One of the least expensive but deadliest street drugs available today is known as KD, Katie or Zombie. This drug may contain different ingredients, but the common denominator is always bug spray. Users take marijuana, banana leaves, tobacco or spice and lace it with a bug spray, most often Raid. This concoction is then smoked, giving users a 45-minute high that leaves them virtually unconscious. Some people choose to make their own drugs, while others buy it for around $20 a bag. Irrespective of where they get it, however, it is incredibly addictive and absolutely lethal.
Onlookers describe users who become “slow and lethargic,” drool, and lose all motor function or the ability to communicate with others. In short, while in the throes of a high, KD users become totally unaware of and utterly unable to control their actions.
“We find them with their clothes off, eating the grass, pulling dirt out of the ground and trying to put it in their mouth,” Fire Department Captain Chris Major told CBS-affiliate WTTV.
“You look at what it does to a bug,” firefighter Scott Lebherz told the Indy Star, “and then you got to think what it’s doing to your brain, and your body and everything else.”
Health officials have warned that smoking this drug carries an “extreme risk of fatality,” but users become addicted so quickly that few have heeded the warnings. The fire department reports that the drug is so fast-acting that many overdose victims are found with the drug still in their hands. (Related: Is your insect repellent made from toxic ingredients?)
Bug sprays often have high concentrations of pyrethroids, a pesticide that is meant to knock out or kill bugs like roaches. According to a 2014 study by Texas Tech University Health Sciences Center, “Animal studies of pyrethroid toxicity have shown hyperglycemia and elevated plasma levels of noradrenaline and adrenaline” — meaning the drug will give users one big adrenaline rush before having a rapid comedown. This quick high can make it highly addictive.
Indianapolis authorities are urgently trying to determine the source of the KD being sold on the city’s streets.
See Zombie.news for more news coverage of zombies. Seriously.
A state-led initiative created within the Rhode Island correctional system showed that offering medication to inmates with opioid use disorders reduced fatal overdoses once the inmates were released. The reduction in fatal overdoses was large enough to have a significant effect on the death rate from opioid overdoses statewide. The research was funded by the National Institute on Drug Abuse and the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, as well as the Centers for Disease Control and Prevention.
Every person entering the Rhode Island correctional system was screened for opioid addiction and those who needed it were provided with evidence-based medication assisted treatment (MAT), which included the drugs methadone, buprenorphine, or naltrexone. In addition, a system of 12 community-based Centers of Excellence in MAT were established to continue MAT therapy and provide support after their release from prison or jail.
In the first six months of 2017, when the program was fully implemented, only nine of 157 fatal overdoses (5.7 percent) in the state occurred among recently released inmates, compared to 14.5 percent of overdose deaths in the first six months of 2016, representing a 60.5 percent reduction in mortality. The authors emphasize that continued study of this program is needed. However, they are encouraged by these early findings, and noted that identification and treatment of opioid use disorder in criminal justice settings with linkage to medication and supportive therapy after release is a promising strategy to rapidly address the high rates of overdose and opioid use disorder in the community.
About the National Institute on Drug Abuse (NIDA): The National Institute on Drug Abuse (NIDA) is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world’s research on the health aspects of drug use and addiction. The Institute carries out a large variety of programs to inform policy, improve practice, and advance addiction science. Fact sheets on the health effects of drugs and information on NIDA research and other activities can be found at www.drugabuse.gov, which is now compatible with your smartphone, iPad or tablet. To order publications in English or Spanish, call NIDA’s DrugPubs research dissemination center at 1-877-NIDA-NIH or 240-645-0228 (TDD) or email requests to email@example.com. Online ordering is available at drugpubs.drugabuse.gov. NIDA’s media guide can be found at www.drugabuse.gov/publications/media-guide/dear-journalist, and its easy-to-read website can be found at www.easyread.drugabuse.gov. You can follow NIDA on Twitter and Facebook.
About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
The report dives into the connections between corporate donations and the advancement of opioids-friendly messaging.
By Katelyn Newman , Digital Producer, Staff Writer |Feb. 13, 2018, at 11:03 a.m.
Senate Report: Drugmakers Spent Millions Pushing Opioids in Patient Groups
An arrangement of pills of the opioid oxycodone-acetaminophen in New York on Aug. 15, 2017. (Patrick Sison/AP) The Associated Press
Drugmakers have given more than $10 million to patient advocacy groups and affiliated physicians since 2012 to promote opioid use to individuals seeking help for chronic pain management, according to a report released by a U.S. Senator Monday.
Published by Sen. Claire McCaskill, D-Mo., the 23-page report looked into the financial connections between five pharmaceutical companies – Purdue Pharma L.P., Janssen Pharmaceuticals, Inc., Mylan N.V., Depomed, Inc. and Insys Therapeutics, Inc. – and 14 patient advocacy groups “working on chronic pain and other opioid-related issues” between 2012 and 2017.
“These groups have issued guidelines and policies minimizing the risk of opioid addiction and promoting opioids for chronic pain, lobbied to change laws directed at curbing opioid use, and argued against accountability for physicians and industry executives responsible for overprescription and misbranding,” the report states.
“Notably, a majority of these groups also strongly criticized 2016 guidelines from the Centers for Disease Control and Prevention that recommended limits on opioid prescriptions for chronic pain – the first national standards for prescription opioids and a key federal response to the ongoing epidemic,” it continued.
The connection between medical culture with the pharmaceutical industry’s goals means that many of the groups – with the U.S. Pain Foundation receiving the largest amount of payments – may have significantly contributed to the conditions that have led to the U.S. opioid epidemic, the report concludes.
“It looks pretty damning when these groups were pushing the message about how wonderful opioids are and they were being heavily funded, in the millions of dollars, by the manufacturers of those drugs,” Lewis Nelson, a Rutgers University doctor and opioid expert, told The Center for Public Integrity.
McCaskill’s report echoes a similar 2012 Senate investigation, led by Sen. Max Baucus, D-Mont., and Chuck Grassley, R-Iowa, that delved into ties between three opioid manufacturers and seven medical organizations that pushed out guidelines on proper opioid prescription tactics to affiliated physicians. That investigation’s findings never left the Senate Finance Committee’s office.
“The financial relationships between these groups and opioid manufacturers should be clear to the general public,” McCaskill said in a press release. “We passed a law ensuring the public had information on payments to doctors by pharmaceutical companies, and I can’t imagine why the same shouldn’t be done in this space.”
A day after the report was released, Purdue Pharma issued a statement Tuesday announcing a restructuring of their opioid promotion that includes no longer promoting opioids to prescribers.
According to McCaskill’sreport, nearly all health advocacy groups accept funding from drugmakers, leading to “concerns regarding the information and initiatives patient advocacy organizations promote.”
Multiplestates, citiesandcounties across the U.S. have issued lawsuits against the leading pharmaceutical companies for downplaying the risks involved with prescribing opioids and thus fueling the opioid epidemic, which accounted for at least 42,000 deaths in 2017 alone.
Source:University of Pittsburgh Schools of the Health Sciences
In just two years, the powerful opioid fentanyl went from nonexistent to detected in more than 1 in 7 stamp bags analyzed by the Allegheny County Office of the Medical Examiner, according to an analysis led by the University of Pittsburgh Graduate School of Public Health. Stamp bags are small wax packets that contain mixtures of illicit drugs, most commonly heroin, packaged for sale and sometimes stamped with a graphical logo by drug dealers to market their contents.
The findings, published in the journal Public Health Reports, suggest that real-time information about stamp bags can be used to supplement current public health surveillance measures and could serve as an early warning of new illegal drugs of high lethality available at the local level. It is the first robust and detailed public health report of a stamp bag surveillance system.
“We believe this way of examining drug evidence could be expanded upon for use in public health surveillance and monitoring in other regions,” said lead author Kathleen Creppage, M.P.H., C.P.H., a doctoral candidate in Pitt Public Health’s Department of Epidemiology. “It could be used to inform educational campaigns, allocate limited resources and devise prevention strategies. First responders also could benefit from knowing what drugs are in circulation so they can take proper precautions to protect themselves and be prepared with overdose reversal medications, such as naloxone.”
In the U.S., fatal heroin overdoses have increased in the past decade by 300 percent, with fentanyl — a substance that is 20 to 50 times more potent than heroin — and its analogs increasingly contributing to overdoses. The drug often is implicated in clusters of overdose deaths when it is mixed with heroin and users do not realize what they are taking is more powerful than usual.
In Allegheny County, stamp bags seized as evidence by law enforcement authorities are submitted to the county’s Office of the Medical Examiner for testing. The drugs are sorted into batches based on similar characteristics, such as the stamp and color of the drug, and a single bag is randomly selected from each batch for testing.
The research team compiled the medical examiner’s drug chemistry laboratory test results of stamp bag contents from 2010 through 2016. A total of 16,594 stamp bags were tested by the lab during that period.
Before 2014, none of the tested bags contained fentanyl. By 2016 it was found in 15.5 percent of the tested stamp bags, with 4.1 percent containing fentanyl as the only controlled substance present.
Toxicology results from overdose victims take weeks or months, and state and national mortality data lag by about 18 months. Drug evidence testing is usually available much more quickly — in Allegheny County it is available for the current month.
“The face of the current opioid overdose epidemic changes quickly from month to month. The ability to rapidly analyze drugs causing these overdoses, and make that knowledge available to all stakeholders, is critical to efforts to deal with the crisis,” said co-author Karl E. Williams, M.D., M.P.H., Allegheny County Medical Examiner. “This study of stamp bags results from a unique collaboration based on technical capabilities of my office and the analytic resources of the Pitt Graduate School of Public Health.”
Stamp bag testing and monitoring should not replace other drug surveillance systems, such as overdose mortality data and toxicology reports, said Creppage, also an intern at the Allegheny County Office of the Medical Examiner.
“But it can be a powerful complement to these surveillance systems,” she said. “The data are available, and we need to identify and explore these different data sources as part of our efforts in understanding and combatting the opioid epidemic.”
Senior author Anthony Fabio, Ph.D., M.P.H., associate professor of epidemiology at Pitt Public Health, added that the work “is an important step in developing multi-disciplinary tools to quickly identify current and future sources of new drugs that enter the illegal market.”
Additional authors on this study are Jeanine Buchanich, Ph.D., M.Ed., Thomas Songer, Ph.D., and Stephen Wisniewski, Ph.D., all of Pitt Public Health; as well as Joshua Yohannan, drug chemistry laboratory manager at the Allegheny County Office of the Medical Examiner.
Kristi L Nelson, USA TODAY NETWORK – Tennessee Published 7:00 a.m. ET Jan. 26, 2018 | Updated 5:32 p.m. ET Jan. 26, 2018
In March, Stephen Loyd was scrolling through Google images for a PowerPoint presentation on addiction when a picture of a bottle of Percocet pills triggered a powerful craving.
His mouth watered. His hand trembled. He couldn’t move the computer mouse.
When it happened, Loyd was in his office on the sixth floor of a government building in downtown Nashville, where he serves as medical director for Substance Abuse Services for the state of Tennessee, one of the states hardest hit by the opioid epidemic.
That’s how powerful opioid cravings are, Loyd said. And cravings are the primary reason it’s so hard to treat opioid addiction.
“The reason people relapse is the cravings,” Loyd said. “The cravings are persistent for the rest of your life. … I always wonder, when I tell this, if people get nervous. I’m the medical director for the whole state. The medical director for the state of Tennessee still gets cravings for opioids? He does.”
How opioids trick the brain
The human brain is designed to reward you with feelings of pleasure when you engage in activities that benefit our species: eating, exercising, sex. When part of the brain — the ventral tegmental area — is signaled that you’re doing these things, it triggers another part of the brain — the nucleus accumbens — to release the chemical dopamine. Brain cells sensitive to dopamine receive it and generate a feeling of pleasure. Meanwhile, other parts of the brain form a memory of what happened to produce that pleasurable feeling.
Opiate drugs, which come from the opium poppy flower, and synthetic, or man-made, opioids also can trigger that brain process in the mesolimbic system. The drugs attach to certain specialized proteins on the same receptor brain cells where the pleasure-causing chemicals the body naturally makes normally attach. So can other drugs, including alcohol — but the body seems to develop a tolerance to opioid drugs more quickly.
That is, it develops a tolerance for the drugs’ abilities to relieve pain or produce pleasure, requiring an increasingly higher amount to fire up the process that produces dopamine, said neuropsychiatrist Dr. Richard Gibson, an addiction specialist who practices, teaches and conducts research at the University of Tennessee Medical Center in Knoxville.
However, Gibson said the body doesn’t develop a tolerance to the amount of drugs needed to depress the respiratory system — which is how most opioid users fatally overdose.
Gibson said opioids can physically change the structure of the brain. That concept of “plasticity” was foreign when he went through medical school in the 1960s.
“We thought the brain was unchanging,” Gibson said. “It turns out the brain can remodel itself quite well in a lot of circumstances” — for better or worse.
Dropped signals, bad judgment
Among the changes that can occur is a disconnect between the part of the brain responsible for insight and judgment — the prefrontal cortex — and the mesolimbic “reward center” that triggers the release of dopamine, Loyd said.
Ordinarily, the prefrontal cortex sends signals to that reward center. The result: the ability to use judgment to restrain bad impulses.
“We do it all the time — we kind of play through scenarios and pick the one that has the most benefit and the least consequences,” Loyd said.
But studies have suggested drug abuse not only could lower the level of the chemical used to transmit those signals, but also could damage the particular circuit that carries the signals from the prefrontal cortex to the reward center. In fact, Loyd said some studies suggest those connections stop developing at the age of first drug use — “so you can have somebody who’s 35 years old, and they’re making decisions like a 12-year-old.”
Those connections can re-form, Loyd said, but it takes time — about 18 months to two years for most people.
That’s why he argues that detox alone — getting addicts over the hump of terrible withdrawal symptoms, which range from a few days to a few weeks, depending on the drug — isn’t enough to ensure they’ll stay clean. Putting people through detox and then turning them back out on the streets is like “sticking them out there with a half a brain,” he said. Since the prefrontal cortex still isn’t functioning normally, “they’re driven solely by rewards, they’re having cravings, and they’re going to relapse 99 times out of 100.”
Why do doctors and pilots do better?
For years, Loyd wore rubber bands around his wrists like bracelets. Few people knew their purpose — it was so he could “snap” his wrist if he felt a drug craving coming on, interrupting the “loop” of fixating on the drug, how it would make him feel and how to get it. Having interrupted the loop, he could then move through the process he knew would keep him from seeking a high: call a buddy, talk about the impulses, engage the prefrontal cortex to remind him of all he had to lose.
Loyd didn’t automatically learn this process. It was, in a sense, a byproduct of his profession. At the time he became addicted, Loyd was a practicing internal medicine physician. After detoxing in a major research hospital, he went into a 90-day inpatient addiction treatment program that accepted only medical professionals and fully prepared him to deal with cravings afterward, teaching him to recognize the onset and reach out for help. It came with five years of aftercare.
In contrast, most people who do manage to get expensive inpatient treatment get, at most, 28 days, Loyd said. Even those people are a tiny fraction of people who need it. A 2015 report by the federal Substance Abuse and Mental Health Services Administration estimated only 10.8 percent of the people who needed substance abuse treatment got any — inpatient, outpatient or even detox.
In various studies, the five-year sobriety rate for opioid addicts ranges from less than 10 percent to about 30 percent. But among doctors and airline pilots, who get intensive inpatient treatment and aftercare, it’s 75 percent to 90 percent, Loyd said.
“We don’t do that well with strep throat!” he said.
Pilots and physicians are examples of high-pressure, high-paying professions. While they may have more resources than average people, they’re also harder to replace — so there’s a vested interest in returning them to the same jobs in which they might have become addicted.
In the case of commercial airline pilots, the Federal Aviation Administration oversees an intensive peer-reported treatment program, the Human Intervention Motivation Study (HIMS), which began in the 1970s, then sponsored by the Air Line Pilots Association International labor union and funded by the National Institute for Alcohol Abuse and Alcoholism. Through the program, most pilots get about a month of inpatient treatment and about three years of follow-up recovery treatment, along with several years of close monitoring for relapse.
For doctors, most states — including Tennessee — have a physician health program that intervenes when doctors are facing mental health or substance abuse issues. The doctor is evaluated, and case managers in the physician health program make recommendations for treatment; the doctor pays for the recommended treatment. After treatment, the physician health program and treatment program make ground rules for the doctor’s re-entry into practice, establishing a contract with the doctor based on their recommendations. Follow-up care usually lasts about five years.
“So, we know the model” for long-term sobriety, Loyd said.
What’s lacking is the funding to provide that type of intensive inpatient treatment to the broader population of addicts.
‘Leveling the field’ with medications
That’s where medication-assisted therapy comes in, Loyd said: “It levels the playing field.”
Methadone, a long-acting narcotic painkiller, fits into the same brain receptors as opioids but doesn’t produce the euphoric “high” the opioid drugs do. It also can block opioids from attaching to the receptors, if a person relapses and takes an opioid after having taken methadone.
Naltrexone, approved to treat opioid addiction in 1984 and alcohol addiction in 1994, binds to the receptors and blocks them altogether so that opioids can’t attach. Because naltrexone doesn’t activate the receptors at all, though, it won’t prevent withdrawal symptoms, and patient compliance with taking it regularly has historically been low. In recent years, naltrexone has been available in an injection — Vivitrol — that’s taken once a month.
Buprenorphine — sometimes combined with naltrexone in Suboxone — fits into the opioid receptors, but it’s not a perfect fit, so the receptor only partially “fires.” The body is tricked into thinking it has opioids, but buprenorphine won’t produce a euphoric high or depress the respiratory system.
The three drugs, available by prescription only, are doled out under a doctor’s supervision. Treatment can be expensive — around $500 a month for cash-paying patients to get an office visit and fill the prescription.
While many people “have very strong moral feelings” against using replacement drug therapy with someone who’s addicted, “there’s a lot of evidence it’s one of the more effective harm-reduction strategies in all of medication,” Gibson said.
At one year after starting medically managed treatment, Gibson said, three-quarters or more of opioid addicts haven’t relapsed; for an abstinence-only program, the success rate is less than 20 percent.
The medications’ “utility is, they quell cravings, and now you’ve got time to hold people in treatment and teach them the skills they need to manage cravings and stay clean going forward,” Loyd said.
Managing cravings is key to long-term success. Powerful cravings can happen suddenly after years of sobriety, the brain reacting as though the body will go into withdrawal if it doesn’t get opioids, Gibson said. Scientists have investigated whether a trace of opioids could be stored somewhere in the brain, emerging randomly, but “every evidence we have suggests this is not possible,” he said.
Instead, most researchers think a cued reminder “triggers” a physical craving — an image, sound, scent. When scientists put a crack addict in a scanner that looks at brain chemistry and flashed a photo of a crack pipe for 33-thousandths of a second — too quickly for him to even be aware he saw it — the image showed a definite reaction in the mesolimbic reward center of the brain.
“It’s like a ticking time bomb for some people,” Gibson said.
Genetics + environment = increased risk
Addictionology isn’t an exact science. Scientists aren’t sure yet, for example, what role genetics play, but it’s clear having a family history of addiction may predispose a person to become addicted.
Environment, too, plays a big part, especially stressors. Men are more likely than women to become addicted to opioids, but scientists don’t know if that’s because of a physical difference in the way the body reacts to drugs, a psychological difference in how men and women handle stress or temptation, or some combination. Several studies suggest up to 75 percent of people who abuse opioids were victims of physical or sexual abuse, with women more likely than men to have been abused.
ACEs can include physical, emotional and sexual abuse; physical and emotional neglect; living with a family member with addiction or other mental illness; living through parents’ divorce or separation; having an incarcerated family member; witnessing a family member being abused; being homeless; being bullied or living in an unsafe neighborhood or a war zone; and being in the foster-care or juvenile detention systems. The study found that the more types of adversity a child experienced, the higher the risk of these physical and mental issues. People who experienced five or more types of trauma were seven to 10 times more likely to use illegal drugs — including injecting them — and to report being addicted.
Dr. Daniel Sumrok, director of the Center for Addiction Sciences at the University of Tennessee Health Science Center’s College of Medicine in Memphis, said the “trauma of childhood” absolutely can cause “neurobiological changes.” He estimates 90 percent of his clients have had three or more ACEs.
In two outpatient clinics, Sumrok combines medication-assisted therapy with therapy to address those childhood traumas. Drug use, he believes, is actually “ritualized compulsive comfort-seeking”; part of his job is to help patients replace it with a safer, legal coping behavior.
Studies suggest that chronic stress during childhood can physically change the developing brain, shrinking the parts that process emotions, manage stress, control impulses, weigh decisions and deal with fear. As a result, as adults, children who had ongoing traumatic experiences may have more fear and anxiety related to even minor stressors, as well as more susceptibility to depression and mood disorders.
Sumrok, an Army veteran himself, spent the early part of his career researching the symptoms of post-traumatic stress disorder — including substance abuse — in Vietnam veterans, eventually concluding it’s not a “disorder” but rather a normal learned response to trauma.
Gibson was in the U.S. Navy when Veterans Affairs and Department of Justice began preparing for an expected onslaught of soldiers returning home from Vietnam addicted to heroin. Heroin was easy to get in Vietnam, and the government knew soldiers were taking it: Around 20 percent of returning soldiers said they were addicted.
Turns out, “when people were not in Vietnam anymore, and they weren’t in danger of being killed every day … the need for opioids was pretty much gone,” Gibson said. “People had some mild effects, but nothing like the degree of addiction that was thought to be present. … This led to a lot of insights into opioid addiction” — specifically, the impact of changing addicts’ environment and routine to help them get clean.
Addiction is as much a social problem as a scientific one, Loyd said. Sending a detoxed addict back into the situation that led to addiction is certain to backfire. The numbers bear out the need for follow-up, he said. An opioid addict who stays clean for one year has a 10-18 percent chance of making it to 15 years of sobriety.
“If you can get them to five years (clean), though, that jumps up to 65 percent,” he said. “It’s a dramatic difference. … The key is keeping them engaged in treatment.”
Research finds new ways to fight the opioid crisis
An interim treatment can get people medication sooner
Date:December 6, 2017
Source:American College of Neuropsychopharmacology
In the US alone, more than 2 million people struggle with opioid use disorders. Opioids, often prescribed as pain medications, have now become the country’s leading cause of drug overdose.
But scientists are identifying ways to help combat the epidemic, which include getting people treatment faster, developing safer opioids, and helping patients choose appropriate treatment. A number of recent breakthroughs are being presented at the upcoming conference of the American College of Neuropsychopharmacology.
An interim treatment can get people medication sooner: As the opioid crisis continues to escalate, the number of people who need treatment for their dependency on heroin or prescription pain killers far exceeds the capacity of available treatment programs. People seeking treatment can wait months or even years for spots in clinics or with certified doctors — and while they wait, they risk becoming infected with HIV or hepatitis, as well as dying from an overdose. But researchers have found an intervention for reducing these risks among opioid-dependent people who are stuck on waitlists. The interim therapy could help protect patients from the potentially fatal dangers of illegal opioid use by safely and responsibly providing medication while they await more intensive treatment.
[Presenter: Dr. Stacey Sigmon at the University of Vermont’s College of Medicine]
Safer opioid drugs could save lives: Opioid drugs are the most widely prescribed and effective type of pain medication, but they are highly addictive and have some unpleasant and potentially deadly side effects. Researchers may have found a way to make opioids safer by separating the drugs’ pain relieving effects from their most dangerous side effect, respiratory suppression, which, in very severe cases, causes patients to stop breathing and to die. Such opioids could help patients and doctors deal with drug tolerance, a frequent complication in which, over time, patients lose sensitivity to the pain-blocking properties of opioids and require higher doses to treat their pain. And as opioid overdose deaths are mostly due to respiratory suppression, safer prescription opioids could ultimately decrease the number of deaths caused by abusing prescription opioids.
[Presenter: Dr. Laura Bohn at The Scripps Research Institute.]
Trials can help people choose between treatments: Two medications, buprenorphine and naltrexone — representing pharmacologically and conceptually opposite approaches — are available for office-based treatment. Yet until now, patients, families, and providers have had no data to help guide their choice of treatment. New findings from two trials (one in the US, one in Norway) comparing these approaches will help people choose between the two very different treatments.
[Presenters: Dr. John Rotrosen at New York University School of Medicine and Dr. Lars Tanum at the University of Oslo and Akershus University Hospital in Norway]
American College of Neuropsychopharmacology. “Research finds new ways to fight the opioid crisis: An interim treatment can get people medication sooner.” ScienceDaily. ScienceDaily, 6 December 2017. <www.sciencedaily.com/releases/2017/12/171206090647.htm>.
OxyContin wasn’t a new drug. It was simply a new pill designed to release an old drug — oxycodone — more slowly. Oxycodone was first synthesized in 1916, and is closely related to heroin.
In 2017, U.S. life expectancy fell for the second consecutive year. Among all of the disturbing headlines that we’ve seen in the past 12 months, this is arguably the worst, and it should make all of us stop and pay attention.In countries like the United States, any decline in life expectancy is unheard of. It speaks to very large forces at work, like World War II, or HIV.In this case, opioid overdoses are to blame. They have quadrupled since 1999, and are continuing to rise. Right now that epidemic is killing more people in the U.S. than AIDS at its peak. About five people are dying per hour — all day, every day.
The story of the opioid epidemic has been told before by the media. But it hasn’t been examined nearly enough. It’s a story that should prompt far larger questions about our country, its values, and its institutions than we have asked.
Opioids affect us in complex and mysterious ways . They don’t stop sensation, like local anesthetics. Instead, these drugs work by activating natural opioid receptors in our brains. They change our experience of pain. They replace pain, in part, with pleasure.
Pain thresholds are built into us for powerful evolutionary reasons. Opioids make us feel good in the short term, but they also distort essential mechanisms necessary for survival in a Darwinian world.
Tolerance is the body’s natural attempt to restore those mechanisms. We become less sensitive to opioids, and need higher doses for the same effect. Tolerance is the first step toward physical addiction; the two are linked. As tolerance rises, the risk of overdose and death follows closely behind.
The time it takes for this process to occur is the key to understanding the opioid epidemic. A week or two of opioids may cause euphoria and pleasure, but it will rarely create physical addiction. Given a few months, however, anyone can be made into an opioid addict.
Purdue Pharma used this distinction as a pretext for claims that OxyContin was safer and less addictive than other opioids and therefore should be widely prescribed for pain of all kinds. The FDA enabled this assertion, and the FDA examiner who approved OxyContin’s initial application took a job with Purdue shortly thereafter.
Once the FDA approved the drug, Purdue unleashed a fraudulent marketing campaign designed to generate as many new OxyContin consumers as possible.
A critical element of their strategy was to expand the traditional indications for opioid prescriptions beyond acute pain into the far more controversial category of chronic pain. Chronic pain is so broadly defined that tens of millions of patients became potential customers.
This was hugely consequential. When drugs are approved by the FDA, health insurance pays for them. The big money was not in acute pain, which goes away, or cancer pain, where patients die quickly, but in chronic pain, which is endless.
Other opioid manufacturers soon joined the effort, marketing their own products for chronic pain. A combination of physician complicity, patient demand and fundamentally flawed retail-based models of medical care then created a dismal synergy that flooded society with oral narcotics.
As steadily increasing numbers of people were encouraged to take prescribed opioids, and became physically addicted to them, more people also turned to heroin and other illicit drugs. Purdue Pharma and others generated enormous sales. Drug cartels and dealers were handed an abundance of new customers. Heroin and even more dangerous illegal narcotics such as fentanyl became more plentiful and cheaper across the country.
A new wave of opioid addiction eventually spread far beyond the control of Purdue Pharma or anyone else. That increased demand had the additional effect of destabilizing Mexico and supporting Islamic extremists with opium revenue from Afghanistan and elsewhere.
Opioid addiction is not a new problem. Ten years before OxyContin appeared on the market, as part of the so-called war on drugs, Congress passed the Anti-Drug Abuse Act, which imposed harsh federal mandatory minimum sentences for drug crimes.
More than 300,000 people are currently serving time in either state or federal prisons for often minor drug offenses. Most of these prisoners are poor, and a disproportionate number are minorities. Hardly any of them are drug kingpins.
Purdue’s efforts, however, were unprecedented. In 2007, three senior executives of Purdue Pharma pleaded guilty to misdemeanor charges for criminally misbranding OxyContin by falsely and deliberately claiming it was less addictive and safer than other opioids.
They were sentenced to a few hours of community service, and fined. Purdue Pharma was also fined some $634 million for these misrepresentations.
Purdue’s fine, large for the pharmaceutical industry, represents less than 2% of the roughly $36 billion of revenue so far generated from sales of OxyContin.
Purdue Pharma is not a publicly traded company. It is owned by a single family, the Sacklers, who control the board and hire the executives. In 2015, the Sacklers abruptly appeared on Forbes Magazine’s richest families list, at number 16, with a net worth conservatively estimated at $14 billion. Much of their wealth came from OxyContin sales.
Most of the discussion around the opioid epidemic stops there. The epidemic has been treated primarily as a tragic yet isolated phenomenon, a cautionary tale of a few bad actors mixed in with regulatory mistakes and the confluence of good intentions gone awry.
This view misses a much more fundamental point.
By any measure, the story of OxyContin is indecent.
What does the opioid epidemic, and the response to it, reveal about our country? Is it in fact an isolated event, or might it be related, at least in spirit, to some of the other abuses we’ve seen in recent years?
Like the subprime mortgage crisis that so nearly caused a global financial collapse, the opioid epidemic was created by corporate predators whose actions were permitted rather than resisted by regulatory agencies.
Like the mortgage crisis, the perpetrators were ultimately rewarded rather than punished. Like the mortgage crisis, tax payers were left with the bill. And like the mortgage crisis, no serious institutional or structural changes were made to correct future abuses. For example, the FDA’s ongoing relationship with both the pharmaceutical and medical supply industries has escaped public scrutiny for far too long.
The victims too, were the same — overwhelmingly middle- and lower-income people trying to get by. Many are both defined and humiliated by their addiction, but most are just ordinary men and women with jobs and bills to pay. I know them well, because they are my patients, and they come to the ER all the time. Not a single day goes by when I do not see a patient on opioids for chronic pain.
There is an important difference, however. The opioid epidemic is far worse than the subprime mortgage crisis. Hundreds of thousands of people have been killed and millions more have lost loved ones and friends. Meanwhile, studies have not shown that chronic pain has improved.
Ordinary people in America, irrespective of race or gender, understand the depth of their vulnerability to economic systems and individuals that care nothing for them. They are both threatened and angry as a result. Their anger is justified, but it’s also dangerous. It’s often incoherent, often misdirected, often ugly and discrediting, often tribal, often selfish, and ripe for political manipulation.
Eventually, enough attention was called to the opioid epidemic generally and OxyContin in particular that sales of OxyContin have dropped by nearly half in the United States. The CDC issued belated guidelines to rein in opioid prescriptions, and prescribers have become more aware of the dangers that many understood were present all along.
As OxyContin revenue drops in the U.S., and the lawyers circle, one might think Purdue would have learned a hard lesson. Instead, they learned an easy one.
Purdue owns a group of international subsidiaries known as Mundipharma. Mundipharma is now marketing opioids in more than 120 countries around the world — in places like Brazil and India — using the many of the same tactics that Purdue applied so successfully here at home.
Millions of people in countries with few regulatory safeguards are at risk. The consequences are predictable.
It’s difficult to argue that conduct like this should be permitted, let alone rewarded, by any society. But we are both permitting it and rewarding it. That permission, and the lack of accountability it demonstrates, is terrifying. It shows us how far we’re willing to fall, and how weak our institutions have become.
If Purdue Pharma’s punishment were proportionate to the crimes it committed, the company would no longer exist and at least some of its executives would be in prison. Instead, they’ve been given a tacit green light for global expansion despite bipartisan congressional protest.
For much of the post-war period, America genuinely believed in its exceptionalism. Despite our many past sins, the U.S. was nonetheless once a legitimately aspirational country.
Fairness, human rights, democratic values, institutional integrity and other cultural expectations of decency may seem naive today, but they had both political and economic value that went far beyond their intrinsic worth. They were a vital engine of both U.S. prosperity and global stability for more than 50 years. It’s hard to imagine the American Dream without them.
Not long ago, I saw a patient my own age with chronic back pain. He was thin, and white, and he screamed at the nurses up front, and he screamed at his elderly mother who had driven him to the ER, and he told me he couldn’t walk as he lay on the gurney. I knew he could walk, and I glanced at his chart.
“Did you run out of your OxyContin?” I asked, and he nodded.
“I get my refill tomorrow,” he said.
“He’s in pain,” his mother said, accusingly.
I was tired. It was the end of a long shift. I usually say no. I usually have the energy to resist. But he exhausted me. I knew he would reduce himself further, and refuse to walk, and keep screaming, and disturb everyone around him.
Behavior like his is one of the many humiliations of opioid addiction.
I wanted to go home, and I couldn’t hand him off to the relief. It’s an unspoken rule. So I took the easier and complicit path, like so many other doctors, in so many hospitals and offices and clinics, across the country.
In Georgia there was about 30 overdose deaths in the first week of June. The Georgia Department of Public Health confirmed in the second week of June a fifth overdose death related to fake Percocet pills that have been circulating the streets. Test results were released last week by the Georgia Bureau of investigation indicating that the drug was a mixture of two synthetic opioids.
According to the analysis made by The New York Times, cases related to drug deaths have heightened with a significant margin across the nation. The report showed a 19% rise from 2015 of at least 50,000 Americans who died from drug use. This percentage supersedes the peak annual death rates from car crash deaths (1972), gun deaths (1993) and HIV which peaked in 1995. The leading cause of death for Americans who are under the age of 50 is related to drug fatalities.
New York Times examined the data of state health department from around the country to compile relevant information that would elaborate the situation. It is usually difficult to track drug deaths and the official statistics from CDC (Centers for Disease Control and Prevention) may not be available till December. It is estimated that the toxicology reports affirming the cause of death might take up to 6 months.
The officials of the National Center for Health Statistics at the CDC find it troublesome to track the reports and the facts that most people are looking for answers.
“It’s frustrating because we really do want to track this stuff,” Said Robert Anderson, Chief of the Mortality Statistics Branch at the CDC.
The reports became even more shocking since it was said that the drug deaths related to opioid abuse were widely unreported. Fentanyl also fueled in large part to the rising death rates. It is one of the strong opioids that has made appearances in street cocaine and heroin, although not frequent. The drug seizures for Fentanyl doubled during 2016 to more than 30,000, an increase from 2015 that reported over 15,000.
According to the New York Times, a tremendous rise in drug-related deaths was widely reported in the East Coast. Some parts which were affected by steep increases included Maine, Florida, Maryland, and Pennsylvania. The death rate rose to more than 25% last year in Ohio, which had filed a lawsuit recently against opioid manufacturers.
Summit County, Ohio had previously ran out of space in the morgue for the bodies of overdose victims. Gary Guenther, who is the county medical examiner’s chief investigator in Summit County, was forced to make a request for refrigerated trailers on three occasions in the previous year.
The statistics indicated that the death rates related to drug abuse had leveled or perhaps declined in some western states. Dr. Dan Ciccarone, a professor at the University of California, San Francisco gave one of the reasons that led to the situation. Ciccarone mentioned to the Times that Fentanyl is more likely to be found in powdered heroin, common on the East Coast than it is to be found in black tar heroin, more popular in the Western States.
He also gave a warning that the death rates would increase rapidly if traffickers begin to ship in fentanyl and other kinds of synthetic opioids into the West.
Huntington is one of the cities that has felt the negative outcome of the nation’s crisis on drug abuse. It is a state situated in the western West Virginia with a community of nearly 50,000. Between 2009 and 2013, it realized an increase in mortality rates from drug overdoses that rose by 65%.
It is one of the states that has been heavily affected with 70 deaths out of 900 people who overdosed in 2015. Jim Johnson, a director of the Mayor’s Office of Drug Control Policy in Huntington, explains how the trends of drug abuse have shifted over the past years in the city of Huntington.
He talks of how several families have been affected by drug addiction ever since he started serving in the police department. “I came onto the police department in 1972, and the people … on heroin were that part of society that you were walking down the street, and you would want to go to the other side” He said. “Now there has hardly been a family that has not been affected” He added.
Since 2002, the rate of overdose deaths related to heroin have quadrupled nationwide. According to the reports, it was estimated that 30,000 people die from opioid overdoses in a year reflecting the scope of the epidemic. Minority populations have experienced a less dramatic increase in overdose deaths and drug addiction compared to the young white adults.
According to the Centers for Disease Control and Prevention, the rate of heroin increased by 114% among the white adults between 2004 and 2013. During the same period, the rate among nonwhite adults remained relatively unchanged.
The professor of health policy and management at Boston University’s School of Public Health, Dr. David Rosenbloom, said that for decades, blacks have been undertreated for pain. The rapid rise in addiction has a long history back to the use of prescription pain relievers such as Vicodin and Oxycontin. The opioid analgesic prescription medications have been on the increase since Oxycontin was introduced in the mid-19990s. About 259 million prescriptions written for opioid drugs were also reported in 2012.
Regulators began implementing more strict limits only a few years ago on the number of pain pills to be prescribed by the doctors. Although it led to lower rates of prescribing opioids, it also led to a sequential increase in the use of heroin. It was regarded as an easier and cheaper alternative to prescription pain medicines.
According to the 2008 JAMA study, it was found that in an emergency department, whites were more likely to receive opioid for pain compared to the minorities. It was also stated that physician prejudice was the resultant cause of prescribing opioids less frequently for the Latino and Black patients as compared to the whites.
Dr. Andrew Kolodny, an executive of Physicians for Responsible Opioid prescribing highlighted the issues faced by the minorities in the hospitals when prescribing the pain relievers.
“It would appear that the prescriber may be more concerned about the possibility of the patient getting addicted or maybe the possibility that the pills will be diverted and sold on the street if the patient is black. If the patient is white, they may feel like there’s nothing to worry about,” he said.
Other people contend that the issue deals more with the white patients, as they have had greater access to health care services in the past compared to the minority patients. In essence, it has heightened their chances of receiving pain treatment unlike the other patients.
John Kelly, an associate in psychiatry at Massachusetts General Hospital in Boston said that more risks related to drug overdose lead to the differences in prescribing the pain treatment.
“It could be that the overall ability to be able to be prescribed these medications has resulted in more exposure among the whites and more risks in terms of addiction and overdose,” said Kelly.
The urgent call to action among the lawmakers, presidential candidates and law enforcement officials is said to be the primary cause behind the changing face of drug abuse. It could also be a similar case to the increased call for treatment unlike the previous ‘war on drugs’ that focused more on the mass arrests and incarceration.
Kolodny said that it was a criminal justice response on how they had responded to the crack cocaine epidemic. “Whenever you hear people talking about our opioid crisis, within the first few minutes you hear someone saying something to the effect that we can’t arrest our way out of this problem,” he added.
The democratic presidential candidates, Hillary Clinton and Vermont Sen. Bernie Sanders have both initiated plans which would emphasize “rehabilitation and treatment” for nonviolent and low-level drug offenses over prison.
Texas Sen. Ted Cruz, the Republican presidential candidate has called for faith-based treatment. He also lost his half-sister who died from a drug overdose. Similarly, he has also advocated for disruption of the drug supply by securing the U.S. border.
Solutions based on treatment have already begun taking shape to address addiction. The District of Columbia and other forty-two states have passed legal protections for medical professionals dispensing naloxone. It is a prescription drug that counteracts the effects of an opioid overdose. Needle exchange programs are some of the controversial measures for drug users that have gained support in the United States and municipalities nationwide.
The needle exchange programs in Huntington have helped combat another health problem regarding the intravenous use of drugs. In 2013, it was recorded that West Virginia had the highest rate of hepatitis B infections. According to the CDC, there were 10.5 cases for every 10,000 residents. Kentucky, a neighboring state, had the second highest rate of hepatitis B infections during the year. It recorded 4.9 cases per 10,000 residents.
The rates of hepatitis C infection have been on the increase nationwide with more Americans switching to intravenous drugs. According to the CDC, the rates of infection between 2006 and 2012 in four states collectively rose by 368%. These states include West Virginia, Virginia, Kentucky, and Tennessee. Of those cases, 73% risk factor was cited on the intravenous use of drugs.
Johnson said that he used not to be a great supporter of the programs that were to reduce harm for substance users. After witnessing the devastating effects of the drug epidemic that the entire community was going through, he changed his mind towards adopting more of a public health approach.
“In our county, we were spending at a minimum of $50 million to $100 million a year just on the healthcare,” said Johnson. “When we started talking about syringe exchange it was like, ‘why aren’t we doing this?’” he added.
On a national level, there have been changes on the approaches taken towards drug abuse. President Barack Obama proposed allocation of $1.1 billion over two years as part of his fiscal 2017 budget. It was to help fight against opioid and heroin drug abuse. In addition, $920 million of the total amount would be used to expand the medication-assisted treatment.
It is still not evident whether the current approach will be applicable to any future drug epidemics that affect the entire racial groups. It has also not yet been proved on how addiction is perceived in the country.
Marc Mauer, an executive director for the Sentencing Project, said that he thought the approach would provide a change to some extent. “I would like to think it would help to shift the climate somewhat, but I am not overly optimistic. We still have ways to go I think to broaden that perspective on how we approach substance use,” added Mauer.
Members of the public have been requested by the American College of Physicians to assist in reducing the stigma revolving around addiction. They have also urged individuals to actively participate in the fight against substance use disorder. According to a paper that was released last week, the largest professional group of doctors gave a proposal that addiction should be perceived as a treatable chronic medical condition.
This approach was solidified by the American College of Physicians (ACP) by position paper that was published in the ‘Annals of Internal Medicine’. Deaths resulting from drug overdose is said to have heightened with the pain relievers that are prescribed to patients. The president of ACP, Dr. Nitin S. Damle said, “Drug overdose deaths, particularly from opioids such as prescription pain relievers and heroin, is a rising epidemic”.
He further mentioned that diabetes and hypertension are some of the chronic medical conditions that could be treated in a similar way to substance use disorders. Other measures were to be taken if the proposal was to turn out to be effective. “That should be addressed through expansion of evidence-based public and individual health initiatives to prevent, treat, and promote recovery”. Said Damle.
Substance use disorders is stressed in the position paper as being common, and also addresses the widespread social consequences that are likely to occur due to these medical conditions. More complications are brought about by treatment of substance use disorders since individuals’ access to treatment is limited or inconsistent.
This point was illustrated by the American College of Physicians comparing the rates of treatment for substance use disorder with other chronic illnesses. It was estimated that 18% of people who required medical attention for substance use disorder in 2014 received any treatment. This estimate is lower than the rates of treatment for individuals with major depression (71%), diabetes (73%) and hypertension (77%).
Members were called upon by the ACP to fight against the addiction stigma. The American College of Physicians encouraged the best practices for treatment and recovery. They also urged people to be updated on the innovations in treatment. The president of ACP mentioned that patients should be given education on their conditions and proper prescriptions that would help solve their problem. “Physicians can help guide their patients towards recovery by becoming educated about substance use disorders and proper prescribing practices, consulting prescription drug monitoring systems to reduce opioid misuse, and assisting patients in their treatment”. Said Damle
Opioid epidemic could be addressed specifically through the measures put in place by the ACP. They called for more widespread use of prescription monitoring systems and increased access to the overdose antidote naloxone. The monitoring systems would be useful in preventing the patients from taking too much of the painkillers. “ACP strongly urges prescribers to check Prescription Drug Monitoring Programs in their own and neighboring states as permitted prior to writing prescriptions for medications containing controlled substances”. Said the ACP president.
According to the position paper, members of the public could help minimize the stigma around addiction so that doctors can participate actively in the fight against addiction. The paper further mentions that for centuries, substance use disorders have been termed as a moral failing. A harmful and persistent stigma has been established by a mindset that affects how the medical fraternity perceive addiction.
“We know more about the nature of addiction and how it affects the brain function, which has led to broader acceptance of the concept that substance use disorder is a disease, like diabetes that can be treated”, states the position paper.
Most of the communities across the country have confronted an opioid epidemic that has led to more overdose deaths. The physicians have been on the forefront by playing a significant role of controlling the situation. They have also spurred the lawmakers to reassess the drug control policy of the nation as it would be essential in creating awareness to the public.
Derrick D. Billingslea is an alcoholism and addictions treatment professional with over two decades in recovery himself and he is the Founder and CEO of HUGS Recovery Centers, located in Atlanta, Georgia.