Addressing the Socioeconomic Complexities of Addiction—Lessons from the Kensington Neighborhood in Philadelphia

From the Monthly Blog of Dr. Lora Volkow, Dir., National Institute on Drug Abuse
Originally Posted October 29, 2019 here.

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This September, Dr. Volkow was invited by Thomas Farley, the Health Commissioner of Philadelphia, to see firsthand how that city is responding to the opioid crisis. With other members of NIDA leadership, she toured Prevention Point, a private non-profit organization providing harm reduction services to Philadelphia and the surrounding area. The group also visited the health unit of the city’s Prisons Department, where they recently started a program that provides medications to prisoners with opioid addiction, and they met with outreach workers from Temple University who operate a mobile treatment unit that provides medications and behavioral health services for opioid addiction, as well as basic wound care.

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Philadelphia’s rate of overdose deaths skyrocketed this past decade, tripling the city’s number of homicide deaths and greatly exceeding the peak number of deaths from AIDS in 1994. With one fifth the population of Manhattan, Philadelphia still has almost as many overdose deaths. It was humbling not only to see the challenges facing a city with a longstanding opioid problem but also to see the engagement and dedication of people on the ground attempting to help, as well as the struggles of those battling their own drug addiction amidst extremely hard socioeconomic challenges.

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Prevention Point’s Wound Care Clinic offers free, specialized wound care for all people

Whenever Dr. Volkow asks people on the front lines of America’s drug crisis what more NIDA can do to support and help their work, they remind her how essential it is to address the basic needs of individuals with addiction, such as stable and safe housing, food, basic medical care, and an opportunity for employment.  In the addiction field, NIDA has recognized the importance of addressing these basic needs as part of recovery support. Yet, it is crucial to realize that these needs have to be met even before a person is in stable recovery in order to facilitate them getting to recovery at all.  People cannot recover from addiction if they are homeless, isolated, and struggling to find food and safety.

Located in Kensington, one of Philadelphia’s hardest-hit neighborhoods, Prevention Point, which began three decades ago in response to the AIDS crisis, offers medications for opioid use disorder (buprenorphine and naltrexone), distributes Narcan (Naloxone) kits for reversal of opioid overdoses, and provides sterile syringes to reduce the risk of infections. It also offers testing for HIV and HCV and treatment referral when needed, wound care (people who inject drugs frequently develop infections), and linkage to behavioral health treatment.

Additionally, the center provides temporary housing and meals, as well as case management and a wide array of other non-medical services to people experiencing homelessness and struggling with addiction, such as legal services and mail services for clients who would otherwise be unable to file and receive needed paperwork. Under the impressive leadership of Executive Director Jose Benitez and Associate Executive Director Silvana Mazzella, Prevention Point provides these services with a very limited budget (facilitated by both public and private funding), in an old church.

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By visibly providing support and care for individuals with addiction, Prevention Point is embraced by some in the community but resisted by others. Some view treatment as competition for the drug market; others fear how it may affect the neighborhood’s potential for renovation and gentrification. With addiction services historically segregated from the rest of healthcare, the “not in my backyard” (“NIMB”) problem has long been a major factor in impeding access to treatment.

NIDA’s visit to Philadelphia drove home why America needs to address the stigma that still surrounds opioid addiction and its treatment. It also drove home why addressing the crisis will require a comprehensive approach—including treatment with medications along with harm-reduction (like needle exchange), as well as case management and an array of non-medical services that can attend to people’s basic needs, including helping them build meaningful social relationships.

It is crucial that drug treatment specialists do more research to find ways of effectively delivering such services and support to all communities, both urban and rural, that need them. It will require more collaborative engagement between researchers and community-level providers, volunteers, and people suffering from substance use disorders—the HEALing Communities Study, which is getting underway in four hard-hit states, is a start.

In conclusion, Dr. Volkow said, “I also strongly encourage scientists who work in other aspects of addiction research to spend time at local addiction service providers to get a firsthand understanding of the challenges faced by those on the front lines, to visit neighborhoods that have been devastated by addiction, and to speak to those afflicted. It can be a valuable reminder of how every aspect of a person’s life—from employment, to housing, to interpersonal relationships—can be either a vulnerability or an asset on the road to addiction recovery. “

Emergency Departments Can Help Prevent Opioid Overdoses

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

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

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Originally Posted at the NIDA Website on August 26, 2019

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

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

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

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

Bottles of Opiate Prescriptions

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

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

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

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

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

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

Let’s Take a Look at Opioid Use Disorder

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

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

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

Are You Struggling?

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

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

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

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

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

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

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

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

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.

 

Ambitious Research Plan to Help Solve the Opioid Crisis

From the blog of Dr. Lora Volkow, National Institute on Drug Abuse Posted June 12, 2018

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In spring 2018 Congress added an additional $500 million to the NIH budget to invest in the search for solutions to the opioid crisis. The Helping to End Addiction Long-term (HEAL) initiative is being kicked off June 12th with the announcement of several bold projects across NIH focusing on two main areas: improving opioid addiction treatments and enhancing pain management to prevent addiction and overdose. The funding NIDA is receiving will go toward the goal of addressing addiction in new ways, and creating better delivery systems for addictions counseling for those in need.

NIH will be developing new addiction treatments and overdose-reversal tools. Three medications are currently FDA-approved to treat opioid addiction. Lofexidine—a drug initially developed to treat high blood pressure—has just been approved to treat physical symptoms of opioid withdrawal. Narcan (naloxone) is available in injectable and intranasal formulations to reverse overdose. Regardless, more options are needed. One area of need involves new formulations of existing drugs, such as longer-acting formulations of opioid agonists and longer-acting naloxone formulations more suitable for reversing fentanyl overdoses. Compounds are also needed that target different receptor systems or immunotherapies for treating symptoms of withdrawal and craving in addition to the progression of opioid use disorders.

Much research already points to the benefits of increasing the availability of treatment options for Opioid Use Disorder (“OUD”), especially among populations currently embroiled in the justice system. Justice Community Opioid Innovation Network is working to create a network of researchers who can rapidly conduct studies aimed at improving access to high-quality, evidence-based addiction treatment in justice settings. It will involve implementing a national survey of addiction treatment delivery services in local and state justice systems; studying the effectiveness and adoption of medications, interventions, and technologies in those settings; and finding ways to use existing data sources as well as developing new research methods to ensure that interventions have the maximum impact.

The National Drug Abuse Treatment Clinical Trials Network (“CTN”) facilitates collaboration between NIDA, research scientists at universities, and a myriad of treatment providers in the community, with the aim of developing, testing, and implementing addiction treatments. As part of the HEAL initiative, the CTN Opioid Research Enhancement Project will greatly expand the CTN’s capacity to conduct trials by adding new sites and new investigators. The funds will also enable the expansion of existing studies and facilitate developing and implementing new studies to improve identification of opioid misuse and OUD. Further, it will enhance engagement and retention of patients in treatment in a variety of general medical settings, including primary care, emergency departments, ob/gyn, and pediatrics.

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A great tragedy of the opioid crisis is that there are a number of effective tools not being deployed effectively in communities in need. Only a fraction of people with OUD receive any treatment, and of those less than half receive medications that are universally acknowledged to be the standard of care. Moreover, patients often receive medications for too short a duration. As part of its HEAL efforts, NIDA will launch a multi-site implementation research study called the HEALing Communities Study in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA). The HEALing Communities Study will support research in up to three communities highly affected by the opioid crisis, which should help evaluate how the implementation of an integrated set of evidence-based interventions within healthcare, behavioral health, justice systems, and community organizations can work to decrease opioid overdoses and prevent and treat OUD. Lessons learned from this study will yield best practices that can then be applied to other communities across the nation.

The HEAL Initiative is a tremendous opportunity to focus taxpayer dollars effectively where they are needed the most: in applying science to find solutions to the worst drug crisis our country has ever seen.

Find Help Near You

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.

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.

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.

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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.