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.

Man Giving Money To Beggar On Street

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. “

Local Opioid Abuse: A Piece of the Nation’s Newest Health Crisis

By Steven Barto

I am no stranger to addiction. I started drinking and getting high the summer after high school graduation. It was 1977 and pot and southern rock went hand-in-hand. I found my answer to all the anger, anxiety, depression, insomnia, and feelings of not belonging. Of course, I had no idea where it would lead, or that it would take me nearly four decades to get clean. I’ve said it before: No one wakes up one day and says, “I think I want to be a full-blown alcoholic or drug addict when I grow up. I want to loose all self-respect, most of my teeth, two wives, four jobs, three cars, and my sense of ambition. I’d love to be estranged from family and friends. It’ll be great. Just me and my drugs!” Anyone whose not an addict or alcoholic and thinks it is a moral or deliberate choice doesn’t understand addiction.

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Map shows areas of opiate use, with the most prevalence noted in dark pink.

Nationally

The “perfect storm” that got us to a nationwide opiate epidemic is intertwined with influences you’d never expect. Heroin used to be limited to the beatniks, poets, jazz musicians, wild-and-crazy rock stars of the 1950s, 60s and early 70s. But things were about to break loose. Congressmen Robert Steele (R-CT) and Morgan Murphy (D-IL) released an explosive report in 1971 covering the growing heroin epidemic among U.S. servicemen in Vietnam. America saw thousands of military personnel coming home from Southeast Asia addicted to heroin. As a result, President Richard Nixon declared a “war on drugs.” In fact, Nixon called drug abuse “public enemy number one.” Initially, the lion’s share of monies thrown at the drug problem went for treatment, which was a good thing. Unfortunately, this did not remain so in subsequent years. Politicians saw the opportunity to “take back the streets” of America from hippies, druggies, liberals, love children, people of color, and other “subversives” who did not seem to be conforming to the American lifestyle. Emphasis changed to criminalizing addicts and locking them up.

Admittedly, cocaine and crack became a serious concern before America fell face-first into the current opiate epidemic. Interestingly, one of the major factors contributing to increased cocaine trafficking was the North Atlantic Free Trade Agreement (NAFTA) signed into law under President Bill Clinton. Goods began to flow into the United States from Mexico at such an increase that border patrol was unable to adequately assure drugs were not coming over the border. There simply were not enough agents to keep up with inspection and enforcement. Prior to the climate of unrestrained trade, President Nixon had ordered that every vehicle returning from Mexico must be searched for drugs. Long lines ensued, and there was no appreciable reduction in drug trafficking.

Heroin and a Handgun

In 1995, The Food and Drug Administration (FDA) approved OxyContin for prescription use. Its active ingredient, oxycodone, was believed since the 1960s to be highly addictive. Purdue Pharma, the inventor of OxyContin, claimed their formula of delayed-release oxycodone would all but eliminate the “rush” experienced by taking the drug in its original form. Purdue launched an extremely aggressive marketing progam, sending drug reps to virtually every family practitioner and pain management specialist, armed with what was eventually deemed a falsified report that less than 1% of OxyContin patients became addicted. Doctors were offered outrageous incentives to prescribe the drug. Purdue Pharma began the practice of sponsoring trade shows and symposiums, often plying physicians with lavish meals and “entertainment.” On the heels of this marketing blitz, the American Pain Society began arguing for medical providers to view pain as the “fifth vital sign.” This is precisely the basis for the How would you rate your pain on a scale of 0-10? question that is asked in every emergency department in America today. Well-intentioned doctors believed it was unconscionable to let patents suffer through severe pain. They didn’t believe Oxy would do more harm than good.

By 1996, Purdue Pharma reported $45 million in sales of OxyContin. As of 2000, the number jumped to over $1 billion. That’s a two-thousand fold increase. Misuse and abuse of opiate painkillers (OxyContin, Vicodin, Lortab, oxycodone) increased significantly beginning in 2000. In 2002, 6.2 million Americans were abusing prescription drugs, and emergency room visits resulting from the abuse of narcotic pain relievers had increased dramatically. By 2009, the total number of visits to ERs for overdose on opiates was 730,000, which was double the number of five years before. More than 50,000 Americans died of a drug overdose in 2016. Heroin accounted for 12,898 of those deaths that year. Synthetic opioids (such as Fentanyl) killed 5,880. Prescription painkillers like OxyContin and Vicodin claimed 17,536 lives.

Companies like Purdue Pharma have restructured the formula of opiate medications in order to make them even harder to abuse. No doubt this had a lot to do with the $635.5 million fine levied against Purdue for intentionally misleading the medical community regarding the potential to become addicted to OxyContin. Typically, addicts crush and snort the drug, or cook it down and inject it. What’s disheartening today is that most people who started out taking and then abusing OxyContin and other opiate pain medication are now using heroin because it’s cheaper – $5 to $7 dollars for enough to be high most of the day versus $10 to $80 for one Oxy, depending on its strength. Heroin is readily accessible virtually everywhere you go, and it is easily converted to a form that can be smoked or injected.

Locally

Front page news in my hometown paper, The Sunday Item, indicates that drug overdoses in Pennsylvania killed nearly 11,000 people in the last three years, fueled largely by heroin and prescription painkillers. The number of deaths has steadily increased year after year. As fatal overdoses have increased, so has public awareness, access to addiction treatment, and legislative initiatives against an epidemic the U.S. Department of Justice describes as the leading cause of death of Americans under the age of 50. It is important to note that this is a disease that affects everybody. Let’s stop playing the New Jim Crow game and stigmatizing, criminalizing, and institutionalizing drug addicts based upon skin color. Heroin and opiate drug addiction is rampant today in all socioeconomic classes, to be sure, but surprisingly it is most prevalent in white males age 18 to 25.

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The Sunday Item interviewed a man named Steven C., 27 years old, who is a recovering heroin addict attempting sobriety after fifteen years of opioid abuse. When he heard the news of an overdose outbreak in the Williamsport (Pennsylvania) area that sent 51 patients to the hospital in 48 hours, with three patients now dead, Steven couldn’t help but realize, “That could have been me.” Steven was brought back to consciousness from a heroin overdose on August 9th of last year. EMTs adminstered naloxone, which is used in the field to reverse the effects of an overdose, but it didn’t work. His heart had stopped. Thankfully, CPR eventually restarted his heart.

The Official Response

Federal and state funding for the opioid and heroin problem in Pennsylvania has been increased 19% to $76 million for the current fiscal year. The funds include $5 million for grant money to provide naloxone for emergency responders, which is proven to reverse the effects of narcotic overdose in most cases, and $2.3 million to establish specialty courts for handling drug-related criminal cases. Great strides have already been taken in fighting this epidemic. Pennsylvania restricts opioid prescriptions to seven days for minors and those discharged from hospital ERs. Emergency room physicians are not allowed to see patients for follow-up visits or refills. Each instance where an opioid prescription is filled is recorded on a state-wide database in order to stop “doctor shopping” or getting refills “too early.” According to the Sunday Item article, the prescription database has been accessed by doctors 8 million times since it was launched.

An estimated 2 million Americans are addicted to painkillers, and another 591,000 are addicted to heroin. Although we’re beginning to made headway regarding opioid prescriptions, much remains to be done regarding heroin addiction. It is noteworthy that taking opioid pain medication for longer than three months makes patients up to forty times more likely to become addicted to heroin. Senator Gene Yaw (R-23) of Williamsport told reporters, “I have said many times that I don’t expect to see positive results for at least ten years. It took a long time to get into the situation we find ourselves and we can’t expect a change to happen overnight. We are addressing many issues and eventually together they will make a difference.” It is abundantly clear that there is a risk of progression from alcohol and other drugs (especially opioid painkillers) to heroin.

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Concluding Remarks

What can you do? Most importantly, as public service announcements state on TV in Pennsylvania, “Mind your meds.” Please don’t react to this suggestion by simply saying drug addicts should be able to be trusted, otherwise they’re just thieves. Or, that they should have better impulse control. Addiction is not about willpower, nor is it a matter of a moral deficiency. Virtually anyone who uses opiates for pain for longer than three months can become addicted. That is the very nature of the morphine molecule found in these medications. It is extremely difficult for an opiate addict to “just say no” to the screaming of their mu-opioid receptors in the brain and spinal cord once the morphine molecule has latched “lock-and-key” into place. Opiates are far more potent than naturally occurring endorphins.

I really had no idea how difficult it can be to quit drinking or taking opiates once your body gets used to the chemical reaction and the euphoria. I have not had a drop of alcohol, a line of cocaine, or a joint since 2008. It was not so easy for me to give up opioid painkillers. It’s a two-edged sword. First, there’s the initial legitimate need for pain relief. Doctors recognized this in the 90s when they decided to not let their patients suffer in chronic agony. Although I was in recovery for other substances, I thought I could use pain medication safely. I’d abused it in the past, sure, but now I was “sober” and I needed help with severe back pain. I didn’t want the drug in order to “party.” The other edge of the sword is the neuropsychology of the addiction itself. These types of medications actually restructure the brain. Sometimes the effects are permanent, as when memory or IQ or motor skills are compromised. Thankfully, this is not the case for me.

If you or someone you know is struggling with a drug or alcohol problem, please consult your physician for a phone number to the nearest help line. You will also find AA and NA phone lines in the phone book or online. If you are a Christian facing addiction, consider Celebrate Recovery. Facebook has numerous groups you can join. You call also email me at stevebarto1959@gmail.com and I will reply as soon as I can.

References

The Sunday Item. (Sunday, July 9, 2017) Sunbury, PA http://dailyitem.com

Karlman, J. (February 16, 2017). Timeline: How Prescription Drugs Became a National Crisis. Retrieved from: http://fox5sandiego.com/2017/02/16/timeline-of-how-prescription-drugs-became-national-crisis/

Moghe, S. (October 14, 2016). Opioid History: From Wonder Drug to Abuse Epidemic. CNN Online. Retrieved from: http://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html

Sandino, J. (May 13, 2015). A Timeline of the Heroin Problem in the U.S. Addictionblog.org Retrieved from: http://drug.addictionblog.org/a-timeline-of-the-heroin-problem-in-the-u-s/

Tribune News Services. (December 8, 2016). More than 50,000 Overdose Deaths. Chicagotribune.com. Retrieved from: http://www.chicagotribune.com/news/nationworld/ct-us-overdose-deaths-20161208-story.html

The Molecule

Andy Coop very nearly spent his career watching paint dry. The son of a machinist and school cafeteria worker, Coop hailed from Halifax in Northern England. He finished his undergraduate work in chemistry at Oxford University in 1991. He was given a choice of where to continue his studies. At Cardiff University was a professor whose specialty was the chemistry of paint. Industry at the time was aiming to find a new paint that dried at a certain temperature. At the University of Bristol was John Lewis, who studied the chemistry of drugs and addiction. In the 1960s, Lewis had discovered buprenorphine, an opiate that he later helped develop into a treatment for heroin addicts.

Coop didn’t remember giving the choice much thought. Drugs sounded more interesting than paint, so off to Bristol and John Lewis he went. It was there, in 1991, in a lab at Bristol, that Andy Coop encountered the morphine molecule – the essential element in all opiates. In time, Andy Coop got hooked on the morphine molecule – figuratively, of course, for he only once took a drug that contained it, and that was following surgery.

Like no other particle on Earth, the morphine molecule seemed to possess heaven and hell. It allowed for modern surgery, saving and improving too many lives to count. It stunted and ended too many lives to count with addiction and overdose. Discussing it, you could invoke some of humankind’s greatest cultural creations and deepest questions: Faust, Dr. Jekyll and Mr. Hyde, discussions on the fundamental nature of man and human behavior, of free will and slavery, of God and evolution. Studying the molecule, you naturally wandered into questions like, Can mankind achieve happiness without pain? Would that happiness even be worth it? Can we have it all?

In heroin addicts, there is a certain debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior. In fact, the United States achieved something like this state of affairs during the last decade of the twentieth century and the first decade of the twenty-first century. It was first observable in widespread obesity. It wasn’t just people. Everything seemed obese and excessive. Massive Hummers and SUVs were cars on steroids. In some of the Southern California suburbs, on plots laid out with three-bedroom houses in the 1950s, seven-thousand-square-foot mansions barely squeezed between the lot lines, leaving no place for yards in which to enjoy the California sun.

In Northern California’s Humbolt and Mendocino Counties, 1960s hippies became the last great American pioneers by escaping their parents’ artificial world. They lived in tepees without electricity and funded the venture by growing pot. Now their children and grandchildren, like mad scientists, were using chemicals and thousand-watt bulbs, in railroad cars buried to avoid detection, to forge hyperpotent strains of pot. Their weed rippled like the muscles of bodybuilders, and growing this stuff helped destroy the natural world that their parents once sought. Today, great new numbers of these same kids – most of them well-off and white – began consuming huge quantities of the morphine molecule, doping up and tuning out.

What gave the morphine molecule its immense power was that it evolved somehow to fit, key-in-lock, into the receptors that all mammals, especially humans, have in their brains and spines. The so-called mu-opioid receptors – designed to create pleasure sensations when they receive endorphins the body naturally produces – were especially welcoming to the morphine molecule. The receptor combines with endorphins to give us those glowing feelings at, say, the sight of an infant or the feel of a furry puppy. The morphine molecule overwhelms the receptor, creating a far more intense euphoria than anything we come by internally. It also produces drowsiness, constipation, and an end to physical pain. Aspirin had a limit to the amount of pain it could calm. But the more morphine you took, Coop said, the more pain was dulled.

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For this reason, no plant has been more studied for its medicinal properties than the opium poppy. As the mature poppy’s petals fall away, a golf-ball-sized bulb emerges atop the stem. The bulb houses a goo that contains opium. From opium, humans have derived laudanum, codeine, thebaine, hydrocodone, oxymorphone, and heroin, as well as almost two hundred other drugs – all containing the morphine molecule, or variations of it. Etorphine, derived from thebaine, is used in dart guns to tranquilize rhinoceroses and elephants. [Amazingly, Etorphine has hit the streets of America as an opiate which teens and young adults are taking to get high, only to be dropping dead due to its potency.]

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Tobacco, coca leaves, and other plants had evolved to be pleasurable and addictive to humans out of the gate. But the morphine molecule surpassed them in euphoric intensity. Then it exacted a mighty vengeance when a human dared to stop using it. In withdrawal from the drug, an addict left narcotized numbness and returned to life and to feeling. Numbed addicts were notoriously impotent; in withdrawal they had frequent orgasms as they began to feel again. Humans with the temerity to attempt to withdraw from the morphine molecule were tormented first with excruciating pain that lasted for days. If an addict was always constipated and nodding off, his withdrawals brought ferocious diarrhea and a week of sleeplessness.

The morphine molecule resembled a spoiled lover, throwing a tantrum as it left. Junkies say they often have an almost constipated tingling when trying to urinate during the end of withdrawal, as if the last of the molecule, now holed up in the kidneys, was fighting like hell to keep from being expelled. Like a lover, no other molecule in nature provided such merciful pain relief, then hooked humans so completely, and punished them so mercilessly for wanting their freedom from it.

Certain parasites in nature exert the kind of control that makes a host act contrary to its own interests. One protozoan, Toxoplasma gondii, reproduces inside the belly of a cat, and is then excreted by the feline. One way it begins the cycle again is to infect a rat passing near the excrement. Toxoplasma gondii reprograms the infected rat to love cat urine, which to healthy rats is a predator warning. An infected rat wallows in cat urine, offering itself up as an easy meal to a nearby cat. This way, the parasite again enters the cat’s stomach, reproduces, and is expelled in the cat’s excrement – and the cycle continues.

The morphine molecule exerts an analogous brainwashing on humans, pushing them to act contrary to their self-interest in pursuit of the molecule. Addicts betray loved ones, steal, live under freeways in harsh weather, and run similarly horrific risks to use the molecule.

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It became the poster molecule for an age of excess. No amount of it was ever enough. The molecule created ever-higher tolerance. Plus, it had a way of railing on when the body gathered the courage to throw it out. This wasn’t only during withdrawals. Most drugs are easily reduced to water-soluble glucose in the human body, which then expels them. Alone in nature, the morphine molecule rebelled. It resisted being turned into glucose and it stayed in the body.

“We still can’t explain why this happens. It just doesn’t follow the rules. Every other drug in the world – thousands of them – follows this rule. Morphine doesn’t,” Coop said. “It really is almost like someone designed it that way – diabolically so.”

The above is taken from Sam Quinones’ best-selling nonfiction book “Dreamland: The True Tale of America’s Opiate Epidemic.” ©2015, New York, NY: Bloomsbury Publishing.

Christianity Today: How Good Church People Become Addicts – and How They Recover

Timothy King’s article Just Say No to Shame in the December 2016 issue of Christianity Today includes a very insightful comment: “My recovery from opioid addiction began when I realized my addiction had chosen me.” King fell to the disease of opioid addiction following suffering from acute necrotizing pancreatitis caused by a surgical procedure. He said, “I had known pain before: crutches, casts, and stitches. But until this moment, pain had always been experienced as something outside of myself. Now it was all that was left of me.”

An opioid, from the root word opium, is a class of pain-relieving drugs that can vary in intensity from fentanyl (extreme) to codeine (mild). According to the Department of Health and Human Services, more than 240 million prescriptions were written for legal opioids in 2014 – more than enough for every adult in the United States to have their own bottle. From 1999 to 2014, the period in which opioid overdose deaths quadrupled, so too did the sales of prescription opioids.

The widespread nature of the opioid epidemic that reaches across typical class, race and geographical stereotypes has challenged myths of who drug addicts are. It has also widened the lens, revealing more moral actors participating in the crisis beyond the addict. Years of distorted public policy, overworked and unrestrained doctors, intentionally misleading pharmaceutical marketing, and even watered-down theology that reduces people to disembodied moral characters instead of whole human persons created in the image and likeness of a good God, have all contributed through sins of both omission and commission.

Many opioid addicts began using these drugs for legitimate physical ailments, merely following their doctor’s orders. In fact, the American Society of Addiction Medicine reports that four out of five heroin addicts started with prescription opioid medications, with nearly all reporting that they eventually switched to heroin because of the price.

Our mental picture of an addict should include the high school honors student who breaks her arm skateboarding and is prescribed an opioid by her doctor. Or the middle-aged factory or construction worker who has permanent back pain from his job and is prescribed an opioid by an overworked doctor who misses the fact that his patient is severely depressed. Or a white, college-educated, employed, middle-class Christian (as in my case, and the case of Timothy King, the author of the article) from a good family who grew up in small-town America.

When King’s doctor informed him he had become addicted to pain medication, he told King, “That isn’t a judgment on you. I’m not saying you’ve done anything wrong or that you aren’t still in pain. But we’ve been giving you this pain medication for so long, your body is now dependent on it. It has gone from helping you to hurting you.” The doctor told King he was not going to just take the pain medication away when he needed it. But he asked King to commit to taking less whenever he could. The doctor said, “For a while you couldn’t have made it without the pain medicine. Now to fully heal, you need to eventually stop taking it.”

In July of this year, Congress passed legislation to address the opioid crisis and heroin epidemic. Even the language  of “crisis” and “epidemic” to describe the bill indicates a shift in mentality. The legislation acknowledges a growing medical consensus that the addict is subject to a disease – one with deep biological and psychological roots that often preclude individual choice. This landmark legislation marked an important step forward in reorienting public policy to reflect this new consensus. Framing addiction as a chronic disease does not remove the moral choices involved, but gives us a broader framework for understanding them. We can’t ignore the reality of our bodies, and when it comes to opioid addiction (as well as other addictions), part of the effect of those chemicals is to actually rewire the brain, making it more difficult, if not nearly impossible, to change patterns of thought and behavior.

King discusses one commonly used analogy helping us understand addiction: heart disease. Like all analogies, it doesn’t explain everything, but it has the virtue of pointing out how clogged arteries cannot be cleared up by giving a pep talk to the patient or urging him to stop breathing so hard after climbing a set of stairs. Its causes are found in a mix of hereditary, environmental, and lifestyle choices. It’s also helpful to think about how often our physical state and surroundings influence our actions.

But the sense that addiction is solely a moral problem is hard to eradicate. After I clearly understood my addiction as a disease (which took nearly four decades and several encounters with the criminal justice system), I still battle internally with my self-image to this day. I grew up with the “Just Say No” anti-drug campaigns aimed at warning youth about illegal drugs. In that model, those with moral fortitude say “no,” and moral degenerates say “yes.” Those who said “no” received praise, and those who said “yes” were shamed and punished.

King recalls how he began to back down from taking opioid painkillers. He writes, “I removed the fentanyl patch first and switched to taking only Dilaudid. Within a day I could again feel my body in ways I did not realize I had been missing. At the same time, it felt as if a thick protective comforter had been ripped off from around me while I lay shivering and naked on my bed. Pain that had been blunted refocused and pressed out from the inside. The doctor was right. I could handle the pain now without the same levels of opioids. But I couldn’t  have continued my recovery if it were all up to the strength of my will alone.” King added, “So much more powerful than saying ‘no’ to an opioid was the opportunity to say ‘yes’ to a slow return to a life of flourishing.”

King said goodbye to narcotic pain medication, but indicated it was not an easy goodbye. He said the feeling was like the tremor in your hand when your blood sugar drops. Desire spreads out to every cell of your body as if each one is making its own demand, aching and promising to be satisfied with “just a little more.” Feelings of withdrawal and the troubled sleep that often comes with them are typically intense for the first few days. They can flare up even months down the road as a reminder of what had been, and the perilously thin line between you and the mounting numbers of long-term addicts and overdose victims. For me, I always thought I could control my usage. I was convinced I would never “take too much” and overdose. And yet it happened. I don’t recall anything from the moment I became unresponsive in my parents’ living room, through the ambulance ride to the ER, and ripping out my IV, to being sedated with haldoperidol. I woke up the next morning in a hospital room.

King relates, “I’ve realized that the word ‘addict’ is a particularly useful descriptor for who I have always been. I always resonated with Paul’s lament: ‘I do not do the good I want to do, but the evil I do not want to do – this I keep doing.’ (Romans 7:19) Some who have never experienced the furious grip of chemical dependence are tempted to split the world into addicts and non-addicts…morally bad and morally good.” He added, “I did not realize how fully I had embraced this view until faced with my own opioid addiction.” For me personally, I will admit I didn’t know I could have an addiction problem and still be a good person.

While addiction science has made strides, there is still no silver bullet. Already there are stories of innovative addicts who have found new ways to abuse the medications intended to help them. Any approach that reduces addiction to a mere problem of brain chemistry and fails to acknowledge humans as moral actors will ultimately fail. But leading researchers and those discussing public initiatives have gone a long way to acknowledge the importance of a both/and methodology.

Churches can be cultural epicenters for shifts in societal norms. The longer that addiction is seen as a struggle for the “sinners out there” and not at the heart of the struggle of each and every one of us, the longer this problem will make headlines and remain in the shadows. Remember, sin takes its deepest root in the cover of darkness where it is never given a name.  King concludes, “When our affliction is named for what it is and brought into the light, that’s when darkness may be overcome.”

Preface to The Surgeon General’s Report on Alcohol, Drugs and Health

Before I assumed my position as U.S. Surgeon General, I stopped by the hospital where I had worked since my residency training to say goodbye to my colleagues. I wanted to thank them, especially the nurses, whose kindness and guidance had helped me on countless occasions. The nurses had one parting request for me. If you can only do one thing as Surgeon General, they said, “Please do something about the addiction crisis in America.”

I have not forgotten their words. As I have traveled across our extraordinary nation, meeting people struggling with substance use disorders and their families, I have come to appreciate even more deeply something I recognized through my own experience in patient care: that substance use disorders represent one of the most pressing public health crises of our time. Whether it is the rapid rise of prescription opioid addiction or the longstanding challenge of alcohol dependence, substance misuse and substance use disorders can—and do— prevent people from living healthy and productive lives. And, just as importantly, they have profound effects on families, friends, and entire communities.

I recognize there is no single solution. We need more policies and programs that increase access to proven treatment modalities. We need to invest more in expanding the scientific evidence base for prevention, treatment, and recovery. We also need a cultural shift in how we think about addiction. For far too long, too many in our country have viewed addiction as a moral failing. This unfortunate stigma has created an added burden of shame that has made people with substance use disorders less likely to come forward and seek help. It has also made it more challenging to marshal the necessary investments in prevention and treatment. We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.

I am proud to release The Surgeon General’s Report on Alcohol, Drugs, and Health. As the first ever Surgeon General’s Report on this important topic, this Report aims to shift the way our society thinks about substance misuse and substance use disorders while defining actions we can take to prevent and treat these conditions.

Over the past few decades, we have built a robust evidence base on this subject. We now know that there is a neurobiological basis for substance use disorders with potential for both recovery and recurrence. We have evidence-based interventions that prevent harmful substance use and related problems, particularly when started early. We also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support. Additionally, we have learned that recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual. As Surgeon General, I care deeply about the health and well-being of all who are affected by substance misuse and substance use disorders.

This Report offers a way forward through a public health approach that is firmly grounded in the best available science. Recognizing that we all have a role to play, the Report contains suggested actions that are intended for parents, families, educators, health care professionals, public policy makers, researchers, and all community members.

Above all, we can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves. Despite the significant work that remains ahead of us, there are reasons to be hopeful. I find hope in the people I have met in recovery all across America who are now helping others with substance use disorders find their way. I draw strength from the communities I have visited that are coming together to work on prevention initiatives and to connect more people to treatment. And I am inspired by the countless family members who have lost loved ones to addiction and who have transformed their pain into a passion for helping others. These individuals and communities are rays of hope. It is now our collective duty to bring such light to all corners of our country.

How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another?

Fifty years ago, the landmark Surgeon General’s report on the dangers of smoking began a half century of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General’s Report on Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can lead healthy and fulfilling lives.

Vivek H. Murthy, M.D., M.B.A., Vice Admiral, U.S. Public Health Service, Surgeon General

To read The Surgeon General’s Report on Alcohol, Drugs, and Health click on the following link: https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf

Governor Tom Wolf Signs Opioid Bills Into Law

Gov. Tom Wolf signed into law a package of legislation meant to curb addiction to prescription painkillers and heroin in a state that saw more than 3,500 people die last year of drug overdose. New laws mandate seven-day limits on painkiller prescriptions like oxycodone for both minors and emergency room patients who are treated and released.

Legislation also establishes curriculum on safe prescribing for medical school students and professionals seeking license renewal, boosts the frequency prescription drug prescribers and dispensers utilize and update the Pennsylvania Prescription Drug Monitoring Program (PDMP), and widely expands potential drop-off locations for unused prescription drugs. The move came five weeks after a rare joint meeting of the state House of Representatives and Senate at which Wolf called for action addressing the opioid and heroin addiction crisis as the end drew near in the 2015-2016 legislative session.

Last week, the General Assembly adopted the bills

Governor Wolf said, “I am proud to sign a package of bills that represents the work that we have all done together to address the heroin and opioid abuse crisis and begins to curb the effects of this public health epidemic in Pennsylvania.” State Senator  Gen Yaw (R) of Williamsport, PA was the prime sponsor of two of the bills. He compared the Legislature’s work to the strength of a rope. Each bill represents a single strand. “Alone, they might not be fully effective, but together, they can strengthen the rope and our collective efforts.” He said he appreciates the support of the legislative leadership, and remarked that he is thankful for the governor’s prompt signing of the bills into law.

Glenda Bonetti, director of Northumberland County’s Drug and Alcohol Program, fully supports the prescribing limits. She estimates the average age of first-time opioid users who seek help through her office as 17. In her experience, many who become addicted tend to progress to heroin. Bonetti is grateful for the legislative action, but said it took opioid abuse to become prevalent in the middle and upper classes to get noticed. She said, “The reason it’s becoming more publicized is because it’s not just the impoverished who are affected. It’s affecting wealthy families, not just poor people.”

– by Eric Scicchitano, The Daily Item, November 3, 2016

Crucial New Guidance on Opioids and Pain

From the blog of Dr. Nora Volkow, Director, National Institute of Drug Abuse
April 6, 2016

Millions of Americans suffer from opioid use disorders involving prescription pain medications, and each day more than 40 people fatally overdose on them. Although these medications have a legitimate and important role in the treatment of severe acute pain and some severe chronic pain conditions, it is clear that they are also over-prescribed or prescribed without adequate safeguards and monitoring, a situation that has significantly contributed to the alarming rise in opioid use disorders, and to the related resurgence of heroin use we are also seeing in many communities.

Last month, the Centers for Disease Control and Prevention took a major step toward addressing these intertwined crises by issuing new guidelines for prescribers about the use of opioids for treating patients with chronic pain—who according to some studies now account for 70 percent of the opioids dispensed in this country. The CDC recommends that opioids should not be the first line or only treatment for patients who present with chronic non-cancer pain.

It is not simply an issue of safety. Recent reviews of the science have found surprisingly little evidence supporting the effectiveness of opioids in the treatment of chronic pain conditions (defined as pain lasting longer than 3 months). In some cases, opioids may even contribute to a worsening of pain (hyperalgesia), leading to a vicious cycle of taking more opioids to treat a condition that the medication itself has made less tractable.

The new guidelines thus recommend that non-opioid therapies, such as non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen, as well as non-drug treatments like exercise and cognitive behavioral therapy, should be considered in lieu of or in conjunction with opioid medications. When opioids are prescribed, physicians should prescribe the lowest effective dose, and closely monitor and follow-up with their patients.  Notably, the new guidelines do not apply to treatment of cancer pain or end-of-life care.

Of course, reducing the use of opioids by primary care physicians must be balanced against the efficacy of these drugs for some patients. The aim is not to take these powerful analgesics away from those who need and safely benefit from them, but to ensure they are only used where they are effective, and at the same time reduce the risk of both diversion and the development of substance use disorders.

As in so many other areas, pain is an area where we need more science. The lack of evidence regarding opioids in chronic pain is matched by a lack of evidence for any treatment in these disorders. Other available pain relievers like NSAIDs also have their liabilities and potential safety issues, and their efficacy for treating chronic pain conditions will also require further study. Recognizing the liabilities and limitations of opioids is also an impetus to redouble our efforts to develop new pain treatments that would be safer and more effective than currently available medications. Compounds that modulate signaling in the body’s endocannabinoid system, for example, are an active area of research and may yield new pain pharmacotherapies in coming years.