attitude when they catch their high-achiever child drinking alcohol. Luthar says, “People assume, ‘How bad can it be? She’s still on the honor roll.'”

We all have a basic need to receive positive regard from the important people in our lives (primarily our parents). Those who receive unconditional positive regard early in life are likely to develop unconditional self-regard. That is, they come to recognize their worth as a person, even while concluding that they are not perfect. Such people are in a great position to actualize their positive potential. Unfortunately, some children repeatedly are made to feel that they are not worthy of positive regard. As a result, they acquire conditions of worth; standards that tell them they are lovable and acceptable only when they conform to certain guidelines. Next comes acquiring a distorted view of themselves and their experiences.

Consider the song “Perfect” by Alanis Morissett:

Sometimes is never quite enough;
If you’re flawless, then you’ll win my love.
Don’t forget to win first place,
Don’t forget to keep that smile on your face.

Be a good boy,
Try a little harder,
You’ve got to measure up,
Make me prouder.

How long before you screw it up?
How many times do I have to tell you to hurry up?
With everything I do for you
The least you can do is keep quiet.

Be a good girl,
You’ve gotta try a little harder;
That simply wasn’t good enough
To make us proud.

I’ll live through you,
I’ll make you what I never was;
If you’re the best, then maybe so am I;
Compared to him compared to her,
I’m doing this for your own damn good,
You’ll make up for what I blew;
What’s the problem, why are you crying?

Be a good boy,
Push a little farther now,
That wasn’t fast enough
To make us happy;
We’ll love you just the way you are
If you’re perfect.

23% OF FULL-TIME COLLEGE STUDENTS ABUSE OR ARE DEPENDENT ON DRUGS AND ALCOHOL – THAT’S TWO AND A HALF TIMES THE NATIONAL AVERAGE.

Daily marijuana use is at its highest level among young adults of college age since the early 1980s, with 4.9% of college students reporting daily use, and 12.8% of non-college peers admitting to smoking pot every day. What’s wrong with a little pot smoking? you might ask. There has been a major movement toward legalization of medical marijuana, as well as recreational marijuana, giving the impression that opponents of marijuana are guilty of much ado about nothing. According to a September 2017 study, however, new research suggests that marijuana users may be more likely than non-users to misuse prescription opioids and develop prescription opioid use disorder. The study was conducted by the National Institute on Drug Abuse, part of the National Institutes of Health, in conjunction with Columbia University.

Heavy alcohol use appears to be higher in college students than in non-college peers. Binge drinking (consuming five or more drinks in a row) is practiced by 32.4% of all college students, compared to 28.7 % among those in the same peer group who are not enrolled in college. 40.8% of college students report frequent intoxication (having been drunk) According to Nowinski (1990), a certain degree of rebelliousness develops in the adolescent. This seems to be linked to tension that exists between teens and authority, and reflects the underlying dynamic of individuation. This basic developmental process is the pathway that leads from childhood to adolescence. If it is successful, individuation ends in identity and autonomy. One key dynamic in individuation is the development of willpower. It is important to note that willpower without the ability to plan and delay gratification – this is what the Bible calls temperance or self-control – is dangerous; both are necessary, and teens who develop willpower without self-control are apt to be reckless and to get into trouble. This is especially true of substance abuse.

CONCLUDING REMARKS

Substance abuse has fast become America’s number one health problem. Of primary concern is the opiate epidemic, including misuse and abuse of opioid painkillers, especially OxyContin and Fentanyl, and heroin. The substance abuse problem touches the life of every American child, family, congregation, community, and school, and is no respecter of socioeconomic status or culture. Interestingly, however, the opiate epidemic seems to be primarily hitting the category of white low and middle class males between the ages of 18 and 49. Geographic evaluation of the trend shows an initial explosion from within the Appalachian region. This seems to be due to the prevalence of occupations requiring hard labor, with frequent work-related injuries, and eventual economic collapse secondary to joblessness.

Given the tremendous negative impact of substance abuse, researchers, policy makers and practitioners look to identify factors that protect people from initiating the use of drugs, and help people who have become addicted to recover. A growing body of research suggests that religion is an important protective factor against substance use, and that religion may help people who are trying to recover from substance abuse by helping them find meaning, direction and purpose in life. Given the likely impact clergy can have on their congregation, they should pursue continuing education about the causes, consequences, risks and protective factors for substance abuse. Additionally, clergy and faith-based leaders should take a public stand against the use of drugs that is consistent with their personal and denominational beliefs and values.
I believe clergy and church leaders should identify and use congregation members with training, expertise, and experience in the area of addiction (e.g., social workers, addictions counselors, doctors, nurses, and people in recovery) to educate the congregation and create programs and ministries that address the problem. This is especially important for churches who also operate or are affiliated with a Christian-based school. It is advisable for churches to make space available for prevention activities, as well as for people affected by substance abuse (such as Celebrate Recovery).

 

REFERENCES

Community Commons. (October 27, 2016). “Mapping the Opioid Epidemic in the U.S.” [Web blog article.] Retrieved from: https://www.communitycommons.org/2016/10/mapping-the-opioid-epidemic-in-the-us/

Marshall, L. (October 2017). “Smart, Privileged, and At-Risk.” WebMD. 55.

NIH. (September 26, 2017). “Marijuana Use is Associated With an Increased Risk of Prescription Opioid Misuse and Use Disorders.” National Institute on Drug Abuse. Retrieved from: https://www.drugabuse.gov/news-events/news-releases/2017/09/marijuana-use-associated-increased-risk-prescription-opioid-misuse-use-disorders

Nowinski, J. (1990). Substance Abuse in Adolescents & Young Adults: A Guide to Treatment. New York, NY: W.W. Norton & Co.

 

COUNTERFEIT OXYCODONE WARNING!

COUNTERFEIT PAIN PILLS CONTAINING DANGEROUS SYNTHETIC OPIOIDS!

Originally posted July 18, 2017
National Institute of Drug Abuse
https://www.drugabuse.gov/

Health and safety agencies in Iowa have issued an advisory to warn Iowans of counterfeit pain pills containing dangerous synthetic opioids. The Iowa Division of Criminal Investigation’s (DCI) laboratory analyzed pills made to resemble the prescription pain reliever oxycodone, finding them to contain more powerful and illicit synthetic fentanyl and U-47700, putting users at higher risk of opioid overdose. U-47700, also known as “Pink” or “U4” on the streets, is a synthetic opioid pain medication currently being distributed as a dangerous designer drug. Since 2015, reports have surfaced of numerous deaths due to street use of U-47700. Law enforcement agencies have traced illegal importation into the United States primarily from clandestine chemical labs in China. It is available through the Dark Web.

Heroin and a Handgun

U-47700 has been seized by law enforcement on the street in powder form and as tablets. Typically, it appears as a white or light pinkish, chalky powder. It may be sold in glassine bags stamped with logos imitating heroin, in envelopes and inside knotted corners of plastic bags. In Ohio, authorities seized 500 pills resembling a manufacturer’s oxycodone immediate-release tablets, but they were confirmed by chemical analysis to contain “Pink.” U-47770 has also been identified and sold on the Internet misleadingly as a “research chemical” at roughly $30 per gram.

Pink is very toxic or deadly in even small doses. Labels on the packaging may state NOT FOR HUMAN CONSUMPTION or FOR RESEARCH PURPOSES ONLY, most likely to avoid legal detection. Fatalities due to U-47770 in the United States join the growing incidents of drug overdose deaths from opioid pain medication. Those who abuse U-47770 may be at high risk of addiction and substance abuse disorder, overdose and death. Fatalities have been reported in New York, New Hampshire, Ohio, Texas, Wisconsin and North Carolina.

In July 2016, a toxicology case report was published in the Annals of Emergency Medicine that detailed events in which fentanyl and U-47700 were being sold misleadingly as the prescription opioid pain medication Norco or Vicodin (acetaminophen and hydrocodone) on the streets of Northern and Central California. In one patient who presented to the emergency room, nalaxone (Narcan) was administered which reversed respiratory depression and pinpoint pupils. After additional chemical analysis, it was found the Norco contained hydrocodone, fentanyl, and U-47700.

Reports indicated that Pink and prescription fentanyl may have been contained in the drug cocktail that led to the death of pop star legend Prince in April 2016. In Utah, two 13-year old boys died in September 2016 reportedly due to use of U-47770 purchased from an Internet website. U-47700 (“Pink”) is a novel synthetic opioid agonist with selective action at the mu-opioid receptors in the brain and on the spinal column. It was originally developed by chemists at Upjohn Pharmaceuticals in the 1970’s as a potent pain reliever for use with cancer patients, post-operative patients with intractable pain, or extremely painful trauma injuries. Although it was never commercially made available, the patent and chemical details remained available, and have been produced on the black market.

prince_slide.jpg

U-47700 has a similar chemical profile as morphine and other mu-opioid receptor agonists; however, it has been reported by the National Institute of Drug Abuse (NIDA) that Pink is “far more potent than morphine” –  possibly by seven to eight times. Unfortunately, the strength of the product can never be assured, and may be much stronger, especially when manufactured overseas in illicit labs as a designer drug. On November 14, 2016, the DEA placed U-47700, as well as its related isomers, esters, ethers, and salts into Schedule I of the Controlled Substances Act due to an imminent hazard to public safety and health. Substances in Schedule I have a high potential for abuse, no currently accepted medical use, and a lack of accepted safety for use under medical supervision.

Temporary emergency scheduling of dangerous illicit drugs is one tool the DEA uses to help restrict potentially fatal and new street drugs. Scheduling will last at least 24 months, with a possible 12-month extension if the DEA needs more time to determine whether the chemical should remain permanently as a Schedule I drug. According to the Federal Register, there are no current experimental or approved new drug applications for U-47700, which can typically hinder its permanent placement in Schedule I if approved. DEA’s Final Order is available in the Federal Register with details on threats to public safety. Prior to DEA’s scheduling, several states had already outlawed the drug under emergency orders, including Florida, Ohio, Wyoming and Georgia.

BOTTOM LINE

U-47700, known on the streets as “Pink” or “U4”, is a dangerous designer drug exported from illegal labs in China to the U.S. It is a strong opioid analgesic, reportedly 7 to 8 times more potent than morphine. Authorities in many U.S. cities have reported that Pink is sold on the streets or over the Internet, often falsely promoted as a prescription opioid like Norco or Percocet, or as heroin. In fact, many of these products have contained the potent designer drug Pink, as well as fentanyl. U-47700 is now illegal in all forms, and the DEA has temporarily placed the substance into Schedule I of the Controlled Substances Act, pending further review, due to an imminent hazard to public safety and health. It is considered not safe for human consumption, and has no acceptable medical use.

Clusters of overdoses and deaths of Pink were reported in U.S. cities in 2015 and 2016. Some of these deaths involved children. According to one case report, the use of naloxone (Narcan) in an emergency setting reversed the effects of U-47700, but this may not always be the case. Emergency physicians should contact their local poison control center, medical toxicologist or public health department in cases where there is a reasonable suspicion of ingestion of designer drugs to help protect the surrounding community. Special lab analysis is typically needed to identify drugs like “Pink,” leaving communities at risk.

The public should be aware that drugs obtained on the street, even though they look like an authentic prescription medication, may be fake and deadly. Don’t take any prescription drug, legal or otherwise, unless it is prescribed specifically for you by a doctor and is dispensed by a reliable pharmacy.

The Role of Science in Addiction

SPECIAL REPORT
From the New England Journal of Medicine
May 31, 2017
By Nora D. Volkow, M.D, and Francis S. Collins, M.D., Ph.D.

Opioid misuse and addiction is an ongoing and rapidly evolving public health crisis, requiring innovative scientific solutions. In response, and because no existing medication is ideal for every patient, the National Institutes of Health (NIH) is joining with private partners to launch an initiative in three scientific areas:

  1. developing better overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery;
  2. finding new, innovative medications and technologies to treat opioid addiction; and
  3. finding safe, effective non-addictive interventions to manage chronic pain.

Overdose-Reversal Interventions

Every day more than 90 Americans die from opioid overdoses. Death results from the opioid’s antagonistic effect on brainstem neurons that control breathing. In other words, the victim succumbs to respiratory failure. Naloxone can be used effectively to reduce the effect of opioid intoxication, thereby reversing the overdose, if it is administered in time. Although naloxone has saved tens of thousands of lives, overdoses frequently occur when no one else is around, and often no one arrives quickly enough to administer it.

Overdose fatalities have also been fueled by the increased availability of very powerful synthetic opioids such as fentanyl and carfentanil (50-100 times and 5,000-10,000 times more potent than heroin respectively). Misuse or accidental exposure to these drugs (e.g., when laced in heroin) is associated with very high overdose risk, and naloxone doses that can often reverse prescription-opioid or heroin overdoses may be ineffective. New and improved approaches are needed to prevent, detect and reverse overdoses.

Treatments for Opioid Addiction

The partnership will also focus on opioid addiction (the most serious form of opioid use disorder), which is a chronic, relapsing illness. Abundant research has shown that sustained treatment over years or even a lifetime is often necessary to achieve and maintain long-term recovery. Currently, there are only three medications approved for treatment: methadone, buprenorphine, and extended-release naltrexone. These medications, coupled with psychosocial support [such as rehab and 12-step programs] are the current standard of care for reducing illicit opioid use, relapse risk, and overdoses, while improving social function. There is a clear need to develop new treatment strategies for opioid use disorders. New pharmacologic approaches aim to modulate activity of the reward circuitry of the brain.

Non-Addictive Treatment for Chronic Pain

The third area of focus is chronic pain treatment: over-prescription of opioid medications reflects in part the limited number of alternative medications for chronic pain. Thus, we cannot hope to prevent opioid misuse and overdose without addressing the treatment needs of people with moderate-to-severe chronic pain. Though more cautious opioid prescribing is an important first step, there is a clear need for safer, more effective treatments.

Foremost is the plan to develop formulations of opioid pain medication with built-in abuse deterrent properties that are more difficult to manipulate for snorting or injecting, the routes of administration most frequently associated with misuse because of their more immediate rewarding effects. Such formulations, however, can still be misused orally and still lead to addiction. Thus, a more promising long-term avenue to addressing pain treatment will involve developing a powerful non-addictive analgesic. There are some fascinating x-ray crystallography studies going on that look promising.

Non-pharmacologic approaches being explored today, including brain-stimulation technologies such as high-frequency repetitive transcranial magnetic stimulation (rTMS, already FDA-approved for depression), have shown efficacy in multiple chronic pain conditions. At a more preliminary stage are viral-based gene therapies and transplantation of progenitor cells to treat pain. NIH researchers are investigating the use of gene therapy to deliver a potent anti-inflammatory protein directly to painful sites. Pre-clinical studies show powerful and long-lasting effects in reducing pain without side effects such as numbness, sedation, addiction, or tolerance.

Public-Private Partnerships

In April 2017, the NIH began discussions with pharmaceutical companies to accelerate progress on identifying and developing new treatments that can end the opioid crisis. Some advances may occur rapidly, such as improved formulations of existing medications, opioids with abuse-deterrent properties, longer-acting overdose-reversal drugs, and repurposing of treatments approved for other conditions. Others may take longer, such as opioid vaccines, and novel overdose-reversal medications. For all three areas, the goal is to cut in half the time typically required to develop new safe and effective therapeutics.

As noted throughout the history of medicine, science is one of the strongest allies in resolving public health crises. Ending the opioid epidemic will not be any different. In the past few decades, we have made remarkable strides in our understanding of the biologic mechanisms that underlie pain and addiction. But intensified and better-coordinated research is needed to accelerate the development of medications and technologies to prevent and treat these disorders. The scope of the tragedy of addiction and overdose deaths plaguing our country is daunting. The partnership between NIH and others will take an all hands on deck approach to developing and delivering the scientific tools that will help end the opiate epidemic in America and prevent it from reemerging in the future.

References

Volkow, N. and Collins, F. (May 31, 2017). “The Role of Science in Addressing the Opioid Crisis.” The New England Journal of Medicine. DOI: 10.1056/NEJMsr1706626

Volkow, L. (May 31, 2017). “All Scientific Hands On Deck to End the Opioid Crisis.” [Web blog comment]. Retrieved from : https://www.drugabuse.gov/about-nida/noras-blog/2017/05/all-scientific-hands-deck-to-end-opioid-crisis