BrightView’s founder and CMO Dr. Ryan discussing the importance of Narcan due to the significant amount of overdoses in the Midwest.
An addiction expert explains the root causes of the opioid epidemic.
“Superficial” is how Anna Lembke describes the common understanding of the opioid painkiller and heroin epidemic.
Lembke, a Stanford psychiatrist focused on addiction care, agrees that the commonly cited causes of the epidemic — doctors hoping to treat previously untreated pain conditions, pain patients demanding better treatments, and big pharma pushing opioids on the market — contributed to the vast overprescription of opioids. That let the pills flow not just to patients’ hands but to their family, their friends, and the black market.
But she argues that the crisis, which amounts to the worst drug epidemic in US history in terms of overdose deaths, goes far deeper.
She doesn’t deny that some people do suffer from horrible, crippling chronic pain. But she points out that the empirical evidence shows that opioids actually aren’t effective for chronic pain, and instead pose many risks in the long term, from addiction to overdose to a higher risk of injury to even increased levels of pain. So doctors, Lembke argues, need to find other solutions, like physical therapy, that may benefit patients.
And if that doesn’t work, then maybe a patient just needs to be taught how to cope with the pain, much like patients with other chronic illnesses are helped with figuring out how to live with their conditions.
“What I think is really important to remind people is that if opioids worked long-term, I would have no problem with patients taking them,” she said. “The fundamental issue is that they stop working and then you have an additional problem.”
Lembke has written and spoken a lot about these kinds of issues, most recently in her 2016 book Drug Dealer, MD. So I reached out to her to talk about the opioid epidemic and what we get wrong about addiction in America. What follows is our conversation, edited for length and clarity.
What are the roots of the opioid epidemic, as you see them?
What you’ll read about in the media is a good superficial summary of this problem. Basically, the epidemic began with doctors prescribing opioids more liberally for patients with pain — in part because we have an increasing number of people with pain in this country, and we were trying to address an unmet medical need. That was combined with aggressive marketing on the part of big pharma and small subgroups of pill mill doctors taking the opportunity to make money despite harming their patients. Those three factors are what you’ll read about.
But I think that’s a very superficial take at the end of the day on what was really going on. If you look more closely, it’s just not pill mill doctors who are overprescribing — we did a piece in JAMA that shows all doctors are overprescribing pain pills.
And as far as big pharma goes, big pharma has always existed in some shape or form, pushing their pills. So why opioids and why now?
And as far as an increasing number of patients in pain, we don’t really have more patients in pain than a lot of other high-income countries who are not consuming opioids at the same rate we are. We come down to 4 percent or 5 percent of the world population but consume 80 to 90 percent of the world’s opioids. So there’s something different about the United States, which I think warrants further examination.
So what do you think are the deeper roots here?
At the end of the day, opioids were the solution not for patients’ problems but for doctors’ problems.
There has been a huge transformation in the past 30 years in health care delivery, beginning with a migration out of private practice into large integrated health care centers. That’s something that I call the Toyotazation of medicine — tremendous pressure on doctors within these large integrated health care centers to practice medicine in a certain way and get patients out in a timely fashion to be able to bill insurers at the highest possible level and to make sure that their patients were satisfied customers.
This was a huge contributing factor to the opioid epidemic — by giving doctors a way to just give a pill to patients to get them out the door, while also feeling like they were doing something to help patients, at least in the short term. Opioids became the proxy for a doctor-patient relationship.
The other underrecognized piece of this is what I call the medicalization of poverty. Opioids have become a proxy for a social safety net. So we have doctors routinely confronted with patients who not only have multiple medical problems — from diabetes to hypertension to asthma to cardiac disease — but also very significant psychological, social, and economic problems. Many of them are undereducated. Many of them are underemployed. Many of them are homeless. Many of them are struggling with multigenerational trauma.
Because we lack a social safety net to take care of these people, we are now medicalizing their problems, and telling doctors that they have to take care of their problems. Doctors are feeling incredibly overwhelmed in this space with this growing population of individuals with very complex biological and psychosocial problems. In the face of that, they’re prescribing opioids — because opioids work quickly, patients are grateful, and it seems to be something they can do in the face of overwhelming problems.
The other piece of it are new illness narratives that have now become commonplace. Everything from “pain is dangerous” to “people are fragile” to “the body can’t heal itself” and “doctors have superhuman abilities to heal” and “illness is an identity” and “victimhood gives you a right to be compensated.” These are illness narratives that I think create a culture in our society, which we’re not even aware of, that’s contributed to the opioid epidemic.
One thing you suggested is that these opioids will provide relief for someone even if they don’t have pain. That’s why people will use them recreationally.
So if I’m understanding you correctly, the argument is that doctors, faced with these patients with all sorts of problems, are like, “Well, I don’t know how to deal with a lot of this, so maybe I will prescribe an opioid because that’ll give them at least some sense of relief.” And maybe the patient will even say that he has pain and the doctor will interpret it to be something that an opioid can treat. Am I getting that right?
A doctor isn’t going to prescribe an opioid unless they can diagnose a condition to justify it, because they’re worried about their practice and their life, and they want to practice what’s considered the standard of care.
But what’s become the standard of care for prompting an opioid prescription is very little in the way of evidence for having any kind of bona fide medical condition. All you really have to do is show up [and] say you are in pain, even in the absence of any objective points of disease or pathology. And that alone is enough to warrant and justify a doctor’s prescription for an opioid — with little oversight or checking on whether that individual has that disease or may in fact be abusing or addicted to opioids.
The CDC [Centers for Disease Control and Prevention] has told doctors to be more careful with prescriptions, essentially creating a few more checks in the system before a doctor prescribes opioids. What else would you like to see done?
On a large scale, the solution is going to depend on closing the gap between mechanized, industrialized, computerized health care delivery and the growing psychological, economic, and spiritual needs of our patients. There’s a huge gap there that’s not being met. So we have to reform our health care system in order to meet the growing needs of our patients that really, on some level, are largely disconnected [from] whether they have a disease in the traditional sense.
Our increasingly industrialized health care system is very poorly suited to meeting those kinds of needs. So it’s really great when it comes to cataract surgery, knee replacement, or even if you have an ear infection or pneumonia and you need some antibiotics or something. We’re really horrible at managing long-term, chronic, and remitting illnesses, which is what the highest consumers of health care have. That’s everything from depression to chronic pain to addiction. We need to reform health care to help those people.
On the smaller scale, there are three things doctors can do. They can initiate opioids less often, and that’s what the CDC guidelines were all about. They said that doctors should not be giving patients more than about three days of opioids for an acute medical condition. They shouldn’t be using [them] for a chronic condition because they don’t work [for chronic pain]. And they have to decrease the number of new initiates.
That doesn’t solve the problem of the very large number of people who are already on prescription opioids and are now dependent. Some of them are probably never going to get off. So the second piece is that we have to train doctors to better monitor and more safely prescribe opioids for patients who need opioids. Some of the ways to do that are to check the prescription drug monitoring database, get urine drug screens, [and] talk to family members.
And when doctors identify that patients who are on opioids are being harmed more than they’re being helped, then doctors have to work with those patients to get them off opioids.
One of the secrets of medicine — secret even to doctors — is that you can’t just stop opioids or quickly go down and the [patient] will be fine. You can’t do that. They’ll go through terrible, excruciating withdrawal. And in my practice I now have what I call a deprescribing practice — most of my efforts are spent on helping patients get off medication that they’ve become dependent on or addicted to after it was prescribed by doctors for a legitimate medical condition. And typically my patients take years, so I can go down by a little bit every couple of months. That’s all they can tolerate.
I get tons of referrals because doctors generally have no idea how to do this work, and many of them don’t have the time or resources that are required.
You mentioned one thing in this broader conversation that just does not seem to be getting through to a lot of people: that the evidence does not show that opioids are effective for treating chronic pain. Given that, what do you tell patients who want to treat their chronic pain and think opioids are an option?
I say it’s absolutely true that if you were to get opioids for your pain, it would be like a magical cure for about a month or maybe two.
But after a while, there’s a very high likelihood that they would stop working. And then you would have two problems: You would have your pain, and you would be dependent on this drug and experience painful withdrawal if you try to get off [opioids].
Then I have to say to patients, “What are we left with if opioids are not a good option for you?” We’re left with trying to help you as much as possible with alternatives to treat your pain. It’s not going to be one thing; it’s going to be a multimodal combination of non-opioid medication — physical therapy, massage, acupuncture.
If you tried all of that and none of it worked, what we’re left with is learning to live with pain. How can we create a lifestyle that you’re comfortable with while knowing that you’re not going to be able to get rid of the pain? That becomes a spiritual, existential question for a lot of people — a very profound one that takes a lot of thoughts and efforts to have questions about. It’s not something you can do in five minutes.
So say somebody has been on opioids for two months. So now if they try to get off opioids, they’re going to have pain. It’s almost a mind game at that point, where they think the pain they’re feeling when they stop taking opioids is their chronic pain that they were treating coming back — when it’s really withdrawal and the pain that comes with that. It’s like the opioids trick them into thinking they’re treating this chronic pain when they’re actually creating another layer of problems that they didn’t have before.
That’s exactly right. And what you just did there is what I spend a lot of my time trying to tell patients about.
I have to tell them very specifically that as we go down on the opioid, they will experience worse pain, because full-body pain is part of opioid withdrawal — even in people who don’t have a pain condition. Since they have a pain condition, as they are withdrawing from opioids, the pain will be even worse for them. They will have pain in the place where they normally had pain, and they may even have pain in other parts of their body.
But then I have to say that the pain they feel is not the pain that they will end up having to live with. It is opioid withdrawal–mediated pain that over time, as their brain adjusts to the new lower dose, they’ll be back at their original pain level.
And then I say to them — and here’s the really hopeful possibility — since we know that chronic opioid use can in some cases make pain worse, there’s a possibility that when they’re all done with withdrawal and they haven’t had any opioids for, say, a month or two or six, their pain might actually be better than it has been in years. It may be better than it was for any of the time they were on opioids.
One common counterargument by pain patients I hear to all of this: When you tell people with live with pain, you would never say to a heart disease patient that they need to just tough it out and live with their problem. How would you respond to that?
Well, I don’t think that’s true. If you have a congestive heart failure, and because of that you have shortness of breath, that’s a chronic illness that a doctor can’t cure. So you need to modify your behavior. You can’t run down the street anymore, because you can’t get enough air. You may have to sleep with an oxygen tank at night, so you can sleep through the night.
Almost every single medical condition has a chronic form that’s incurable, and it just becomes an issue of palliation.
What I think is really important to remind people is that if opioids worked long-term, I would have no problem with patients taking them. The fundamental issue is that they stop working and then you have an additional problem.
That gets at why I’ve personally always been skeptical of that counterargument. If you have a disease and don’t have a cure for it, you wouldn’t just throw dangerous drugs at it in hopes that it would maybe help. You would find a way to work around it.
So a seriously ill cancer patient, you would try to find ways to make them comfortable and mitigate the symptoms. But you wouldn’t just throw potentially dangerous drugs at them.
So, for example, this is a clinical scenario that happens to me all the time: I have a patient that I’m prescribing an opioid. Then they come in and tell me that they ran out three days early. And I tell them, “You can’t do that. You have to take it as prescribed.” And they tell me, “Well, I was doing yard work, and I had to cut down all these trees, I was chopping wood, and my pain was horrible. So I had to take more.”
And then I have to find a way to say to the patient, that’s not okay. You can’t use the pill to compensate for what your body can’t do anymore.
If you take additional opioids, you can’t hear the signals from your body about what you shouldn’t be doing, and then maybe you’re going to do some long-term damage above what’s already been done.
But even more importantly, you can’t use the pills to extend your limits. You have to accept that there’s some things you just won’t be able to do anymore.
People are very resistant to that idea. I think that speaks to some of the core hope for at least Americans that they should really be able to keep doing what they were doing in their 20s, and that somehow a doctor should be able to fix them and make that happen, instead of accepting that maybe that’s something they just can’t do anymore.
I wanted to zoom out a bit to talk about patients who already are addicted. Based on your practice and talking to other doctors, what do you think are the big things that we get wrong in treating and dealing with addiction in America?
The biggest thing we get wrong is not embracing the idea of addiction as an illness. What I say to people is even if you don’t really believe that addiction is an illness, you as a doctor have to pretend like it is an illness. Because meanwhile, you’re treating all these other invisible conditions, from ADHD to chronic pain to depression. If you lump addiction in there too, you’re going to be contributing to the prescription drug problem.
So we have to totally embrace this idea that addiction is an illness. We have to put it on the problem list when we identify it. And instead of rejecting these patients or getting angry at them or kicking them out of our practice, we have to give them treatment for addiction.
There is treatment out there. It works just as well as the treatments for other chronic illnesses, from asthma to diabetes Type 2 to various forms of heart disease. The data shows this fundamentally: that there’s about a 50 percent response rate for treatment for addiction, which is on par with response rates for other chronic medical conditions. There are similar rates for remission and relapse for treatment.
Once we do that, I think not only patients will be better off but doctors will be happier, because they will actually have the toolbox to address these problems when they arise.
What’s happening now is that doctors are not educated in how to intervene when substance abuse problems come up. So they feel incompetent. When these issues come up, they’d rather not know, because they don’t know what to do about them when they find them. But if doctors were really educated in this arena, then at least we’d refer [patients] to someone else who can treat it.
The other main thing we get wrong is the enormous stigma against opioid agonist therapy [such as methadone and buprenorphine] for opioid addiction. People are just fundamentally repelled by using opioids to treat opioid addiction. I can certainly relate to the paradox and being uncomfortable with it. But the data at this point is just overwhelming that somebody with severe opioid addiction, if you get them on opioid agonist therapy, their lives are vastly better.
Some people are still skeptical of the idea of treating addiction as a disease. How do you persuade someone that it is a disease, not a moral failure or anything else they might think it is?
Well, again, I start by saying, “I don’t care if you believe or not. Pretend like you do, because otherwise you’re a part of the problem.”
But all you have to do is, in your family or in your clinical work, if you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual’s control on some level.
I’ve seen this concept clinically that people who are addicted are in denial. No, they’re not. A lot of them know they’re addicted, and they still can’t stop. And they want help.
I think what can really help — and this has been shown to help — is personal stories of addiction. When doctors really see that, it makes a huge difference in opening their eyes to the reality of addiction in its severe form really being a disease.
Link to article here: The real causes of the worst drug crisis in US history
The study reinforced earlier, smaller studies, including one in September 2015 that used data from the National Survey on Drug Use and Health to demonstrate how the U.S. gender gap in drinking had narrowed from 2002 to 2012.
The authors of these studies don’t explain why this is happening. But clinicians and other professionals have opinions.
“It’s presumably [caused by] all the factors associated with women having a different culture than they did 100 years ago,” George Koob, the director of the National Institute on Alcohol Abuse and Alcoholism, said in an interview. “Instead of being at home, they’re in society, and drinking is part of business and social gatherings. Another issue that’s relevant, there has been a decline in underage drinking in men that is not happening with women.”
He added that “women report depression and anxiety twice as much as men, and . . . depression and anxiety are often comorbid with addictions.” Furthermore, among women who drink, “alcohol use tends to escalate more quickly than with men” — what doctors call a “telescoping effect.”
The main problem with women drinking like men is that they don’t have the same physiology as men. Women are more susceptible to alcohol’s effects, largely because they have lower body mass, and in particular less water to disperse the alcohol through their bodies. “Therefore, a woman’s brain and other organs are exposed to more alcohol and to more of the toxic byproducts that result when the body breaks down and eliminates alcohol,” notes the NIAAA, part of the National Institutes of Health.
In the short term, alcohol is quicker to affect women’s ability to function. Long term, women who drink are more likely than men who drink to develop breast cancer, alcoholic hepatitis and certain heart problems.
Food addiction, in contrast, can lead to weight gain and its well-documented health effects, including higher risks of diabetes and heart disease. Food addiction is still an emerging field of research, but the relatively few studies so far that sort data by gender show that women appear to be more vulnerable here, too. Of the 652 adults who participated in a 2013 Canadian study, more than twice as many women as men met the Yale Food Addiction Scale criteria for food addiction. And a 2016 U.S. study designed to test an update of the Yale Scale found that “gender was significantly associated with addictive-like eating symptoms with women, on average, reporting a higher number of symptoms” than men.
Ashley Gearhardt, the lead developer of the Yale Food Addiction Scale, noted that women might be more vulnerable to addictive eating patterns because of “so many pressures” in their lives — “pressures in the workplace, pressures regarding child care.”
And there are other social pressures. “Women, more than men, are held to unattainable beauty ideals against the backdrop of a toxic food environment,” she said. “This can increase the likelihood that women will bounce back and forth between the extremes of intense dietary restriction and binge eating.”
No matter where stresses come from, experts agree that they can push a merely unhealthy food or drinking habit into an addiction. But how does one tell when a fondness for a snack or nightly cocktail starts becoming an issue?
“It stops being about how much you like it,” Gearhardt said. “People say, ‘I don’t even like it anymore. I want it or crave it.’ You start to feel you can’t control it. Some people say that they’re ‘addicted to chocolate.’ You can like chocolate or look forward to it or have it as a special treat. That’s not an indication of a concern, normally — but it is when you experience such intense cravings that you feel you can’t manage, when it impacts your life.”
Recently, scientists have been fine-tuning the diagnostic tools for what constitutes a substance-use problem, making it easier for people to recognize when their ritual becomes risk.
Notably, when the American Psychiatric Association updated the Diagnostic and Statistical Manual of Mental Disorders in 2013, it changed the way it categorized drug and alcohol issues: Instead of dividing them into two categories — abuse and dependence — the new DSM-5 established a spectrum of “substance use disorders,” based on 11 questions about symptoms. The questions emphasize psychological issues, such as a new question about cravings: “In the past year, have you wanted a drink so badly you couldn’t think of anything else?” (The list can be found online, including at the NIAAA’s website, niaaa.nih.gov.)
According to the manual, the presence of at least two of the 11 symptoms indicates a substance or alcohol disorder, and six or more symptoms mean it’s severe.
Echoing that update, Gearhardt and her colleagues revised their Yale Food Addiction Scale in February 2016. The original 2009 scale, considered the yardstick for measuring food dependence, included 25 questions about a person’s relationship to food, but the Yale Scale 2.0 has 35 more-specific questions, which pay attention to psychological symptoms, and food’s effects on personal life. (The questionnaire is downloadable at fastlab.psych.lsa.umich.edu/yale-food-addiction-scale/ .)
As in the DSM-5, cravings were added to the Yale Scale — “I had such strong urges to eat certain foods that I couldn’t think of anything else.” Gearhardt, who directs the Food and Addiction Science and Treatment Lab at the University of Michigan, said these cravings go well beyond most people’s everyday hunger — like having to get up and leave a business meeting to satisfy a desire for a specific treat.
“Other things we’ve seen clinically, someone may go from grocery store to grocery store to buy food to binge,” Gearhardt said. “They don’t go to just one place to buy it, because of the shame and embarrassment. Or they may have a social engagement but they lose control and cancel so they can stay home and binge. People lose control and really feel not well as a result.”
A few bouts of excessive drinking or eating may not indicate a severe problem: A Centers for Disease Control and Prevention fact sheet notes that “approximately 12 percent of adult women report binge drinking three times a month” but goes on to say that “most (90 percent) people who binge drink are not alcoholics or alcohol dependent.”
But both Koob and Gearhardt stressed that when a substance negatively affects someone’s life, or they answer positively to criteria on the DSM or Yale Scale, they should seek further help.
“One of the really good things about the DSM-5,” Koob said, “is that it emphasizes that you don’t have to be what we used to call an ‘alcoholic’ to have a problem. Now you can try to seek out a counselor, seek out a family physician, seek out a religious person in your community so that problems with alcohol can be stopped before they progress. It may make it a little clearer that a problem with alcohol is a spectrum of intensity, and is not always the guy you see out on the street. And the guy on the street is often the exception. Alcohol use disorders pervade our society.”
Gearhardt said, regarding food addiction, “We’ve treated people clinically who tried to manage for 20 years on their own, trying any diet they could get their hands on, but they didn’t see a therapist or psychologist, and they ran out of options.”
In Maynard’s case, her longtime enjoyment of wine kicked into high gear after her late husband, Jim, was diagnosed with pancreatic cancer in November 2014. During the worst of his illness, she says, she drank every night, sometimes half a bottle. After several failed attempts to quit in 2015, she decided she had to quit cold turkey in January 2016. A month later, she wrote a widely read online essay about her case.
Since then, she said, women have reached out to her about their addictions.
“So many women experience this,” she said. “We live with an enormous amount of stress. Reaching for a bottle of wine is one of the easiest, quickest ways to take the edge off.”
Today, Maynard is back to drinking, but in moderation; she says she always intended to drink again when she believed she could manage it. However, she has new rules: She will not drink every night, and never alone. She rarely has more than one drink. She attends Al-Anon meetings, organized for families of problem drinkers, as her late father was an alcoholic.
“I love to cook. I love wine with good food,” Maynard said. “There are times I wish that I could have more and know I cannot.”
She added: “I would say I had an addiction” — then, correcting herself — “I have an addiction that I’m always aware of. There may be people who will hear this or read this and say: ‘She’s kidding herself. She’s an alcoholic. She needs to not drink.’
“If I get to the point where I can’t maintain it, it will tell me the problem is too severe.”
The scourge of opioid addiction in the United States was one of the most talked-about issues during the campaign cycle — often panned as a devastating failure of the U.S. medical system.
But painting opioid addiction as a uniquely American phenomenon ignores the mounting evidence that opioid abuse is a growing threat beyond our borders. If we allow pharmaceutical companies to influence medical care in other countries, the epidemic we have here could quickly spread around the globe.
A recent review of research published in the journal “World Psychiatry” highlights that prescription drug abuse is already a worrisome trend in a number of middle-income or developed countries — particularly among young people. While each study included in the review uses slightly different methodologies for each country, they all underscore that populations outside the United States are at major risk of surging painkiller abuse.
The review looked at survey data from young people in Canada, Australia and Europe, and found non medical prescription drug use among teenagers and people in their 20s that is comparable to the United States. It also found high prescription abuse among high school and college students in the Middle East — specifically, Beirut and Saudi Arabia — and in China, where a survey conducted in southwest China found that one in 10 students have tried prescription drugs non medically at least once in their lives.
This also isn’t just confined to the young. Other research has found similarly high rates of non medical prescription drug usage throughout Europe, particularly in Spain and Great Britain. Meanwhile, opioid overdoses appear to be on the rise globally.
None of this is to say that opioid abuse elsewhere in the world is comparable to that found in the United States — we’re still the reigning champion in that regard, with more than 11 percent of the U.S. population using prescription drugs non medically. But’s it’s the devastating impact that these drugs have had on our country that makes these trends extra troubling. Today, overdoses account for more deaths than car accidents or gun violence.
Doctors in the United States began prescribing opioids — powerful narcotics that include pill-form painkillers such as methadone, oxycodone and hydrocodone — to treat pain at unprecedented rates in the 1990s. The medical community adopted the practice more commonly despite long-standing fears that the drugs would lead to addiction, mostly as a result of promises from pharmaceutical companies that their products were safe treatments for pain. Over the past few decades, drug companies flooded parts of the country with the drugs, especially in places where patients were highly vulnerable to addiction.
We know all too well how that ended: Despite no change in the amount of pain reported in the United States, abuse of prescription painkillers and heroin has exploded. Over the past few decades, experts estimate that Americans consumed the vast majority of the global opioid supply — including about 81 percent of oxycodone and almost 100 percent of hydrocodone. And by 2015, deaths due to opioid overdoses surged to about 62 a day, according to the Centers for Disease Control and Prevention.
But as the prescription opioid market in the United States begins to shrink, pharmaceutical companies are reportedly looking elsewhere to sell their products, according to an in-depth investigation by the Los Angeles Times. What’s more, these companies are offering the same false promise of safely ending pain. Embedded in these marketing campaigns are the same calls made to American doctors to let go of their “opiophobia” — or their fear of prescribing potentially addictive pain pills.
“Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse],” said Silvia Martins, an epidemiologist at Columbia University and author of the World Psychology paper. “It worked here. Why wouldn’t it work elsewhere?”
The opioid epidemic in the United States shows that it is possible to drastically change the cultural norms in medical communities that are reluctant to treat pain with powerful opioids. It’s also an easy way for doctors to make patients feel like they’re solving their problems — especially if they give them a bottle of pain medication that could last months on end. We often forget that for a lot of people, opioids are a solution — however heavy-handed — to chronic pain. For that reason, the lure of strong opioid medication is particularly troubling in places outside the United States where doctors might not have much training on addiction.
“(Physicians in other countries) need to be very aware of where their information is coming from,” said Scott Novak, an epidemiologist at RTI International who studies drug abuse internationally. “For many doctors, the number one source of information on drugs is pharmacy representatives, but you really need to do your homework.”
Hopefully, the tragedy of opioids in America will help stem the tide in other countries. The lesson should be loud and clear: Powerful painkillers should not be our first line of defense in treating pain. And when we do have to resort to the drugs, they should be heavily regulated.
Link to original article: here
Addiction isn’t an illness like any other. Patients need not just the right medicines but therapy, support and, in some cases, tough supervision.
The grim faces of the nation’s opioid epidemic—an overdosing parent slumped in the front seat of a car, mouth agape, with a neglected child in the rear seat—have become too familiar in recent years. More babies are now being born with narcotics in their systems, foster care is strained, and growing numbers of grandparents are raising the children of their own addicted children.
With an estimated 2.6 million people addicted to opioids—including heroin, fentanyl and oxycodone— the toll is daunting. Fatal opioid overdoses have risen from around 8,200 in 1999 to 33,000 in 2015, according to the Centers for Disease Control and Prevention, making them a leading cause of accidental death. Last year, deaths from heroin slightly edged out gun homicides for the first time since the government began keeping such data.
Politicians and health agencies are deeply concerned. They overwhelmingly call for a “public-health approach” to the epidemic, emphasizing treatment with anti-addiction medications. As the U.S. surgeon general recently implored, it’s time for us to view addiction “not as a moral failing but as a chronic illness.”
As a psychiatrist who has treated people addicted to heroin for more than 25 years, I endorse treatment over punishment. But the medicalized rhetoric of the public-health establishment—namely, that addiction is a brain disease in which neural circuits are “hijacked” by drugs—oversimplifies the problem.
Consider an addict’s typical course of treatment under this approach. A young woman—let’s call her Kristy—is found curled up on the floor of a supermarket restroom, passed out with a needle still in her arm. Emergency personnel rush to the scene and quickly administer Narcan, a nasal spray containing a fast-acting opiate antidote called naloxone. A few minutes later, Kristy sits up, coughs and looks around hazily.
When taken to the emergency room after being revived, Kristy may simply bolt before any referral to treatment can be made. The siren call of the next fix is strong.
Let’s hope, instead, that Kristy, frightened by her near-death experience, does want treatment. The emergency-room clinician would refer her to a local physician or an outpatient clinic, where she is likely to be offered a popular anti-addiction medication called buprenorphine, or “bupe.”
As an opioid drug itself, bupe is a pharmacological replacement therapy, like methadone, the classic anti-addiction opioid medication. It prevents withdrawal symptoms and suppresses drug craving, and usually comes as a filmstrip that dissolves under the tongue.
Bupe has some clear advantages over methadone. Its chemical properties make it less risky if taken in excess. And unlike methadone, which must be dispensed in clinics tightly regulated by the DEA, bupe can be prescribed by any qualified physician, who can refill a month’s worth of the drug from his or her office.
Some patients do very well with bupe, but there are problems. Too many patients continue to use illicit opioids while using the drug. Federal guidelines recommend that those taking bupe receive routine urine toxicology screening (for illicit drugs) and behavioral counseling, but overseeing such a program is a lot to ask of busy primary care doctors, who are the usual prescribers.
Another challenge to recovery is dropout. Despite the heartache that addicts cause themselves and others, ambivalence surrounding quitting is great, and premature termination of treatment is common. Attrition rates of 40% to 60% within a few months of admission are typical in treatment programs. Less time in treatment means that addicts have less time to learn recovery strategies, like identifying the specific circumstances in which they are most vulnerable to craving the drug.
Rushed treatment in the office of a primary-care doctor also means less attention to fixing the often broken lives of addicts. Healing family rifts, reintegrating into the workforce, creating healthy social networks, finding new modes of fulfillment—all are imperative, but they take time and focused therapeutic care.
The unstructured setting of a doctor’s office can lead to the abuse of bupe itself. Sometimes patients cut off pieces of their bupe strips and sell them to other addicts, who use the drug to detox themselves or to get through times when heroin isn’t available or is too costly. Bupe is now the third most diverted prescription opioid after those containing oxycodone (e.g., Percocet) and hydrocodone (e.g., Vicodin).
My own work in treating addiction takes place in a traditional methadone clinic. Our nurses watch patients swallow the cherry-flavored liquid daily for at least the first few months. If a patient starts using heroin again, we can provide more frequent counseling, do more regular toxicology screening and suspend any take-home doses of methadone to spur better self-control. This careful monitoring is why there is a very low rate of diversion of methadone from clinics.
A similar system could be developed for the early stages of treatment with bupe. Patients would only be referred to local physicians once they are stabilized, a process taking anywhere from a few weeks to a year. Community doctors, who are now often reluctant to accept addiction cases, would be more amenable to treating patients who are securely into their recovery.
‘Few heavy users can simply take a medication and embark on a path to recovery.’
I speak from long experience when I say that few heavy users can simply take a medication and embark on a path to recovery. It often requires a healthy dose of benign paternalism and, in some cases, involuntary care through civil commitment.
Many families see such legal action as the only way to interrupt the self-destructive cycle in which their loved ones are caught. Users sometimes want it, too. “If I don’t do this, I’m going to lose my freedom eventually anyway,” a 33-year old heroin user told NPR as he prepared to ask a judge in Springfield, Mass., to commit him to care.
Drug courts are a way to leverage supervision from the criminal-justice system. If participants fail drug tests or violate other rules of the program, the judge tries to sway behavior by imposing consequences ranging from community service to more intrusive supervision to “flash incarceration” (jail stays of a few days).
Many drug courts expunge the records of those who complete treatment, and other variants of criminal-justice supervision can shape behavior using such carrots and sticks alone. The addition of bupe or an opioid blocker (naltrexone) can be offered as an adjunct to these programs.
With public attention and resources now closely trained on the opioid epidemic, there is a real opportunity for enlightened systems of care. Never before in the history of addiction management have there been so many different therapeutic elements to apply in combination to promote recovery. But we can’t afford to focus on just one set of these tools under the false idea that addiction is a disease like any other.
By Sally Satel
Jan. 13, 2017 11:07 a.m. ET
—Dr. Satel is a resident scholar at the American Enterprise Institute and a part-time psychiatrist at Partners in Drug Abuse Rehabilitation and Counseling in Washington, D.C.
Link to full article at Wall Street Journal: How to Treat an Opioid Epidemic
After sharing an article I found interesting on Facebook this past weekend, I did something I never do: I engaged with a troll who opted to spew unwarranted, unsubstantiated and unwanted vitriol in the comments. It was dumb of me to stoop to that level, but he started it and really pissed me off.
The article I shared was a recent New York Times story that details the extent of opioid addiction in the U.S. In short, opioid addiction in America is huge. In 2015 33,000 died from opioid addiction, and the number of opioid-related deaths nearly matches the number of deaths from automobile collisions. Additionally, the Times’ story highlights that heroin-related deaths alone surpassed the number of deaths from gun homicide. It’s a crisis our society has to face, which is why I found it paramount to share. Erudition can help eradicate, or at least reduce, ignorance and lead to scientific discoveries that help mitigate symptoms associated with mental health issues.
Addiction is a sensitive subject for me that hits close to both home and office in my case. Family members on my mother’s and father’s sides have suffered from addiction, which caused a persistent fear in my mother that my sister or I would also be taken by the curse that’s in our blood. Instead, it’s seemed to have the opposite effect. I have difficulty attaching; I’ve always had a curious ability to go off things simply because I could. Maybe it’s similar to the way the product of two negative integers is a positive in math. I’ve seen family members go through the torment of addiction and witnessed the fear, frustration and sadness it’s caused my mother throughout my life. Working as a music journalist I’ve seen the effects of addiction while conducting interviews backstage or watching an admired musician stumble in performance. It’s by no means a fun lifestyle, and anyone who suggests it’s a choice is grossly misinformed. It’s for these reasons and more the troll’s comment affected me so deeply.
The comment was simple: “addiction is a social behavior, not a mental health issue.” Statements like this are the problem because they lead to incorrect beliefs, bigotry, and the perpetuation of social stigmas. According to the DSM-5, addiction is best defined as a maladaptive pattern of substance abuse that leads to clinically significant impairment or distress that is manifested through myriad criteria.
Despite medical and psychological support that addiction is in fact a mental illness, many dismiss the symptoms and the behaviors exhibited as a result of it, and shame people who suffer from addiction through the use of pejoratives such as “junkie” or “druggie,” or suggestions of simply “quitting.” You don’t tell a person suffering from a medical ailment like cancer or a broken leg to just stop.
But science is getting closer to unraveling the many complexities that contribute to addiction. A vital new study shows that addictive cravings exist after life. A team of researchers discovered addictive cravings are detectable in the brain after death. Researchers at Medical University Vienna have reported finding traces of a specific protein, FosB, that is altered in the reward center of the brain of people with addictive disorders, after death. The protein is genetically modified under the stimulus of drugs, which causes the protein to become more stable and therefore remain in the brain for a much longer period of time. This means cravings for the stimulus persists as the brain develops a sort of memory of the high felt from the satisfaction of the craving being satiated, effectively making both the brain and the body crave it more.
The high induced in the reward center of the brain isn’t exclusive to drugs and alcohol. As society becomes increasingly intertwined with activity on social media, our brains are becoming conditioned to seek the pleasure-inducing rewards of online validation. A 2016 study from UCLA found the brains of teenagers were exhibited greater neural activity in the regions responsible for reward processing by receiving more likes on Instagram.
In that way, the troll wasn’t entirely wrong on Facebook. Relevance and popularity are socially reinforced behaviors that can be dangerous. Given the ubiquity of social media and the value placed on gaining followers, likes and reposts, our society is being conditioned to crave attention in the form of online endorsements that can be exacerbated by a predisposition to addiction. A combination of addictive tendencies and genetic predispositions should be seen as an augur for our culture. Telling someone to get off their phone might not be any easier than telling someone to stop abusing drugs or other substances. We need to be more cognizant of the biological impact of addiction in a person’s life now that research can prove its traces after death.
Link to article here: http://flip.it/36rSR2
Written by: Erin Coulehan
Date: Jan 12th, 2017
CINCINNATI — It’s official: Ohio leads the nation in opioid-related overdose deaths.
There were almost 2,700 cases in 2015, which is a 28 percent increase from 2014, according to the newly released Centers for Disease Control and Prevention WONDER data that examine the number of reported opioid-related overdose deaths in each state.
While our state has made strides in addressing unsafe prescribing practices, combating drug trafficking, and expanding access to, and the availability of, naloxone, the opioid-overdose reversal medication, we have not been able to escape this unfortunate reality. Why?
As physicians work to implement new prescribing guidelines aimed at limiting patients’ exposure to opioids to help prevent future overdoses, naloxone, a potentially life-saving tool, isn’t getting into the hands of the people who are typically first at the scene of an overdose.
Community access to naloxone is part of the larger solution to the opioid epidemic that involves all Ohioans, and we must act now.
Overdoses are occurring in people’s homes, in our schools and libraries, and even on our roads.
It is of the utmost importance that our authorities ensure that residents across the state have the overdose antidote available to them. We must clearly outline where to get naloxone and how to use it, even for those who aren’t personally affected by the epidemic. Lives are being lost in unimaginable, yet extremely common places each day.
While unsafe prescribing practices have contributed to Ohio’s high rate of overdose deaths, we must ensure that ordinary people have access to easy-to-use naloxone products and understand how to use them.
Empowering our neighbors to have naloxone on-hand could prevent many of the thousands of lives lost year after year. Naloxone is the true first step in not only saving lives today, but also helping those in need of long-term rehabilitation get the care they need to overcome addiction.
Our government and community groups have done a tremendous job in putting this potentially life-saving medication in the hands of police officers and community-based organizations, which have played a crucial and effective role in preventing potentially fatal overdoses.
Additionally, our state has implemented policies that expand naloxone access on a broader level. Thanks to laws called Standing Orders, you can purchase naloxone without a prescription in nearly any pharmacy across state, including CVS, Walgreens, Rite Aid and Kroger. This brings naloxone into the community setting, where most overdoses occur. Even more, Ohio’s Good Samaritan law grants immunity to the victim and to those who call for medical assistance in an overdose emergency.
The policies are set in place to provide access to naloxone, but we need to make sure people understand them. Here’s what you need to know about naloxone in Ohio:
- Anyone can request naloxone from their pharmacist without presenting a hand-written or phoned-in doctor’s prescription.
- Most insurance covers the majority of the cost of naloxone; some pharmacies offer rebates for those without insurance.
- Naloxone is not an illicit drug and cannot itself cause an overdose.
- Naloxone works even if someone is not or appears not to be breathing.
- You should always call 911 in an overdose emergency. Ohio has laws protecting the rights of those who call for help.
There are two versions of naloxone approved by the U.S. Food and Drug Administration:
* A ready-to-use nasal spray called NARCAN(r) Nasal Spray
* An interactive muscular injection named EVZIO(r)
Could you imagine if community-friendly, easy-to-use naloxone were carried in purses and backpacks and stored in medicine cabinets across our region? Overdose deaths would dramatically decrease, lowering the tremendous burden associated with this horrible epidemic, and allowing those suffering from addiction to enter treatment and recovery programs.
When it comes down to it, in hard-hit states like Ohio, opioid overdoses are a community problem and require a community solution. By giving each of us the tools to save a life in an emergency situation, we can get that much closer to ending this epidemic.
No one should succumb to an overdose simply because bystanders weren’t aware of naloxone or how to get it. By ensuring Ohioans have the facts and ability to easily access and effectively administer naloxone, we can begin to release this state from the grip of opioid abuse and turn to recovery.
Dr. Shawn A. Ryan, an assistant professor and emergency medicine physician at the University of Cincinnati Medical Center, is president of the Ohio Chapter of the American Society of Addiction Medicine. He also is president and chief medical officer of BrightView LLC in Cincinnati.
Link to original article here: http://www.cleveland.com/opinion/index.ssf/2017/01/with_ohio_no_1_in_opioid_overd.html?
The ads started popping up about a decade ago on social media. Instead of selling alcohol with sex and romance, these ads had an edgier theme: Harried mothers chugging wine to cope with everyday stress. Women embracing quart-sized bottles of whiskey, and bellying up to bars to knock back vodka shots with men.
In this new strain of advertising, women’s liberation equaled heavy drinking, and alcohol researchers say it both heralded and promoted a profound cultural shift: Women in America are drinking far more, and far more frequently, than their mothers or grandmothers did, and alcohol consumption is killing them in record numbers.
White women are particularly likely to drink dangerously, with more than a quarter drinking multiple times a week and the share of binge drinking up 40 percent since 1997, according to a Washington Post analysis of federal health data. In 2013, more than a million women of all races wound up in emergency rooms as a result of heavy drinking, with women in middle age most likely to suffer severe intoxication.
This behavior has contributed to a startling increase in early mortality. The rate of alcohol-related deaths for white women ages 35 to 54 has more than doubled since 1999, according to The Post analysis, accounting for 8 percent of deaths in this age group in 2015.
“It is a looming health crisis,” said Katherine M. Keyes, an alcohol researcher at Columbia University.
Although federal health officials and independent researchers are increasingly convinced that even moderate drinking poses health risks, American women are still receiving mixed messages. Parts of the federal government continue to advance the idea that moderate drinking may be good for you. The National Institute on Alcohol Abuse and Alcoholism, a division of the National Institutes of Health, is overseeing a new $100 million study, largely funded by the alcohol industry, that seeks to test the possible health benefits of moderate drinking.
Meanwhile, many ads for alcohol — particularly on social media — appear to promote excessive drinking, which is universally recognized as potentially deadly. These ads also appear to violate the industry’s code of ethics, according to a Post analysis of alcohol marketing.
For example, when girl-power heroine Amy Schumer guzzled Bandit boxed wine in the movie “Trainwreck,” Bandit’s producer, Trinchero Family Estates, promoted the scene on social media. Young women responded with photos of themselves chugging Bandit. Within months, Trinchero said, sales of boxed wines — sometimes called “binge in a box” — jumped 22 percent.
“We saw it first with tobacco, marketing it to women as their right to smoke. Then we saw lung cancer deaths surpass deaths from breast cancer,” said Rear Adm. Susan Blumenthal, a former U.S. assistant surgeon general and an expert on women’s health issues. “Now it’s happening with alcohol, and it’s become an equal rights tragedy.”
Alcohol marketing is regulated primarily by industry trade groups, but dozens of studies have found lapses in their record of enforcing the rules. As a result, an international group of public health experts convened by the World Health Organization’s regional office in Washington, D.C., plans to call in January for governments worldwide to consider legislation similar to laws adopted a decade ago to sharply curtail tobacco advertising.
“The industry’s system of self-regulation is broken,” said Thomas F. Babor, a professor at the University of Connecticut School of Medicine who is aiding the effort. “The alternatives are clear: Either you have to take their system and put it into independent hands, or you have to go with a partial or full legal ban on alcohol marketing.”
Officials with the Distilled Spirits Council of the United States (DISCUS), one of the largest U.S. trade groups, defend their record of oversight, saying it has received high marks from federal regulators.
“The Council’s Code of Responsible Practices sets more stringent standards than those mandated by law or regulation, or that might be imposed by government due to First Amendment constraints,” council Senior Vice President Frank Coleman said.
DISCUS tells members that ads should not “in any way suggest that intoxication is socially acceptable conduct.” The Beer Institute tells members that their “marketing materials should not depict situations where beer is being consumed rapidly, excessively.” And the Wine Institute prohibits ads that make “any suggestion that excessive drinking or loss of control is amusing or a proper subject for amusement” or that directly associate use of wine with “social, physical or personal problem solving.”
But these rules appear regularly to be flouted, particularly on alcohol companies’ websites and social-media feeds, which are soaking up a growing share of the more than $2 billion the industry is expected to spend on advertising this year. And the trade groups acknowledge that they do not investigate or act on possible violations unless they receive a formal complaint.
Some of the edgiest ads appear on social media — Facebook, Twitter, Instagram — where they can be narrowly targeted toward the inboxes of the most eager consumers.
“They can be very specific,” Facebook spokeswoman Annie Demarest said. “The ads could go to married women ages 21 to 60 who read about wine and leisure. They can also target the ads based on location, interests, demographics, behaviors and connections.”
Jokes about becoming inebriated are common. One Twitter ad features a woman with a bottle the size of a refrigerator tilted toward her lips. Its contents: Fireball Cinnamon Whisky.
Women also are frequently shown drinking to cope with daily stress. In one image that appeared on a company website, two white women wearing prim, narrow-brimmed hats, button earrings and wash-and-set hair confer side by side. “How much do you spend on a bottle of wine?” one asks. The other answers, “I would guess about half an hour . . . ” At the bottom is the name of the wine: Mommy’s Time Out.
Another ad on a company website features a white woman wearing pearls and an apron. “The most expensive part of having kids is all the wine you have to drink,” it says above the name of the wine: Mad Housewife.
This spring, Mad Housewife offered a Mother’s Day promotion: a six-pack of wine called Mommy’s Little Helper.
The trend extends to wine-related housewares. A flask promoted on the Mad Housewife site features two women from the “Mad Men” era asking, “Who is this ‘Moderation’ we’re supposed to be drinking with?”
An ad on the Etsy marketplace website promotes a stemmed glass big enough to hold an entire bottle of wine with the line: “She will be telling the truth when she says ‘I only had 1 glass.’ ” And Urban Outfitters — a retailer that markets to 18- to 28-year-olds — stocks whole-bottle wine glasses that say: “Drink until your dreams come true” and “This is how you adult.” Urban Outfitters did not respond to calls and emailed messages.
Alcohol marketing experts see a feedback loop between alcohol advertising and popular culture. They cite Trinchero’s repurposing of Schumer’s scene in “Trainwreck” as a prominent example.
“The rise in hazardous drinking among women is not all due to the ads. But the ads have played a role in creating a cultural climate that says it’s funny when women drink heavily,” said Jean Kilbourne, who has produced several films and books about alcohol marketing to women. “Most importantly, they’ve played a role in normalizing it.”
Multiple experts on alcohol marketing said Trinchero’s use of the scene to promote its wine violated industry standards.
Wendy Nyberg, Trinchero’s marketing vice president, defended the company’s behavior, saying Trinchero officials had no role in the production of “Trainwreck” and no control over how their wine was portrayed. It’s “easier when you control the messaging,” she said, adding: “We have to promote moderation in everything that we do. We stick to the code of ethics.”
The owner of Mommy’s Time Out did not respond to requests for comment, and marketing promotions sent to the company for a response have been removed from the company’s public Facebook page.
Damian Davis, the owner of the Seattle-based Rainier Wine, which produces Mad Housewife, said he does not think his ads crossed a line.
“We treat wine like a lifestyle product. I grew up in a big Catholic family, and having it with dinner was a way of life,” Davis said. “I certainly don’t encourage binge drinking. It certainly is a drug, and it can be dangerous.”
Even responsible drinking campaigns can send conflicting messages. A Facebook ad for Smirnoff Ice — ranked among the five most popular beverages by young female drinkers — shows a stack of caps from four pint-size bottles. The tagline: “Know Your Limit.”
“That’s binge drinking,” said David Jernigan, who runs the Center for Alcohol Marketing and Youth at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Jernigan, who advocates limits on alcohol marketing and has come under frequent attack from the alcohol industry, uses the Smirnoff ad in a presentation he calls “Virginia Slims in a Bottle.”
“Not only is that not responsible drinking,” he said. “That’s hazardous drinking.”
In a statement, Diageo, the maker of Smirnoff Ice, defended the ad, saying that by “saving the bottle caps, you keep track of how much you have had. Each individual has their own individual limits and for each individual these limits can vary based on time period of consumption, food intake and many other factors.”
Officials with Fireball Whisky declined to comment.
As it happens, drinking can be especially hazardous for women.
Women tend to have smaller bodies than men, and differences in physiology that make blood-alcohol levels climb faster and stay elevated longer. Some studies have found that women have lower levels of the stomach enzymes needed to process the toxins in alcoholic beverages.
As a result, according to the Centers for Disease Control and Prevention, women are more prone to suffer brain atrophy, heart disease and liver damage. Even if a woman stops drinking, liver disease continues to progress in ways it does not in men, said Gyongyi Szabo, a professor at the University of Massachusetts Medical School. And research definitively shows that women who drink have an increased risk of breast cancer.
“There is no gender equity when it comes to the effects of alcohol on men versus women,” Szabo said. “Females are more susceptible to the unwanted biological effects of alcohol when they consume the same amount of alcohol and at the same frequency — even when you adjust for weight.”
Many women don’t know this — nor do they understand what constitutes excessive drinking, said Robert D. Brewer, leader of the CDC’s alcohol program. For women in the United States, anything more than one drink a day is considered excessive. That’s one ounce of distilled spirits, 12 ounces of beer or five ounces of wine.
Four drinks consumed within two hours is considered binge drinking. That’s about two-thirds of a bottle of wine.
“Most people do not understand what binge drinking looks like, and they don’t yet recognize how dangerous it is,” Brewer said. “Smoking, eating unhealthy foods, not exercising — people get what that can do to your health. But we are in a way different stage with binge drinking.”
The alcohol industry and some government agencies continue to promote the idea that moderate drinking provides some health benefits. But new research is beginning to call even that long-standing claim into question.
This year, Jennie Connor, a professor at the University of Otago Dunedin School of Medicine in New Zealand, published a paper that found “strong evidence” that drinking as little as two servings of alcohol a day can cause cancer at seven sites in the body — mostly in areas where human cells come in direct contact with alcohol. Connor’s research included a survey of dozens of studies of the issue by prominent organizations, including the World Cancer Research Fund, the American Institute for Cancer Research and the International Agency for Research on Cancer.
In an earlier paper examining alcohol and cancer in the New Zealand population, Connor found that about a third of alcohol-related cancer deaths among women were associated with less than two standard drinks per day.
About the time this work was appearing, DISCUS chief scientist Samir Zakhari produced research casting doubt on its validity.
Zakhari also wrote an opinion piece directly attacking Connor’s study, using earlier research to dispute her findings.
Connor fired back at Zakhari in an op-ed published in a New Zealand newspaper, noting that Zakhari relied on — and misrepresented — her own earlier research. “The author cites Health Promotion Agency research showing how wrong I am,” she wrote. “If he had opened the report, he would have discovered that I wrote it.”
Zakhari scheduled and then canceled an interview with The Post to discuss his criticism of Connor and other alcohol researchers.
“I occasionally write op-eds or letters to the editor, most often in response to news coverage that contains flawed science,” he ultimately said in a statement.
The CDC’s Brewer, however, said that Connor’s research — and other recent work highlighting the health risks of drinking — is persuasive.
“The current and emerging science does not support the purported benefits of moderate drinking,” Brewer said. “The risk of death from cancer appears to go up with any level of alcohol consumption.
“The guidelines talk about low-risk consumption, but there is no such thing.”
Julie Tate contributed to this report.
Link to the article here The Washington Post: For women, heavy drinking has been normalized. That’s dangerous.
It took a lot of convincing to get John Evard into rehab. He was reluctant to give up the medications that he was certain were keeping his pain at bay. But ultimately he agreed — and seven days into his stay at the Las Vegas Recovery Center, the nausea and aching muscles of opioid withdrawal are finally beginning to fade.
“Any sweats?” a nurse asks him as she adjusts his blood pressure cuff.
“Last night it was really bad,” he tells her, “but not since I got up.” Evard, who is 70, says he woke up several times in the night, his sheets drenched with sweat.
Evard says it is hard to understand, even for him, how he ended up 300 miles away from his home in Scottsdale, Ariz., at this bucolic facility in the suburbs of Las Vegas. “This is the absolute first time I ever had anything close to addiction,” he says. He prefers the term “complex dependence” to describe his situation.
“It was, shall we say, a big surprise when it happened to me,” he says.
As the nation grapples with a devastating opioid epidemic, concerns have primarily focused on young people buying drugs on the street. But many elderly people in America also have a drug problem. Over the past several decades, physicians have increasingly prescribed older patients medication to address chronic pain from arthritis, cancer, neurological diseases and other illnesses that become more common in later life. And sometimes those opioids hurt more than they help.
A recent study of Medicare recipients found that in 2011, about 15 percent were prescribed an opioid when they were discharged from the hospital; three months later, 42 percent were still taking the pain medicine.
It’s perhaps no surprise, then, that some, like Evard, end up addicted.
Evard spent his life working as a corporate tax attorney. He’s lively and agile, with a contagious grin. A few years ago he and his wife retired to Arizona with their eyes on the golf course. But the dream didn’t last long. Just months into retirement, a virus infected Evard’s left ear. Overnight, he lost half his hearing and was left with chronic pain. In January, he had surgery to fix the problem.
“From the surgeon’s standpoint, the operation was successful,” Evard recalls. “The problem was, the pain didn’t go down. It went up.”
His doctors prescribed opioids, including Oxycontin. “They decreased the pain, particularly at first,” says Evard. “As time went on, [the pills] had less and less effect, and I had to take more and more.”
As the doctors increased his dosage, in hopes of managing the pain, Evard’s once active life fell apart. He was confused, depressed, and still in pain.
“I was effectively housebound,” he says. “I couldn’t play golf anymore. I couldn’t go to social events with my friends or my wife.”
He couldn’t think of anything except the pills, focusing on when he’d be able to take the next one. He knew he was in trouble — despite having taken them exactly as his doctor instructed.
“I was a rule-follower,” he says. “And I still ended up in a mess!”
In 2009, the American Geriatric Society came out strongly in favor of opioids, updating its guidelines on pain management to urge doctors to consider using opioids for older patients who have moderate to severe pain. The panel cited evidence that seniors were less likely than others to become addicted.
Dr. Bruce Ferrell,a geriatrician and pain specialist at the University of California, Los Angeles, served as chairman of the panel that issued the AGS guidelines.
“You don’t see people in this age group stealing a car to get their next dose,” Ferrell told the New York Times at the time.
Dr. Mel Pohl, medical director of the Las Vegas Recovery Center, calls that conclusion a “horrible misconception.”
“There’s no factual, scientific basis for that,” he says. “The drug takes over in the brain. It doesn’t matter how old the brain is.”
The problem is that there aren’t many good options to treat chronic pain as people age. Even aspirin and ibuprofen carry bleeding risks that can be serious.
The 2009 AGS guidelines are no longer in use, but opioid medications remain a crucial tool to treat pain in older people. And most people are able to take opioids in small doses for short periods of time without a problem.
“We really don’t use opioids necessarily as the first line of treatment, because we understand what the risks are,” says Dr. Sharon Brangman, past president of the AGS. “But we also don’t want to see our patients suffering needlessly if we can provide them with relief.” The trick, she said, is to first try non-pharmacological options such as acupuncture, and to use the smallest effective opioid dose possible.
Nonetheless, in the past 20 years, the rate of hospitalization among seniors that is related to opioid overuse has quintupled.
It took John Evard about a week to get over the vomiting and flu-like symptoms of detox, which can be particularly hard on older patients. He still has some of the chronic pain that first led him to seek help from a doctor, he says, but he takes Tylenol to deal with it. He’s speaking out now about opioids because he doesn’t want other seniors to fall into the same trap.
“Don’t just take the prescription because it’s part of the checkout process from the hospital,” he cautions. “It’s your body. Take charge of it, and push for alternatives at all costs. And if you do go on, get off them as fast as you can.”
You can listen to the entire transcript on NPR’s All Things Considered, here: Aging and Addiction
About the Author: Jenny Gold – covers the health care industry, overhaul and disparities for radio and print. Her stories for KHN have aired on NPR and been printed in USA Today, the Washington Post, McClatchy and MSNBC.
When I was 22 years old, I was treated for an addiction to opioids. In the five years since, I wake up each morning and scan my news filters to read about some of the 78 people who die each day from overdose. Which depressed Rust Belt city was hit today?
The opioid crisis is one of few in public health that, despite all efforts, continues to worsen. Nearly 2 million people in the United States are addicted to painkillers and an additional 450,000 are addicted to heroin. Fortunately, we have a proven way of lowering the death rate and easing the ills of addiction: medication-assisted treatments like methadone and buprenorphine. Unfortunately, thanks to a moral and policy-driven opposition to these treatment techniques, we’re not using it.
The first hurdle comes from misunderstanding how medication-assisted treatment works. Here’s the science behind it: Our brain produces natural opioids. But with the continued flooding of external opioids like heroin, the brain gradually stops producing its own. An internally depleted opioid system leaves us constantly sore, sensitive to pain, depressed, fatigued but unable to sleep. When I was still addicted but not using, I always felt a pang of doom impossible to relieve. These medications—which are synthetic and semi-synthetic opioids—help stabilize users and stanch these side effects while giving the brain a chance to heal.
Once maintained on the right dose, the receptor sites are activated just enough to keep the opioid system sated without producing the intense highs and lows (the hallmark of addiction) of opioids like heroin. This gives the brain, and most importantly, one’s connection with the world, a chance to rebuild. Simply put, these medications hydrate a thirsty system. On these drugs we can work, drive, and behave virtually indistinguishably from ordinary Janes and Joes.
Research also consistently shows that methadone and buprenorphine save lives. A 2015 study in the U.K. compared 151,983 opioid dependent patients who received different kinds of treatment: It found that over four years those who received only counseling were twice as likely to die from a fatal overdose than those treated with medication. A 2014 study in New South Wales, Australia, found a similar result in opioid-dependent patients leaving prison: In this high-risk population, being on either methadone or buprenorphine meant the risk of dying was reduced by a staggering 75 percent.
The World Health Organization calls these medications “essential” because expanding access to them reduces crime, infectious disease, and death. In blocking access, these all rise.
Given all of this, it should come as a shock that only a quarter of patients who sought treatment for opioid-use disorders in the U.S. received these medications. This is particularly problematic because drug treatment programs have a notoriously high dropout rate. Those that are given these medications stay engaged in the process for longer than those who don’t use them.
Outside of the lab, certain areas provide a real-world testament to the medications’ effectiveness: In 1995, during an HIV outbreak in France, the government instituted what’s called a “low threshold model” that let doctors prescribe methadone and buprenorphine on demand. Since, 2004, France has seen a remarkable 80 percent reduction in overdose deaths. Baltimore did something similar in 1995 and by 2008, the city saw a 66 percent reduction in overdose deaths. In contrast, the rest of America makes it extremely hard for doctors to prescribe these essential drugs: Methadone can only be used to treat addiction at highly regulated clinics; and to prescribe buprenorphine, doctors must take an eight-hour course and apply for a special license from the Drug Enforcement Administration. They also have patient limits (which were recently bumped from 100 to 275).
America needs to implement this model. But there is rampant misinformation, rigid ideological resistance, and outdated policy that keeps it from happening. To prescribe opioids to a person addicted to them simply does not compute within America’s deeply carved grooves of a medication-adverse, 12-step self-help culture that dominates our version of addiction treatment. Close to 80 percent of our residential treatment centers are steeped in the 12 steps of Alcoholics Anonymous, many of which operate on unscientific beliefs about which medications are appropriate.
It’s an odd stance for a country that so often throws pills at our problems. But in rehab, if you have anxiety that means no Xanax. If you have ADHD that means no Adderall. Some rehabs are so chemophobic that they once debated whether or not coffee should be allowed. At Hazelden in Minnesota, where I went, their largesse came in the form of half-caffeinated coffee. (If you made nice with the cafeteria workers, they’d hook you up with the real stuff.) So it’s no shocker that giving opioid users opioids is rejected, almost on principle.
I often hear medication-assisted treatment called “trading one addiction for another.” This stems from a fundamental misunderstanding of what addiction is. Addiction, as defined by psychiatry, is the agonizing, compulsive pursuit of a behavior despite the negative consequences said behavior reaps. The perturbed opioid system that users experience—the thing that makes it so hard for them to actively live in the world—is a medical problem. Why wouldn’t we use a medication to treat it?
My friend Hal kindly volunteered his experience to illustrate why he’s not addicted to buprenorphine, which he has taken for a couple years. He’s 26 and had a brutal habit that occupied his formative years. After a near-death overdose, a detox facility gave him the drug and referred him to a doctor to prescribe it. Now, he takes this maintenance drug, lives with his sister in Chicago, works as a barber, and contributes to his community.
So where is the addiction? He’s no longer stealing his grandmother’s jewelry to buy drugs. Hal left his addiction behind when he rejoined the world with the help of buprenorphine. Hal would go into withdrawal without the drug, but that is not addiction. That is what’s called physical dependence, and it happens to anybody and everybody who takes opioids. His vocation, his relationships, that he thinks life is worth living, is excited about what the future holds—this is what recovery looks like. It doesn’t matter what molecules are in his bloodstream.
Nonetheless, a collective miasma emanating from a treatment industry deems Hal as not being truly in recovery because he’s still taking some form of opioid. Frustratingly, it took Hal three different treatment attempts that cost his family tens of thousands of dollars before he finally found the doctor who gave him buprenorphine. And that doctor was not affiliated with any residential treatment facility (an industry that rakes in an estimated $35 billion per year).
Because I write openly about addiction and my experience of it, I get all kinds of messages. Not long ago a business developer at a South Florida treatment center called Banyan wrote to me: “Doing my best to stop the spread of medically assisted treatment that exists throughout the Midwest … I’d love to get you involved in some way.”
Of course, I’d like to do the exact opposite. In 2011, after I finished five days of detox, much like Hal, I was given a bottle of buprenorphine and a doctor to keep my refills flowing. I was then enrolled at Hazelden, a treatment center in Chicago close to where I grew up, to begin intensive outpatient treatment. This entailed a few hours a day of group therapy and educational lectures.
Before enrolling, I was told by several different staff that I had to get on a plan to taper off the buprenorphine. “We don’t do that here,” they said. I even heard from the clinical director that these drugs stunt spiritual development. Being young, unfamiliar with the scientific literature, I thought I should listen. They seemed to know what they were doing.
But when I tapered off the buprenorphine, I was back in hell. The drug not only relieved cravings, but it curbed my Kierkegaardian-sized dread. Being alive day after day in that way is unbearable. Eventually, heroin seems like a sensible solution, and sure enough I found myself back to the needle within a couple months of getting off it.
It wasn’t before long until I wound up in Hazelden’s residential facility. The doctor gave me buprenorphine for only a few days—called a rapid taper. This approach is unscientific and is not supported by the literature. As a result, I suffered through months of withdrawal. What kept me there wasn’t the treatment, certainly wasn’t the coffee, but rather my parents’ commitment to me—something that ended up costing a college’s tuition. I’m lucky—most who wind up in my situation have nowhere near the resources to stay long enough to fully go through withdrawal. And doing so was terrible, but eventually it worked for me. I’m 27 now and haven’t touched the stuff.
Just after my discharge in 2012, Hazelden instituted a buprenorphine maintenance policy. Too many of their clients were dying weeks, sometimes days after they left the facility.
The stigma against these medications also comes in the form of policy barriers. For no other drug does a doctor need to take an eight-hour course, get licensed by the DEA, and adhere to strict patient limits, but these strict standards reduce the number of doctors even able to prescribe methadone and buprenorphine. A friend of mine in Akron, Ohio, was trying to kick her habit but told me her community health center is turning patients away because they’ve hit an arbitrary limit of patients they’re allowed to treat. The limit was supposedly put in place to prevent the doctors authorized to prescribe from becoming “licensed drug dealers,” as many who fear the medication assume. But France saw no such problem—neither did Baltimore. A low-threshold model would make these medications easier to get for those who need them.
There seems to be light at the end of the tunnel. Cigna, one of America’s biggest health care providers, recently announced that they dropped a longstanding “preauthorization” policy that made doctors fill out time-consuming forms about any opioid-dependent patient they planned on treating with medication. Others providers plan to follow suit. And a recent report from the surgeon general called “Facing Addiction” fully embraced these medications, stating that they are “surrounded by misconceptions and prejudices that have hindered their delivery.” Of course, the Trump administration, which is already off to a rocky start when it comes to accepting evidence-based anything, may hinder the continued acceptance of such treatments.
Zachary Siegel is a master’s degree candidate at the University of Southern California’s Annenberg School for Communication and Journalism. Follow him on Twitter.