Emergency Departments Can Help Prevent Opioid Overdoses

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

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

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

Originally Posted at the NIDA Website on August 26, 2019

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

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

girl-overdose.jpg

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

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

Bottles of Opiate Prescriptions

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

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

Naloxone kit

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

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

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

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

Let’s Take a Look at Opioid Use Disorder

DSM 5

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

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

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

Are You Struggling?

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

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

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

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

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

call-911-in-an-emergency_fi.png

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.

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

Secret Opioid Memo

opioid-epidemic-pic-of-vidodin.jpeg

A confidential government document containing evidence so critical it had the potential to change the course of an American tragedy was kept in the dark for more than a decade. The document, known as a “prosecution memo,” details how government lawyers believed that Purdue Pharma, the maker of the powerful opioid, OxyContin, knew early on that the drug was fueling a rise in abuse and addiction. They also gathered evidence indicating that the company’s executives had misled the public and Congress.

Bottles of Opiate Prescriptions

There has been a recent wave of lawsuits against opioid makers and members of the Sackler family, which owns Purdue Pharma. Opioid abuse has ravaged America over the past two decades. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2017 more than 700,000 Americans have died from a drug overdose. Approximately 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid. In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999. On average, 130 Americans die every day from an opioid overdose.

The confidential Justice Department “prosecution memo” represents a missed opportunity that might have changed the course of the opioid epidemic. It also suggests that Purdue Pharma and members of the Sackler family knew far earlier than they admitted that OxyContin was being abused. The memo had the potential to change the course of the opioid crisis but was kept from circulation for more than a decade. The report states that Purdue Pharma executives were implicated in the crisis.

The Department of Justice chose not to pursue felony charges against those executives, paving the way for a settlement that ended a four-year investigation. The settlement did not produce any vital changes to industry behavior regarding the prescribing of narcotic painkillers. Secrecy surrounding the memo is emblematic of a legal process that favors the suppression of corporate information. If disclosed, this information could benefit the public’s health and safety. It is truly extraordinary to see after all these years that the opioid industry is finally being held to account.

Analysis of the DEA database obtained by the Washington Post reveals that a relatively small number of pharmacies—15 percent—distributed roughly half of prescription opioids nationwide from 2006 to 2012. It seems the DEA wasn’t paying attention to its own data, instead relying on drug companies and pharmacies to police themselves. In one engaging multimedia story, the Post took a close look at a southwestern Virginia area that was flooded with 74 million opioid pills over seven years—enough for 106 pills per resident every year. Journalists from over 30 states have now published over 90 separate articles based on the previously undisclosed DEA data.

It’s unbelievable that millions of oxycodone and hydrocodone pills flooded poor communities in Appalachia as pharmaceutical companies and the DEA failed to heed signs of large-scale inappropriate prescribing. Yet there is a certain liberation in being able to point to specific data, which might help assign responsibility for what may be U.S. health care’s most fateful systemic failure in recent history.

Miami Pill Mill.jpg

It is bad enough that many doctors and pharmacies were little more than “pill mills” supplying untreated addicts with their drug of choice rather than treating legitimate pain patients. It is quite another to know that nearly 35 billion opioids — about half of all distributed pills — were handled by just 15 percent of the nation’s pharmacies between 2006 and 2012. A single drugstore in tiny Albany, Kentucky purchased nearly 6.8 million hydrocodone and oxycodone pills during that period, equivalent to 96 a year for all 10,000 or so men, women and children in surrounding Clinton County. This was the most on a per capita, per county basis in the United States.

There is always a tension between discretion and disclosure—between keeping the public informed about the workings of large medical treatment systems and permitting specialists who operate them to handle delicate matters in private. Nowhere is that tension more relevant than in health care, where medical expertise, proprietary information and patient privacy are all at a premium. Like all good things, however, those may be taken to an extreme or turned into excuses for unwarranted concealment.

Any ordinary person who learned that a single pharmacy in small-town Kentucky was handling millions of potentially addictive pills over a seven-year period might have sounded an alarm, even if government bureaucracy, industry leaders, and doctors did not. Unfortunately, no ordinary person could know—until now.

For more information, click here: OxyKills.com

Hazelden Betty Ford Foundation Recovery Advocacy Update

Startling data recently made public show the details of how pharmaceutical companies saturated the country with opioids. In the seven years from 2006 to 2012, America’s biggest drug companies shipped 76 billion oxycodone and hydrocodone pain pills in the United States. The result? Opioid-related deaths soared in communities where the pills flowed most. These new revelations come from the Washington Post, which spent a year in court to gain access to a DEA database that tracks the path of every single pain pill sold in the United States.

Opioid Epidemic Pic of Vidodin

The database reveals what each company knew about the number of pills it was shipping and dispensing and precisely when they were aware of those volumes, year-by-year, town-by-town. The data will be valuable to the attorneys litigating cases to hold manufacturers accountable, including a huge multi-district case in Ohio, where thousands of documents were filed last Friday. The data show that opioid manufacturers and distributors knowingly flooded the market as the overdose crisis raged and red flags were everywhere.

The Post has also published the data at county and state levels in order to help the public understand the impact of years of prescription pill shipments has had on their communities. Hazelden Betty Ford Foundation says to expect many reports from local journalists using the data to explain the causes and impact of the opioid crisis in their communities. The Post did its own local deep-dive, taking a close look this weekend at two Ohio counties that soon will be at the center of the bug multi-district litigation. Barring a settlement, the two counties are scheduled to go to trial in October as the first case among the consolidated lawsuits brought by about 2,000 cities, counties, Native American tribes and other plaintiffs.

Meanwhile, the CDC posted preliminary data suggesting that the number of Americans who died from drug overdoses finally fell 5% in 2018 after years of significant increases. This new data, while still preliminary, covers all of 2018, so it is firmer. And it is a rare positive sign. But it’s only one year and no cause for celebration or complacency—especially with continued funding for opioid crisis grants are uncertain and the decline in deaths anything but uniform across the states. For example, 18 states still saw increases in 2018. Policymakers must be reminded that we’re still very much in the midst of the nation’s worst-ever addiction crisis—one from which it will take years to recover. Federal funding remains essential, as advocate Ryan Hampton points out in his latest piece making the case for the CARE Act, a Congressional bill that would invest $100 billion over the next 10 years.

Chris-Herren

If you missed the premiere of  “The First Day,” a powerful, one-hour documentary that shows the evolved talk of former NBA-player-turned-recovery advocate Chris Herren, you can catch it again July 30 at 10:00 p.m. Eastern on ESPN. It is also now available for sale as a download. Herren has spoken to more than a million young people, and the film follows him on a dozen or so speaking engagements up and down the East Coast.

Delta Air Lines announced that naloxone, the medication used to treat (reverse) an opioid overdose, will be available in all emergency medical kits on flights beginning this Fall.

Delta’s decision comes after a passenger tweeted that a man died aboard a Delta flight last weekend from an opioid overdose. It’s unfathomable why naloxone isn’t already on all flights for all airlines. Last year, Hazelden Betty Ford Foundation joined the Association of Flight Attendants in urging the FAA to require it. No one should have to die before airlines take this common-sense step.

Oklahoma’s lawsuit against Johnson & Johnson went to the judge, who will decide later this summer whether to hold the drugmaker accountable for the state’s opioid epidemic. Oklahoma is seeking more than $17.5 billion to abate the costs of opioid addiction. Purdue Pharma and Teva Pharmaceutical settled their part of the Oklahoma case. But they and other drugmakers and distributors face some 2,000 similar lawsuits by states and local municipalities.

Bottles of Opiate Prescriptions.jpg

Purdue Pharma, a pharmaceutical company owned by the Sackler family, invented the so-called non-addictive drug OxyContin. The company was found to have falsified the addiction rate at less than 1% when in fact it was over 10%. Raymond Sackler had a personal net worth of $13 billion in 2016. He passed away on July 17, 2017. The Louvre in Paris has removed the Sackler family name from its walls, becoming the first major museum to erase its public association with the philanthropist family linked with the opioid crisis in the United States.

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

Dr. Nora Volkow, director of the National Institute on Drug Abuse, has written and spoken extensively about the importance of prevention in addressing the opioid crisis. NIDA studies have shown that teens who misuse prescription opioids are more likely to initiate heroin use. You can visit NIDA’s site by clicking here.

 

 

AT-121: A Promising Alternative to Opioid Pain Medications

By Eric Sarlin, M.Ed., M.A.
NIDA Notes Contributing Writer
National Institute on Drug Abuse

Dr. Eric Sarlin’s recent research reveals an experimental compound with a dual action at two opioid receptors which may provide powerful pain relief without many of the usual harmful opioid side effects. The compound may also have potential as a treatment for opioid addiction.

The reason AT-121 is promising is because it provides pain relief without producing the side-effect of euphoria.

This is a novel compound representing potential advancement toward the goal of non-addictive pain medications that are at least as effective as opioids but without typical opioid liabilities. The new compound—called AT-121—may also have potential as a treatment alternative for opioid addiction. Most of the potent analgesics currently in use act through mu-opioid receptors. AT-121 seems to relieve pain in monkeys without causing physical dependence. Most pain medications work by activating a receptor in the neurons the mu-opiate receptor. Mei-Chuan Ko, a professor of physiology and pharmacology at the Wake Forest School of Medicine, says “Oxycodone, morphine, fentanyl, heroin—they all work through the mu-receptor.” Ko is one of the authors of the study.

Dr. Nurulain Zaveri and colleages at Astraea Therapeutics, manufacturer of AT-121, used medicinal chemistry, computer modeling, and structure-based drug design to create and develop AT-121. Like opioids—such as morphine and oxycodone—AT-121 also binds to the mu-opioid receptor. Unlike those opioids, AT-121 also binds to another opioid receptor called the nociceptin/orphanin FQ peptide receptor. According to Dr. Zaveri, this interaction with the NOP receptor enhances AT-121’s analgesic effect and blocks unwanted side effects often seen with current opioid medications.

References

NIDA. (February 12, 2019). “A Promising Alternative to Opioid Pain Medications.”

The Opioid Issue: Part 2

Part Two: Collateral Damage

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

opioid-crisis-word-cloud

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

Agony in the Womb

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

One Baby Every Half Hour

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

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

It All Adds Up

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

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

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

Drug Dependent Newborns.png

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

The True Cost

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

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

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

 

 

The Opioid Issue: Part 1

Part One: Dangerous Prescriptions

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

Opiates in Pill Bottles

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

no-pain.jpg

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

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

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

How it All Began

Chronic Pain The Silent Condition

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

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

pain-management-word-cloud-e1453101800676

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

The Blame Game

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

oxycontin pills.jpg

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

Overdose Deaths Not Just Related to Opiate Prescriptions

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

Heroin and Fentanyl in Bottles.jpg

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

The Road Ahead

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

22SCI-NUMBER-articleLarge

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

The Christian Perspective

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

Celebrate-recovery.jpg

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

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

Power in the Name of Jesus

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

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

 

 

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.

opiate painkillers

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?

capsules-87113__340 (2)

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.