Using Science to Address the Opioid Crisis in America

FROM THE BLOG OF NORA VOLKOW, MD
September 19, 2018

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The public health emergency regarding opioid misuse, addiction, and overdose affects millions of Americans and requires innovative scientific solutions. Today, during National Prescription Opioid and Heroin Awareness Week, we are sharing news of an important step towards these solutions through the HEALing Communities Study—an integrated approach to test an array of interventions for opioid misuse and addiction in communities hard hit by the opioid crisis.

Six months ago, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-Term (HEAL) Initiative, a bold multi-agency effort to catalyze scientific discoveries to stem the opioid crisis. HEAL will support research across NIH, using $500,000 of fiscal year 2018 funds, to improve prevention and treatment of opioid use disorder and enhance pain management.

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Through HEAL, NIH will harness the power of science to bring new hope for people, families, and communities affected by this devastating crisis. The current menu of evidence-based prevention, treatment, and recovery interventions has not been fully implemented nationwide. An unacceptably low fraction – about one fifth — of people with opioid use disorder receive any treatment at all. Of those who do enter treatment, only about a third receive any medications—which are universally acknowledged to be the standard of care—as part of their treatment. However, even when medications are used as a component of treatment, the duration is typically shorter than clinically indicated, contributing to unacceptably high relapse rates within the first 6 months. 

To take on this challenge, as part of the broader HEAL initiative, NIH has partnered with the Substance Abuse and Mental Health Services Administration (SAMHSA) to launch the HEALing Communities Study. This study will evaluate the impact of implementing an integrated set of evidence based practices for prevention and treatment of opioid use disorders in select communities with high rates of opioid overdose mortality, with a focus on significantly reducing opioid overdose fatalities by 40%. Targeted areas for intervention include decreasing the incidence of opioid use disorder, increasing the number of individuals receiving medications for opioid use disorder treatment, increasing treatment retention beyond 6 months, receiving recovery support services, and expanding the distribution of naloxone.

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Toward this goal, today NIDA issued funding opportunities for cooperative agreements for components of the HEALing Communities Study: a data coordinating center and up to three research sites to measure the impact of integrating evidence-based prevention, treatment, and recovery interventions for opioid misuse, opioid use disorder, opioid-related overdose events and fatalities across multiple settings, including primary care, behavioral health, and justice. We also encourage evidence-based interventions for prevention and treatment that involve community resources such as police departments, faith-based organizations, and schools, with a focus on rural communities and strong partnerships with state and local governments.

The evidence we generate though the HEALing Communities Study, the most ambitious implementation study in the addiction field to date, will help communities nationwide address the opioid crisis at the local level.  By testing interventions where they are needed the most, in close partnership with SAMHSA and other Federal partners, we will show how researchers, providers, and communities can come together and finally bring an end to this devastating public health crisis.

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 6

Part 6: Hope, Not Handcuffs

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In a growing number of towns, police aren’t arresting people facing addiction. Instead, they’re providing a doorway to treatment.

Judge Linda Davis hasn’t only seen the toll opioids take from the bench. She’s also seen it at home—with one of her daughters. “I thought our family would be the last family on earth this would happen to,” she says. “I was a judge and a former prosecutor who’d run the drug unit. We talked about these issues constantly.”

Then one of her daughters—a fine student and athlete—got hurt at age 17 and needed knee surgery. Pills were prescribed. That led to heroin. And later, a four a.m. confession: “Mom, I’m a heroin addict. I need help.”

That was 12 years ago: Davis’ daughter has been clean since then. “I’m just one of many parents with a story like that,” Davis says. “It amazes me that every time I share it, someone says, ‘I have a son or daughter or grandson or nephew or mother or grandmother with a problem like that.’ It’s that widespread.” Davis hasn’t stopped at telling her story. She volunteers her lunch hours to serve on drug court on top of her normal docket as a judge in Clinton Township, Mich. She co-founded a group, Families Against Narcotics (FAN), which has spread across the state. And that group is taking a leading role in promoting a new approach to fighting opioid addiction.

Angels Among Us

In May 2015, Gloucester, Mass. Police Chief Leonard Campanello posted a Facebook announcement: Anyone could come to the police department, report an opioid addiction, and police would get them into treatment. No arrests, no punishment. Just help. In the first year, 376 people showed up. Almost 95 percent got direct referrals for treatment. Today, that’s grown into a national program: the Police-Assisted Addiction and Recovery Initiative (PAARI), with nearly 400 participating police departments in approximately 30 states. Some 12,000 people have been ushered into treatment so far.

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The largest of those partners is Macomb County, Mich., comprised mostly of 860,000 Detroit suburbanites—FAN’s home base—where an important new element was added. FAN’s idea, successfully pitched to police and community leaders: Rather than burden police in such a populous area with getting people into treatment, specially-trained community volunteers—known as “angles”—would help with the load.

Under the Macomb County program—called “Hope, Not Handcuffs,” an angel is called to the police station to give one-on-one attention to the person reporting an addiction. The volunteer sits with him or her, helps fill out forms and makes the calls to get into a treatment center right away. The angel is there after treatment too—helping, if needed, to find housing or support services, among other things.

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It’s an approach which has captured a lot of hearts and minds. Some 250 people have stepped up to the angel role. Three emergency-service ambulance companies agreed to provide free transportation to treatment centers. Hope Not Handcuffs already is operating in eight Michigan counties, and spreading. “The program started a little over a year ago, and already we’ve placed almost 1,300 people in treatment,” Davis says. “We’re working with up to 90 police departments on implementing this in the state of Michigan. “We get calls from all over the U.S. wanting to initiate the program. But as an all-volunteer group, we don’t have the resources to coordinate with them. We can’t grow that fast.”

After decades as a judge and prosecutor, Davis is struck by the change in law enforcement’s approach. “Police officers are leading the charge for reforms,” she says. “We’ve had a big shift from the ‘lock ’em up’ mentality they were taught in the academies. “Now you’ll hear officers say it all the time: ‘We can’t arrest our way out of this. This is a disease, and locking up people with a disease won’t work.’ For them to say that is really changing the stigma of addiction and opening up new possibilities.”

Living Testimonies

Signs of that changing mentality in law enforcement are popping up all over. There are more than 3,100 drug courts in the country, the U.S. Department of Justice reports—specialized docket programs focusing mostly on treatment and rehabilitation. Roughly half of them deal with juveniles; the other half, with adults.

In Macomb County, a lot of people are grateful. And some are giving back. Micki Dodson’s mom was an addict. Micki, now 30, eventually followed in her footsteps, spending the better part of a decade on pills, heroin, and crack cocaine. Only after her mother died of an overdose last year did she turn the corner. Dodson has been clean since May 2017, and she’s scheduled to graduate from the drug court program in October. “I’m a huge fan of Hope Not Handcuffs,” she says. “Drug court has been my saving grace. I can’t thank them enough: They worked wonders for me. I couldn’t stay clean on my own.”

Now Dodson plans to undergo angel training, so she can do for others what someone did for her. “I have to give back,” she says. “It helps me. I want to let them know there’s hope. If I help one person today, I’ve done my job for that day.”

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Anthony Mattarella is giving back too. Much like Davis’s daughter, he was injured in his youth and went from prescription opioids to heroin and other drugs. That lasted eight years, with numerous fruitless stints in jail or rehab. Three years ago, when his case was bounded over to Davis’ drug court, things changed. “Before I got into the program, I wanted to die,” Mattarella says. “When I got in, I was willing to do anything they asked of me. I knew I was either going to kill myself or I was going to get sober.”

Now he’s a peer-recovery coach for 41B Drug Court in Clinton Township, Mich.—the same court where Davis serves. He’s helping lost people find their way, using his experience to connect with them and guide them. “It’s so rewarding,” he says. “I see them go through the [recovery] process; I see the smiles on their faces when they start to understand.”

Looking back, Mattarella marvels at the change in his life.

“It’s absolutely unbelievable to me,” he says. “I never thought I’d be here. I never thought I’d be someone who helps people.”

FOR MORE INFORMATION: To learn more about Hope, Not Handcuffs, go to familiesagainstnarcotics.org/hopenothandcuffs. For more information on the Police-Assisted Addiction and Recovery Initiative, visit paariusa.org.

The Opioid Issue: Part 4

Part Four: Taking It to the Streets

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The opioid epidemic doesn’t stay behind closed doors. It’s spilling into public life, spurring crime and homelessness.

The opioid crisis has hit hard in Macomb County, Michigan. Composed of 27 Detroit suburbs, the county has the state’s second-highest opioid-related overdose death rate, more than double the national average. District Court Judge Linda Davis has been on the bench 17 years. She sees the consequences pretty much every day. “When I look at the docket I handle, I’d say 70 percent is addiction-related,” she says, not counting low-level traffic offenses like driving on a suspended license. “We’ve definitely seen a rise in thefts with this opioid surge.”

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Although opioid addiction often starts out legally, recent years have seen a shift toward illegal opioids. It’s an all-to-familiar story: People get hooked on prescription painkillers, often moving on to heroin, which can be cheaper on the street. Since 2011, as prescription opioid overdose deaths leveled off, heroin overdoses started rising. Starting in 2014, illicit fentanyl deaths began spiking upward. Whatever the substance, the cost mounts up fast. So many users resort to theft. They’ll steal from family, friends, acquaintances or strangers. They’ll shoplift, commit fraud, rob pharmacies, break into homes or cars. Even commit armed robbery. And whether or not they’re committing those crimes themselves, their desperate dependency can feed some even worse ones.

Lethal Combination

In 2015, the nation’s homicide rate rose sharply (11 percent) after decades of decline. The uptrend continued in 2016, climbing another 8 percent. Some observers looked for racial reasons for it. There could be one, says Richard Rosenfeld, an emeritus professor of criminology and criminal justice at the University of Missouri-St. Louis. But he thinks there’s more to the story. When Rosenfeld looked into the data, he quickly saw homicides had jumped among several ethnicities—and it was very pronounced among whites.

“The increase is quite abrupt, quite recent and quite large, at levels we hadn’t seen since the early 1990s outside of 9/11,” Rosenfeld says. “The ‘Ferguson Effect’ doesn’t explain that. So what might explain it? The opioid epidemic, for one thing—which crosses racial lines, but is most concentrated among whites. Drug-related homicides rose more than 21 percent in 2015, a rate far higher than other common categories of homicide, which rose between 3 and 5 percent. Rosenfeld said it stands to reason that there’d be a connection between the spikes in opioid use and lethal violence.

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“It’s not opioid use per se that sparks violence, but the markets,” Rosenfeld says. “When disputes arise between sellers or buyers, they can’t be settled by police or courts or the Better Business Bureau. As the number of buyers expands, so does the number of disputes that turn deadly will also go up.”

Just how big a role do opioids play in driving the rise in homicides? That calls for more research, Rosenfeld says. But he sees ample evidence to sound the warning and to call for addressing the root causes. “Policymakers and law enforcement are framing this as a public-health crisis more than as a criminal-justice crisis, and I’m very much in favor of that,” he says. “The bottom line is: If we reduce demand, we reduce crime.”

“We Don’t Want Those People Here!”

Reducing demand for opioids would likely reduce other social pathologies too. Like homelessness. “For those of us who’ve been providing health care to people who are homeless, this is not a new problem,” says Barbara DiPietro, senior policy director for the National Health Care for the Homeless Council. “We’ve been seeing opioid addiction and overdoses for decades.

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“When people are in a spiral and aren’t getting the help they need, oftentimes they lose their jobs and their ability to pay rent. Before you know it, you cycle through family and friends, and you’re in a shelter or on the street.” Of course, not all people who are homeless have addiction issues, but those that do have a harder time getting into treatment once the stability of housing is gone. Living on the street could easily drive anyone to substance abuse. Maybe you started with alcohol, but once you were on the street, you found other things. It’s very hard to get well when you’re homeless.

Federally-qualified health centers provide care to 1.2 million people a year, and the Council provides technical assistance to help improve quality and access. DiPietro says homeless service providers often see clients who never expected to be in this situation. “We see a lot of clients who come from construction work or other hard-physical-labor jobs, who got hurt and got prescriptions for legitimate reasons,” she says. “We see a lot of people who’ve experienced trauma in their lives—child abuse, domestic violence, sexual assault. So they self-medicate to deal with the pain.” And on the street, their problems are much more visible than those of people who engage in their addictive behavior behind closed doors.

“They’re living their private lives in a public space,” DiPietro says. “They’re subject to public scrutiny, arrest and incarceration at a much higher rate. And once you have an incarceration history, it’s hard to get housing assistance or a job again.”

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While more medical facilities and first responders are being equipped with opioid-overdose medications like naloxone (Narcan), that’s just an emergency measure, not a solution. DiPietro says what people struggling with addiction and homelessness need most is stable housing where they can get effective treatment. Health care providers the Council works with can help, but not enough to meet the scale of the problem.

Right now, communities don’t have the capacity desperately needed to get people into treatment. Another big obstacle is the attitude known as NIMBY—Not in My Back Yard. “Everyone believes treatment is important, but no one wants the services near them,” DiPietro says. “When that’s proposed, they rise up in community meetings and say, “We don’t want those people here.”

We’ve simply got to get beyond that attitude.

A Parting Thought

I spent forty years in active addiction. It started simple enough: A case of beer and an ounce of Colombian Gold. Eighteen months later I was serving 3 to 10 in state prison. Drug and alcohol abuse continued throughout parole and into my thirties, forties and early fifties. My drug use ran the gamut, from weed to cocaine to crack to opiates. When I couldn’t get enough oxycodone through doctors, I began stealing it from friends and family. My addiction cost me plenty, yes, but it also cost my children, my two ex wives, my brothers, my sister, and my parents. I lost jobs, cars, apartments, friends and family. I blew every penny I made, bounced checks, embezzeled, fenced stolen goods. I was enslaved to addiction. Not only did my family disown me for nearly two years, my youngest son didn’t talk to me for five years.

It’s not only the family of addicts that can become fed up and turn their backs on their loved ones struggling with addiction; society has become rather fed up and impatient. One of our local television stations airs a nightly feature called “Talkback 16,” where viewers call to voice their grievances, pet peeves, and, yes, an occasional compliment. Several days after a news story aired about plans to build a drug and alcohol treatment center in the Pocono Mountains (Pennsylvania), a viewer called to complain about the plan, adding, “Not in my neighborhood. [Addicts and alcoholics] can’t be trusted. Besides, they did it to themselves.”

Truly, this attitude must change.

 

The Opioid Issue: Part 1

Part One: Dangerous Prescriptions

The opioid crisis seems to hit everyone, everywhere, regardless of socioeconomic class, geography, age, profession, or religious affiliation. Overdosing on drugs, especially opiates and heroin, is now the most common cause of death for Americans under fifty years of age. I spent forty years embroiled in active addiction. It started innocently with a case of beer, but quickly led to marijuana, cocaine, and inhalants. The longer I struggled, the more hopeless I became. Friends stopped calling me or inviting me to parties. Family felt they could no longer trust me given the hundreds of broken promises and countless runs on their medicine cabinets for opiates. Although I was able to stop drinking and taking street drugs in 2008, I battled with benzodiazepines (Xanax, Ativan) and oxycodone for another eight years. I am blessed presently with nearly two years without taking narcotics.

Opiates in Pill Bottles

This epidemic has reached every corner of the United States. This is the first in a series of blog posts regarding opiate addiction in America. This series will address dangers of opiate prescriptions, collateral damage, impact on the nation’s foster care system, homelessness and addiction, troubling developments in drug rehabilitation, addiction and crime, and a Christian response to the crisis.

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Current medical opinion indicates the reason the U.S. is experiencing a disastrous epidemic of opioid abuse can be summed up in two words: pain avoidance. In the 1990s there was a proliferation of health care professionals trying to address the symptom [of pain] and not so much the underlying causes of the pain a person has. In 2015, opioid-related deaths stole the lives of over 33,000 Americans. To put this number into perspective, this outnumbers fatal car crashes and gun deaths during the same year. According to the federal government, in 2016 the nation mourned close to 64,000 deaths from drug overdoses. Two-thirds of those involved the misuse of opioids. Karl Benzio, M.D., a Christian psychiatrist and member of Focus on the Family’s Physicians Resource Council (PRC), fears the toll could reach 80,000 deaths in 2018.

We wouldn’t be here if opioids weren’t so effective. Americans want something for their pain—regardless of whether that pain is physical, mental, or emotional. We live in a psychologically compromised society that is impatient and entitled, whose citizens feel there should be no pain in life. Accordingly, greater demands have been made on providers to eliminate all pain with medication. The problem is—and I know this all too well firsthand—once a patient gets a taste of the relief, some develop a dependence that leads them down a dark path. Ironically, that path leads only to deeper struggles. For some, the exit will only come in the form of fatal overdoses as opioids shut down the body’s ability to breath.

It is time we start helping patients deal with life’s pain and its root causes head-on, rather than masking it through medication.

How it All Began

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The current crisis can be traced back nearly forty years. Medical researcher Hershel Jick and graduate student Jane Porter of Boston University Medical Center analyzed data from patients who had been hospitalized there. Close to 12,000 had received at least one dose of a narcotic pain medication during their stay. Of those, Jick and Porter’s analysis found only four had developed a well-documented addiction. Jick sent the findings to the New England Journal of Medicine, who published his analysis as a letter to the editor in 1980. “Despite widespread use of narcotics [sic] drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction,” Jick wrote. Unfortunately, this quote was given far more merit than it deserved. Moreover, the conclusion had not been subjected to peer review.

In 1990, Scientific American called the Jick/Porter research “an extensive study.” About a decade later, Time proclaimed it “a landmark study.” Most significantly, Purdue Pharmaceuticals, maker of the popular narcotic OxyContin, began a promotion asserting less than one percent of patients treated with their time-released opiate medication OxyContin would become addicted. In the 1990s, pain was correlated with a greater probability of a patient having ongoing health issues. So the medical community elevated it to the position of the fifth vital sign along with heart rate, blood pressure, body temperature, and respiratory rate. The medical community, thinking that reducing pain would help long-term patient satisfaction, health and outcomes, started to prescribe more pain meds.

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The ’90s also saw the development of stronger and more effective opioid painkillers. As the decade drew to a close, the opioid epidemic was ignited. It took some time for most of the country to realize the metaphorical fuse had been lit, but the numbers back up this concern. According to the U.S. Department of Health and Human Services (HHS), between 2000 and 2017 opioid prescriptions increased 400 percent. Between 2000 and 2010, misuse involving noncompliance with prescription instructions or using medications prescribed for another person doubled. Now, the results are playing out in heartbreaking fashion nationwide, which are impossible to ignore. Overdose deaths—116 per day, according to federal statistics—are shaking Americans of all incomes, ages, and ethnicity. From the rural back roads of Appalachia (Kentucky, West Virginia) to the urban sprawl of New York and Los Angeles, the epidemic is cutting a path that threatens to leave no family unscathed.

The Blame Game

It’s become quite popular (if not convenient) to lay the blame for the epidemic squarely at the feet of the big pharmaceutical companies. For example, according to an article in the Los Angeles Times in May of this year, more than 350 cities, counties, and states had filed lawsuits against makers and distributors of opioid painkillers. The LA civil action accuses drugmakers and distributors of deceptive marketing aimed at boosting sales, claiming the companies borrowed from the “tobacco industry playbook.” One of the companies most frequently put under scrutiny has been Purdue Pharma, maker of OxyContin.

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In May The New York Times called Purdue “the company that planted the seeds of the opioid epidemic through its aggressive marketing of OxyContin.” The Times article uncovered a disturbing report on OxyContin compiled by the U.S. Department of Justice, which found that Purdue Pharma knew about and concealed significant incidents of abuse of OxyContin in the first years after the drug hit the market in 1996. The article further noted that Purdue Pharma admitted in open court in 2007 that it misrepresented the data regarding OxyContin’s potential for abuse.

Overdose Deaths Not Just Related to Opiate Prescriptions

Government reports have recently stated that today’s increase of fatal opioid-related overdoses is being driven by abuse of heroin and illicit fentanyl. A study prepared by the National Institute on Drug Abuse last September found that overdose deaths from heroin and other drugs laced with fentanyl increased 600 percent between 2002 and 2015. Street dealers have increasingly been cutting their drugs with fentanyl—a particularly dangerous and relatively inexpensive substance 50 to 100 times more powerful than morphine—to boost their profit margins. In most cases, the users don’t even realize they’re buying fentanyl-laced products.

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It is important to note that although many people believe Big Pharma is complicit in fueling the epidemic and should shoulder the loin’s share of the blame, Dr. Benzio sees it differently. “Pharmaceutical companies only make the meds,” Benzio says. “Only about 6 to 8 percent of people who take an opioid will misuse or overuse it in a destructive way. It is the doctors who over-prescribe and a society that is looking for a quick fix and can’t tolerate any discomfort [that’s to blame].”

The Road Ahead

The opiate epidemic may have grown somewhat quietly, but the nation’s attention is riveted to it now and policymakers aren’t sitting still. In 2016, Massachusetts became the first state to limit the duration for painkiller prescriptions at seven days. Since then, more than two dozen other states have also established limits. In my home state of Pennsylvania, Governor Tom Wolf initiated a statewide prescription drug monitoring system to help prevent prescription drug abuse. Of concern is the practice of “doctor shopping,” which involves a patient visiting multiple doctors and emergency departments in search of opioids. Unfortunately, this is something I did quite often while in active addiction. This practice often necessitates filling prescriptions at multiple pharmacies. The governor’s new policy includes the monitoring program, a standing order for naloxone (Narcan, used to reverse the effects of an opiate overdose), a patient non-opioid directive (which allows patients to opt out of opioid pain medicine in advance) a “warm hand-off” where ER attending physicians and other providers can set up a face-to-face introduction between a patient and a substance abuse specialist, and revised prescribing guidelines relative to opiates.

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At the federal level, President Donald Trump declared the opioid crisis a public health emergency in 2017, and formed a commission to fight it. Meanwhile, HHS now has a multi-pronged strategy to get the crisis under control, including getting better data through research and improving prevention, treatment, pain management, and recovery services. The federal crackdown is estimated to cost $13 billion to $18 billion over the next two years. Dr. Benzio believes this is “a good start,” but said providers must resist the urge to automatically jump to the quick fix of narcotics for those in pain. “There are many ways to combat pain through physical therapy and fitness, relaxation, better sleep and nutrition,” says Benzio. It seems likely that we will not get a significant handle on opioid abuse until the core issues that lead people to the drugs are addressed.

The Christian Perspective

W. David Hager, M.D., a member of the PRC, notes three principle root issues in addiction: rejection, abandonment and abuse. Hager has been a facilitator for the Christian program Celebrate Recovery. He said, “Unless we enable [people] to identify their root issue and deal with it first, the rates of relapse are high. When they are able to deal with their root issues by offering forgiveness, making amends, and seeking a personal relationship with Jesus Christ, we find that large numbers are able to enter and maintain sobriety.” That is why the Church has the unique ability to make a difference in combating the opioid crisis.

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“We have to convince faith-based communities to get their hands dirty, to get involved and realize that this is an issue,” Benzio says. He suggests inviting laypeople to develop a working knowledge of dopamine, the brain chemical that provides the pleasure-inducing sensation many who use drugs are seeking. “There is only one [higher] power that can sever synapses in the brain that have been stimulated by a substance to achieve [a certain] dopamine level,” he adds, “and that’s the power of the Holy Spirit.”

Exactly how Christians appropriate the Spirit’s power to take on the opioid crisis will vary from case to case. The point, Benzio and Hager say, is that this needs to become a top-of-mind concern for the Church. But are North American churches up to the mission of addressing opioid use among their members? Pastors are in a unique position to proclaim and demonstrate the Gospel to individuals struggling with addiction. Many are too ashamed to confess an addiction to pain medication. As the opioid crisis deepens, so must the response of the local church. If the Christian church has anything to offer those hurting from drug addiction, it is hope and community. I was only able to break the bondage of addiction over my life through the Power in the Name of Jesus.

Power in the Name of Jesus

Programs such as Narcotics Anonymous and Celebrate Recovery have been extremely effective in changing lives, but it’s not always enough. Addressing the root of addiction is one of the most effective long-term solutions, which for Christians is about the heart. The church must be willing and capable of seeing those struggling with addiction as not merely a program of the church’s community outreach; these individuals are children of a God who loves them no matter their current condition. I believe America’s recovery can find its roots in the local church.

What does love look like? It has the hands to help others. It has the feet to hasten to the poor and needy. It has eyes to see misery and want. It has the ears to hear the sighs and sorrows of men. That’s what love looks like. -St. Augustine

 

 

Opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as Fentanyl, and pain relievers available by prescription such as codeine, oxycodone, Vicodin, morphine, and others.

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All opioids are chemically related and interact with opioid receptors on nerve cells in the brain and on the spinal column. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose, and death. 

An opioid overdose can be reversed with the drug naloxone (Narcan) when given right away. Improvements have been seen in some regions of the country in the form of decreasing availability of prescription opioid pain relievers and decreasing misuse among the Nation’s teens. However, since 2007, overdose deaths related to heroin have been increasing. Fortunately, effective medications exist to treat opioid use disorders including methadone, Buprenex and Vivitrol. 

A National Institute of Drug Abuse (NIDA) study found that once treatment is initiated, both a Buprenex/Vivitrol combination and an extended-release Vivitrol formulation are similarly effective in treating opioid addiction. However, Vivitrol requires full detoxification, so initiating treatment among active users is difficult. These medications help many people recover from opioid addiction.

What are Prescription Opioids?

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Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made by scientists in labs using the same chemical structure. Opioids are often used as medicines because they contain chemicals that relax the body and can relieve pain. Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can also make people feel very relaxed and high, which is why they are sometimes used for non-medical reasons. This can be dangerous because opioids can be highly addictive. Overdoses and death are common. Heroin is one of the world’s most dangerous opioids, and is never used as a medicine in the United States.

How Do People Misuse Opioids?

Prescription opioids used for pain relief are generally safe when taken for a short time and as directed by a doctor, but they can be misused. People misuse prescription opioids by:

  • taking the medicine in a way or dose other than prescribed
  • taking someone else’s prescription medicine
  • taking the medicine for the effect it causes—getting high

How Do Prescription Opioids Affect the Brain?

Opioids bind to and activate opioid receptors on cells located in many areas of the brain, spinal cord, and other organs in the body, especially those involved in feelings of pain and pleasure. When opioids attach to these receptors, they block pain signals sent from the brain to the body and release large amounts of dopamine throughout the body. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience.

Opioid misuse can cause slowed breathing, which can cause hypoxia, a condition that results when too little oxygen reaches the brain. Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, or death. Researchers are also investigating the long-term effects of opioid addiction on the brain, including whether damage can be reversed.

What are Other Health Effects of Opioid Medications?

Older adults are at higher risk of accidental misuse or abuse because they typically have multiple prescriptions and chronic diseases, increasing the risk of drug-drug and drug-disease interactions, as well as a slowed metabolism that affects the breakdown of drugs. Sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV.

Prescription Opioids and Heroin

Prescription opioids and heroin are chemically similar and can produce a similar high. Heroin is typically cheaper and easier to get than prescription opioids, so some people switch to using heroin instead. Nearly 80 percent of Americans using heroin (including those in treatment) reported misusing prescription opioids prior to using heroin. However, while prescription opioid misuse is a risk factor for starting heroin use, only a small fraction of people who misuse pain relievers switch to heroin. This suggests that prescription opioid misuse is just one factor leading to heroin use.

The Numbers

More than 64,000 Americans died from drug overdoses in 2016, including illicit drugs and prescription opioids. This number has nearly doubled over the past ten years. 2015 was the worst year for drug overdoses in U.S. history. Then 2016 came along. In that year alone, drug overdoses killed more people than the entire Vietnam War did.

A chart of US drug overdoses going back to 1999.

The Opioid Epidemic Explained

This latest drug epidemic is not solely about illegal drugs. It began, in fact, with a legal drug. Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About 100 million U. S. adults suffer from chronic pain, according to a report from the Institute of Medicine.

Chronic Pain The Silent Condition

Pharmaceutical companies took advantage of this concern. Through a big marketing campaign they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term non-cancer related chronic pain is very weak despite their effectiveness for severe short-term, acute pain—while the evidence that opioids cause harm in the long term is very strong. So painkillers inundated society, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.

As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (Xanax, Ativan, Valium) typically prescribed to relieve anxiety. By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths. The numbers have grown exponentially over the past three years.

What Can We Do?

Seeing the rise in opioid misuse and deaths, officials have cracked down on prescription painkillers. Law enforcement, for instance, now threaten doctors with incarceration and loss of their medical licenses if they prescribed the drugs unscrupulously. Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being instructed to give more thought to their prescriptions.

Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids bought off the street, such as heroin and Fentanyl. Not all painkiller users went this direction, and not all opioid users started with painkillers. But statistics suggest many did. A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention (CDC) found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

So other types of opioid overdoses, excluding painkillers, also rose. That doesn’t mean cracking down on painkillers was a mistake. It appears to have slowed the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders. But the likely solution is to get opioid users into treatment. According to a 2016 report by the Surgeon General of the United States, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options. Given the exorbitant cost of health care in America today, that is simply unacceptable. Federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and Buprenex.

Source: National Institute on Drug Abuse; National Institutes of Health; U. S. Department of Health and Human Services.

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

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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.

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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.

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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.

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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.