The tidal wave of compassion and support for Demi Lovato in the wake of her apparent drug overdose last month is indicative of society’s long overdue, shifting views on addiction. Social media platforms have been inundated since the singer’s hospitalization with comments acknowledging her strength and admiring her courage. Instead of finger-pointing, demeaning or judging her, Lovato’s fans and fellow entertainers are showering her with love, and her friends and family are standing firmly by her side. We are, in essence, offering her a giant group hug.
All of this is encouraging. However, we have a lot of work to do as a society when it comes to applying this inclusive, compassionate approach to non-celebrity, everyday Americans and families dealing with addiction.
Why? Because isolation kills. As Johann Hari writes in his seminal book, Chasing the Scream, “The opposite of addiction isn’t sobriety, it’s connection.” Yet we continue to look the other way and deny the obvious truth: Our children, our friends and our family members are being rejected, judged and shamed for the same struggles that celebrities receive endless support for ― and they are dying alone, desperate and afraid.
And no one is immune. In my small corner of Los Angeles over the past four years, a total of nine kids and young adults I’ve known and loved have died of accidental overdoses. Each one, likely driven by shame and self-loathing, was alone at the time of their deaths ― isolated from their families, sober living communities and those who loved them.
In my small corner of Los Angeles over the past four years, a total of nine kids and young adults I’ve known and loved have died of accidental overdoses.
I can’t know exactly how Lovato’s friends and family felt when they got word of her hospitalization, but I can relate to their experience. A few years ago, my then 20-year-old son began waging his own addiction battle. An up-and-coming electronic music producer, he suffered a nonfatal overdose on the night of his very first on-stage performance. I was both surprised and not surprised as I wept on my knees with gratitude that my son survived; the music industry is, and always has been, inextricably tied to substance use.
We praise our favorite artists, admire them and nod to the allure of the altered states that “fuel” their creativity. In other words, for musicians, it’s cool to get high. And if our favorite artists become consumed by addiction, we generally stand by them as fans. Yet when our own fathers, sons, sisters, brothers, mothers, daughters, friends, co-workers and teachers struggle with substance abuse, society abandons them and quickly looks the other way.
Thankfully, the tide is turning. Individuals in the music industry are coming out and sharing their stories, like Lovato, Macklemore, J Cole, Eric Clapton, James Taylor and far too many more to list here. Macklemore has said in the past, “I’m not ashamed anymore, and never want to hide who I am because of society’s potential judgment.” These are courageous moves in the right direction, and this kind of leadership is vital; music and musicians carry healing powers to uplift, inspire and unite. Can we harness that power as a society and actually make a difference?
I was both surprised and not surprised as I wept on my knees with gratitude that my son survived; the music industry is, and always has been, inextricably tied to substance use.
In the aftermath of crisis or tragedy, our nation often collectively looks to Fred Rogers (aka Mister Rogers) for his gentle wisdom: “When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’”
It’s time to look for, and support, the helpers ― those individuals and grassroots organizations out in the trenches raising their voices, educating and saving lives. We must become those helpers ourselves and work to change this country’s view of addiction from one of isolation to one of inclusion. If society can create the stigma, then society can begin to erase it.
Whether you believe addiction is a disease, a choice, something rooted in pain or past trauma, or all of the above, those who suffer should be acknowledged ― with dignity. Using the recent outpouring of love and support for Demi Lovato as an example, let’s rise above the noise and offer those dealing with substance abuse the healing power of love, acknowledgment and a promise never to look away.
Barbara Straus Lodge is a co-founder of Above the Noise Foundation, which creates sober music festivals and provides grassroots funding to U.S. cities affected by the addiction epidemic. Rhode Island Recovery Fest 2018, headlined by Macklemore, aims to unite communities, heal families and shift America’s addiction response from one of rejection to one of inclusion. Her writing has appeared in a variety of publications and anthologies, one of which was a finalist for the 2018 Lambda Literary Awards.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
LAWRENCE, Mass. ― Rachael Pomerleau, 40, had taken opioids before, having had procedures like wisdom teeth removal and gallbladder surgery.
But during the tumultuous two years that her children, now ages 7 and 8, were born, opioids took over her life, she told HuffPost. She was put on bed rest as a result of complications with the pregnancy of her daughter. A few months after her daughter’s birth, she became pregnant with her son. This time, her back and abdominal pain grew so severe that doctors prescribed Vicodin followed by Percocet during her pregnancy ― which wasn’t an unusual prescription for pregnant women at the time, prior to the onset of the opioid epidemic.
“It hurt so bad,” she said. “There were times when I could hardly walk without being in pain.”
When Pomerleau returned from maternity leave for the second time, she said, she lost her job at a local health care services company. And she kept taking opioids ― oxycodone this time ― this time prescribed to her by her primary care doctor.
Women like Pomerleau, who was prescribed opioids in a medical setting and became addicted to them, are a growing demographic in the United States’ opioid epidemic. Although men continue to have higher rates of substance use than women do, the gap between the sexes is narrowing, with prescription opioid overdose deaths rising 583 percent among women between 1999 and 2016, compared to 404 percent among men, according to the National Institute on Drug Abuse.
But even as prescription opioid death rates grow among American women, doctors, researchers and policymakers don’t yet understand how to properly screen for or address female opioid users’ unique needs. In an essay published in the most recent issue of the medical journal, The Lancet, two Yale medical researchers warn that America won’t be able to address its raging opioid epidemic if it continues to overlook women’s unique pathways to opioid misuse ― and the factors that hinder their access to treatment.
“The system is evolving — but we’re at a point now where there’s a need to have it do so more rapidly, just based on the sheer volume of women who are being impacted,” said Dr. David Fiellin, who directs Yale’s addiction medicine program and co-authored The Lancet article.
Women Have Unique Exposure To Opioids
There are several factors, both biological and cultural, that differentiate women who use opioids. Population-based studies suggest that women are more sensitive to painful stimuli than men are, putting them at a higher risk for chronic illness that includes pain and making them better candidates for painkillers.
There’s also some evidence that women become addicted to substances more quickly than men do, although the biological mechanism for this phenomenon isn’t understood, said Fiellin.
Women are more likely to have medical interventions than men are, including reproductive and childbirth-related procedures. As a consequence, women are more likely than men to be prescribed opioids in medical settings.
Pregnancy and postpartum pain in particular lead to significant initial exposure to opioids. For example, 1 in 300 women who didn’t previously use opioids and had a cesarean section will become a persistent opioid user, according to the American Congress of Obstetricians and Gynecologists. And two separate studies each published this year in the journal Obstetrics and Gynecology found that women were over-prescribed opioids after both vaginal and cesarean births.
Depression and anxiety disorders are also more common among women, as are sexual trauma and partner violence, all of which are risk factors for abusing opioids. Women are also more likely than men to report that they use opioids to cope with negative emotions and pain.
For Pomerleau, physical pain was compounded by an abusive relationship and childhood trauma, she said, that left her with post-traumatic stress disorder, major depression and anxiety. But her steady access to opioids during and after pregnancy was the ignition that has led to a multi-year struggle with addiction that has included homelessness, loss of custody of her children and struggles to get the resources she needs.
Importance Of Screening At-Risk Women For Opioid Addiction
During the five years after her kids were born, oxycodone and constant pain were the backdrops of Pomerleau’s life. Her tolerance for the pain pills grew and she says she sometimes gave them away to family and friends. Then one day, she came home and realized that sharing her prescription had backfired ― her supply had run out and her doctor wouldn’t prescribe her more pills.
“I got so sick,” she said of the withdrawal that followed. “It was horrible. I had no way of doing anything.” She went to a methadone clinic for help. “There was no other way,” she explained. “My tolerance was like someone who was out doing dope for years.”
It took five years for Pomerleau’s doctors to notice she had a problem.
Her story is sadly representative of what Carolyn Mazure, the director of Women’s Health Research at Yale and the lead Lancet author, has found in her research. She likened the current gender blind spots in opioid use disorders among medical professionals to the way heart disease was approached in the past.
“People thought [cardiovascular disease] was the greatest killer of men, which it is, but they were not aware of the fact that it also was the greatest killer of women,” Mazure said.
As recently as 2005, fewer than 1 in 5 physicians knew that more women die of cardiovascular disease each year than men do, according to a study published in the journal Circulation, a knowledge gap that likely contributed to women arriving later to the ER and experiencing delays in treatment when they had the same cardiovascular symptoms that men did.
That same knowledge gap has created a murky territory for doctors and their female pain patients.
On the one hand, the potential for addiction among women who were prescribed opioids has often been overlooked by medical professionals. On the other, many women report that their doctors aren’t taking their pain seriously nor sufficiently treating it.
“So many people think it’s a cop out,” Pomerleau said of her own ongoing pain. “I have no problem doing whatever the doctor says or suggests. He’s the one that’s supposed to be making the best decisions for me. At the same time, I can’t have this much pain.”
A failure to focus on women can result not only in inappropriate treatment but serious medical misjudgments, according to Mazure and Fiellin, who pointed to a study that found that women in Rhode Island were three times less likely than men to receive the opioid overdose reversal drug naloxone in emergency medical settings, a discrepancy which could indicate unrecognized gender bias among emergency medical service providers.
Women-Centered Services Require More Than Treating Addiction
Lawrence, Massachusetts, has uncommonly comprehensive health and homeless services compared to many areas of the country. There’s a mobile health service where Pomerleau, now on a daily methadone dose, has sought care, and a homeless shelter where she lived this spring, before moving in with a friend.
Historically speaking and nationally, however, methadone programs haven’t been particularly friendly to women, Fiellin explained, since they lacked supportive services like screening and counseling for intimate partner violence, job training, childcare and resources for pregnant women, all of which can help retain female clients.
There is a cultural expectation that women are the primary caregivers of children, and a social stigma against mothers with addiction that can cause women to delay treatment, fearing they’ll lose custody of their kids, particularly if they’re pregnant.
To help meet women’s needs, treatment centers might have to spend more time figuring out how women are going to be able to come for treatment if they have kids at home, and talking to them about intimate partner violence if that’s something that worries them, Mazure explained.
That’s the reason women tend to do better at tailored programs that offer women-centered services, like childcare and domestic counseling, she said.
Despite the lifesaving care of her clinic, Pomerleau faces an uphill battle trying to accrue these services for herself. Her days are consumed with efforts to keep her social security benefits intact, court appearances to determine the guardianship of her children and daily treatment.
Until then, her kids are living with her sister in nearby Methuen.
There have been some efforts to focus on women, such as by the National Institute on Drug Abuse, which has invested in studying pregnant and parenting women with opioid addiction. But as Mazure and Fiellin note in their article, bridging the gap to treat and prevent opioid addiction in women will require significant commitment from researchers, clinicians and policymakers.
In the meantime, women like Pomerleau are caught in the balance.
“I always had an apartment. A nice place to live,” she said, describing how losing housing changed everything for her.
“All I really want is just to have [my kids] back,” she said.
It’s no secret that the United States is in the middle of a full-blown opioid pandemic that’s responsible for killing more than 100 people a day. There’s widespread media, political, legal, social and psychological attention dedicated to this issue, yet people are still suffering.
The painful memories of my own opioid addiction get reignited every time I hear of another fatal overdose. It’s not uncommon for me to find myself sobbing in my car on my way home from work as I become consumed with the pain of complete strangers who continue to be victimized by this crisis: a mother who must bury her child, a child who must force his or her parent into treatment, a client who has relapsed and died or a friend who asks for advice on how to help a loved one.
For years, my father struggled with his own addiction that shattered our family in more ways than one. My community has been ravished by this public health crisis, and it seems like every week, the death toll continues to rise. The breadth of this crisis is all encompassing, aggressive and merciless on its victims. The antiquated beliefs that addicts simply choose this life and that we’re beyond compassion and the opportunity for healing is simply ignorant and insulting.
I have lost more than 40 people in my life to opioid-related overdoses, and not one of those individuals deserved to die. They were sick, suffering and desperate for a human embrace, not a cruel rejection. Sadly, they didn’t survive the grips of their addiction long enough to experience the true freedom of recovery and show the critics what they were made of. Society continues to get robbed of the opportunity of knowing and loving some of the most caring, intelligent, creative, hard working and inspiring human beings to ever gift this planet. For that, I am forever wounded.
I, too, was one of those people whose value as a human being was overshadowed by my sickness. Countless times, I tried to get well and stay well with no success. As a result, my hope of a full recovery diminished with each day that passed. Eventually, I discovered a non-opioid medication called Vivitrol and began treatment after I completed the detoxification process. Vivitrol is a non-addictive, once monthly injection used to treat opioid addiction, which provided me the opportunity to remain opioid-free for approximately 30 days at a time – something I couldn’t have accomplished on my own. As result of receiving treatment and committing to the process of my recovery, my cravings and compulsive thoughts to use opioids began to disappear. I was able to put in the necessary work to sustain long-term success in my recovery and began to recognize the person I once knew – the person who had become a distant memory.
Soon after, I enrolled in a master’s program to become a clinical mental health counselor and started to regain my confidence that my brain, body and soul could be repaired. I began proving to myself that I no longer had to survive a sad, depressed or mundane existence. I learned that I could thrive in this world and achieve my dreams. As a result, I began to feel joy again, and that excited me.
I continued to gain traction in my recovery and decided to pursue another degree, this time in clinical psychology. I am now a third year clinical psychology PsyD student and dedicate my life to helping people who are stuck in the same cycle of torture I experienced. I want others to know how tangible recovery can be for them. The truth is that I’m not special; there’s nothing unique about me that allowed me to turn my life right side up and find my purpose. I want to share my experiences with anyone who will listen with the hope that it could save a life, heal a family or alleviate the anguish of someone’s internal imprisonment. For those who don’t see a way out of the abyss, I share my hope with you until you build your own.
This summer, I celebrate six years of recovery from opioid addiction, and I want to rejoice. I want to wear my sobriety proudly on my sleeve and fully embrace the sweeping movement across the nation to speak up, speak out and recover out loud. Yet, I’m often faced with the overwhelming barriers that we still need to overcome.
It’s essential that we combat the social, personal and institutional stigma that keeps us ill and begin shifting the conversation about addiction treatment to be more accepting and open-minded. I call on all my of my recovery brothers and sisters to end the stigma in our own community so the rest of society can follow suit. It doesn’t matter how we get to the finish line, as long as we do. We need not impose our definitions on one another of what recovery should look like and the way in which one must achieve it. We’re all working towards the same goal – who cares how we get there?
To the incredibly resilient and strong parents, spouses and loved ones doing their best to support people like me, please know that you could never hate us or our disorder more than we do when we’re in active addiction. We are consumed with the shame, guilt and disappointment we feel for hurting you and ourselves, which often emerges after failed attempts at recovery.
A treatment option that is effective for one person will never be the answer for everyone. It’s scientifically impossible. Please have some patience and love us through this process until we figure it out. Most importantly, help us keep fighting.
I encourage everyone to advocate for the proper treatment option that suits you or your loved one best, whatever that may look like. There is no right way to achieve recovery; rather, myriad helpful avenues to explore that can range from medication to mindfulness, and everything in between. Check out some of my favorite recovery resources here:
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 firstname.lastname@example.org. 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.