“Addictions thrive in populations that don’t.”
– David B. Nash, MD, MBA, FACP
Dean of Jefferson College of Population Health
More from this series
As with any crisis that involves complexities like those presented by the current opioid epidemic, there is no single, concise answer as to how to fix it. Many things must happen before our country overcomes this problem and recognizes what it will take to prevent it from happening yet again. Unfortunately, we are in an era where taking pills to deal with symptoms of an illness, injury or disease has become the default method for “treating” it. Oftentimes, physical conditions that cause pain can be mitigated (or even cured) with other treatment modalities including counseling, physical therapy and lifestyle changes, just to name a few. Unfortunately, the modern, fast-paced demands of work and family typically result in patients opting for easier, quicker and less expensive prescription drugs to address everything from minor aches and discomforts to severe or chronic pain.
How did we get here?
The terrible combination of physicians wanting to help patients (while being forced to turn them over quickly), and patients who expect immediate relief (and believe that their doctors are giving the best treatment) has resulted in the widespread misuse and abuse of opioids that occurs thousands of times in this country every single day. These drugs are an important tool in the medical community’s arsenal, and are very effective at keeping pain at bay, but are highly addictive and (given the right set of circumstances) are subject to abuse.
Many people unwittingly fall into the abyss of addiction because they are given a prescription for OxyContin (or another opioid) to deal with post-surgical pain or a sports or work-related injury. While these prescriptions are certainly appropriate in many circumstances, some of these situations might also have been successfully treated with a less potent over-the-counter product. Because people typically don’t challenge a physician’s recommendation, they dutifully take the prescription, and (after finishing a course of these powerful medications), sometimes find that they can no longer function without them. Once this withdrawal period kicks in, doctors (who don’t make the connection) prescribe more drugs (often benzodiazepines) to treat the symptoms. The lethality of this combination has been discussed at length in this series and MUST be addressed if this crisis is ever to be solved. Additionally, major changes must be incorporated into the practice of medicine, the way insurance companies operate and the methods that drug companies use to develop and distribute their drugs. Sweeping reform in all of these areas is vital, but ultimate success is hinged on transforming the psyche and the actions of the patient.
The United States has endured several periods of widespread iatrogenic addiction. It can be argued that earlier bouts were the result of inferior medical training (Civil War era), less governmental oversight (patent medicine era) and even the genuine desire to cure patients (Methadone), but it can also be argued that what we learned from these episodes should have served as a blueprint for how to avoid the current (and most devastating) crisis to date. Opioid abuse disorders cost our country billions of dollars annually and result in thousands and thousands of avoidable deaths.
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What can be done?
Below is a partial list of areas that should be addressed in order to combat the crisis. There are many more that are not listed here, but perhaps these can begin to spark some awareness and discussion about the issue.
No more stigma
For starters, the stigma associated with having an addiction must be dismantled. The DSM-V, which is the American Psychiatric Association’s reference book, identifies ten classes of drugs associated with what they now categorize as substance use disorders. These range from caffeine and tobacco to opioids and hallucinogens.
Understanding that these disorders are not moral failings is also critical to dealing with them. While it’s true that a recreational user likely made the initial choice to take the addictive substance illegally, these drugs can quickly highjack the “wanting” system of the brain and result in a stunning downward spiral that renders the user all but defenseless against the pull of the drug. Most people do not realize the potential of this consequence and are unprepared to deal with the impending enslavement that can occur. The population of recreational users, as well as those who have been legitimately prescribed, are both extremely vulnerable to the pitfalls of taking drugs that have highly addictive properties. We must reframe the way we talk about these disorders and the people who are battling them.
Make the systems that are already in place more effective
We live in a world that operates and relies on technology to run smoothly, yet systems that are in place to prevent drug abuse are not yet functioning to their fullest potential. The Prescription Drug Monitoring Programs (PDMPs) are electronic databases that track prescriptions of controlled substances. Theoretically, a provider should be able to enter a patient’s name and instantly find out if he/she has received similar prescriptions from other doctors, but unfortunately, this isn’t always the case. Historically, the system has been patchy, cumbersome and notoriously inaccurate, so physicians often bypass it in order to spend more time with patients. Despite its shortcomings, the states are making progress towards streamlining the tracking process. Hopefully, this system will become more precise and serve as a reliable system for providers in the very near future.
Increase education for providers
In a perfect world, physicians would have as much time as they need to assess a patient’s case. This would culminate in an accurate diagnosis, a thorough explanation of all the treatment options and careful follow-up. If pain is part of the patient’s complaint, non-addictive analgesics should be considered along with other types of therapies and social services. All avenues need to be investigated because pain is often a physical manifestation of other problems. If opioids are absolutely necessary, they should be prescribed in low doses for short periods. Thoughtful consideration should be given to the patient’s drug history and current prescriptions as well. But we don’t live in a perfect world. People want quick fixes and physicians are hamstrung by insurance companies and overhead costs. Prescription drugs treat the pain effectively and doctors need to process patients, so powerful opioids are often the first and only treatment. Some doctors may deny more opioid prescriptions after the initial one runs out, but others are happy to continue filling them, upping the dosages and even adding more drugs into the mix if deemed necessary. It should come as no surprise that many of these cases end in substance use disorders. An article published in the Journal of American Medicine in 2014 found that seventy-five percent of heroin users in treatment started with prescription painkillers.
Many substance abusers will continue down the path until they are destitute, estranged from their friends and families, incarcerated or dead. Those who do seek help may consult a family doctor first, and though this is an excellent (and crucial) first step, most family doctors are patently unqualified to treat addiction. Unfortunately, they don’t always acknowledge this deficit and endeavor to treat it anyway. This is an extremely important moment in a patient’s recovery because terrible (if unintended) mistakes can be made which may impact his/her life forever.
Would you let your dentist give you a heart transplant? Of course not. Would you consult your dermatologist about a detached retina? Not likely. Even though the first stop in treating a substance use disorder might be a family doctor, he or she is probably not well-versed in this area and thus a referral is prudent. Most people don’t know that this is a specialized area that requires very specific medical treatment from people who have been trained to administer it properly. Patients often stop taking licit prescriptions (or illicit drugs) only when they are put on medication assisted therapy like Methadone or Suboxone. These drugs are attractive to patients because they help manage discomfort and cravings, but they are also opioids! They cause physical dependency and are highly addictive. They come with their own set of problems and many people never get off of them. Shockingly, many doctors who prescribe these powerful drugs have only had a few hours of on-line training before doing so.
Physicians also need to be knowledgeable about the community resources that are available so they can make appropriate referrals to patients who need help.
Revamp/rethink treatment strategies
Many professionals who regularly deal with addiction believe that harm reduction is the best answer for people with chronic problems. They argue that drug abuse can’t be stopped so it should be made safer. They promote syringe exchanges and wider distribution of Naloxone, a lifesaving drug that reverses the effects of an overdose. Many experts also favor drug-checking, (a system that tests drugs for dangerous contaminants prior to ingestion), and supervised consumption spaces.
One of the more controversial ideas is currently being implemented in Vancouver, British Columbia. The Providence Crosstown Clinic dispenses legal grade heroin to approximately one hundred and fifty patients a day who come to inject themselves under medical supervision. This program prevents death from overdose and allows its patients to access drugs legally without having to steal or commit crimes. Legal regulation of heroin and other illegal drugs offers users a safer version of what they can obtain on the streets. This may sound extreme, but it actually doesn’t differ much from medication-assisted therapy. Opioids are opioids, despite how they are dispensed. In fact, several countries have already instituted “shooting galleries” where people can use safe drugs and also be put in touch with medical professionals and social services.
Most experts would agree that access to good treatment programs is critical for anyone who is suffering with a substance abuse disorder. This includes everyone from the stay-at-home mom who is dependent on OxyContin for chronic back pain to the inmate who got hooked on Suboxone in prison prior to his release.
Develop more effective medicines and modes of treatment
Researchers are developing new medicines that will address different aspects of the problem, including biologics such as vaccines and monoclonal antibodies. These may eventually be used to treat people who suffer from substance use disorders.
Neurocarrus was founded by two doctors who were inspired by the actions of Botox. Their developmental drug, “N-001,” is aimed at treating severe and chronic pain without the side effects of opioids. They are developing a targeted delivery system that uses bacterial proteins to disrupt pain signals without disrupting muscle control. Needless to say, a potent painkiller that can treat pain effectively without the euphoria and withdrawals that accompany opioid use could be a game changer.
Medications made with abuse-deterrent formulas are also an important piece of the puzzle, but until a foolproof method is developed, industrious abusers will continue to discover new diversion methods.
It is important to remember that there will never be a “magic bullet” that solves this issue. Each person who suffers from addiction comes to it with his/her own history and constellation of complex contributing factors. As such, every person will likely require a multi-disciplinary approach upon entering treatment. Along with the appropriate medical interventions, people who suffer from substance use disorders will need the full spectrum of social services as well as spiritual and psychological counseling.
The effectiveness of mutual aid societies cannot be underestimated when it comes to treating addiction. Twelve-step and other similar support programs typically do as well or better than other modes of treatment and are critical to the success of many patients. They also give addicts the opportunity to advocate on behalf of their cause and serve as mentors for others. These programs are a vital component to the process and can make important contributions to the patient’s recovery – particularly if a warm hand-off is conducted. This occurs when a healthcare professional affects a personal introduction between a patient and a member of the twelve-step community. Research shows that a warm hand-off increases the chances of success.
Phone apps like Addicaid and Companion by A-Chess are providing new e-tools for people who are dealing with addiction. These do everything from helping patients to find meetings and track progress to allowing clinicians and counselors to correspond directly with patients.
Efficient and effective governmental intervention and oversight
In 2017 the Department of Health and Human Services declared the opioid crisis a public health emergency and announced a five-point strategy to combat it. This came on the heels of new opioid painkiller prescribing guidelines that the Centers for Disease Control released in 2016. Designed to slow down the epidemic, the guidelines urge doctors to avoid opioids if possible, to prescribe the lowest possible dosages and to monitor patients closely. Several high-ranking governmental officials are also sponsoring legislation to deal with this epidemic.
The current opioid epidemic is the result of many contributing factors. Some of these are innocent and some nefarious, but they have all conspired to create the mess in which we presently find ourselves. The United States has weathered several drug epidemics during the course of its relatively short history, and yet we have failed to learn (let alone apply) valuable lessons and insights that might have prevented future episodes.
Is society’s collective hubris, stupidity and denial to blame? Is it the result of unbridled greed, shoddy science or less-than-truthful sales tactics? Is it the fault of the drug companies? The doctors? The patients? Why have we repeatedly failed (or refused) to recognize the signs of an impending crisis? All parties are undoubtedly culpable to some degree, but at the end of the day, each person must take responsibility for him/herself.
Some experts in the field argue that drugs are a normal part of the human experience and that we must abandon any notion of a “drug-free” society. They purport that such a goal is not only unrealistic – it’s impossible – and advocate for the development of strategies that promote responsible use.
Socio-economic status is an important indicator of the potential for developing a substance abuse disorder. Abuse rates are higher in poorer communities because childhood trauma, mental illness and unemployment rates also tend to be higher. Blue-collar workers experience more job-related injuries and are therefore more vulnerable to developing dependencies on painkillers, but it doesn’t have to be this way. People need to be made aware that opioids are not the only answer. The medical community needs to offer reasonable and effective alternatives to addressing pain and we, as a society, need to start a new chapter on pain management. Patients need to understand that living with a certain amount of pain is likely preferable to fighting an opioid use disorder. They must be encouraged to take advantage of social services, twelve-step programs and physical therapy rather than to rely on narcotics. The social roots of this crisis need to be addressed thoughtfully if we are ever to overcome this epidemic – let alone avoid another one.
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Solving this problem won’t be easy. It’s going to require sweeping changes in the way we think about and treat pain. The medical community needs to own up to its role in the epidemic and stop prescribing opioids frivolously. The drug companies and pharmacies must exercise oversight and restraint when it comes to the distribution of these drugs. The government must enact legislation that protects its citizens and, the role law enforcement is vital. Local police agencies must be considered a valuable partner in addressing this issue. We live in a culture that vilifies people who suffer from substance use disorders, yet keeps them hooked and offers little in the way of alternative treatments. Children reach their teenage years and indulge in secretive, all-out binges, sometimes combining drugs and dying tragic, avoidable deaths.
If you are a parent, it is imperative that you teach your children about the risks of taking (and mixing) narcotics. Ask your healthcare providers questions and challenge them if necessary. There are appropriate uses for opioids including post-surgical pain, orthopedic cases and cancer pain, but they be should used sparingly (some cancer and end-of-life pain may require different protocols). That being said, consider the following: Just because your son had his wisdom teeth removed does not mean that he will need a powerful narcotic to deal with post-surgical pain. Some discomfort is acceptable when recovering from a surgery. Ask yourself if an over-the-counter option will do the job. You are the most important steward of your health and the health of your minor children. Educate yourself and your children about the inherent dangers of opioid abuse. Some of these conversations might be uncomfortable, but they are necessary. They may be the difference between life and death.
If you or someone you know has a substance use disorder, please get professional help.