Healthcare Providers Helped Bring About the Opioid Epidemic; Now It’s Time to Help End It

Some programs already in place, many more needed

By Toby Cosgrove., M.D.

Cleveland Clinic president and CEO

Too many of the stories we hear about opioid-related deaths start the same way – with a patient prescribed a pain medication for an injury or medical procedure.

The stories then progress to street drugs like heroin or fentanyl, leading all too often to death. In 2016, about 60,000 Americans died of opioid abuse, an American death toll greater than the whole of the Vietnam War.

This has to stop and healthcare providers have a key role in turning the tide. One of the most sobering statistics, from a physician’s point of view, is that over 75 percent of opioid and heroin deaths begin with a prescription pain killer. The healthcare industry bears some responsibility.

That’s not to say that patients aren’t in legitimate pain. They are, maybe as many as 100 million by some estimates. But we as healthcare providers have to approach pain differently, smarter.

Declaring the opioid crisis a National Public Health Emergency is a good first step. But we in healthcare can’t wait for Washington. We have approaches at our disposal that can effect very real change.

Cleveland Clinic Statistic

Better policies have shown to make a difference quickly. In just the past few months, we’ve:

  • Reduced the number of opioid prescriptions exceeding 3 days by 50 percent in our emergency departments, simply through education and communication.
  • Reduced the number of patients receiving opioids by one-third in a group of colorectal surgery patients.
  • Hired a full-time Doctor of Pharmacy, who as a pain-management specialist can improve prescribing practices and clinical care.
  • Designated every hospital unit with “pain champions,” who are conversant with alternative pain strategies.

What it boils down to is this: healthcare providers have to make this a priority and we have to give physicians the tools they need to effect change.

Essentially, we can attack the opioid epidemic in four ways: giving healthcare providers the prescribing tools and resources they need; insisting on team engagement among hospital departments; tracking prescribing data and demanding accountability; and sharing information with other hospitals in the region.

Our electronic medical records system has been an indispensable tool. It has allowed us to connect directly to the Ohio Automated Rx Reporting System (OARRS); now, a physician can see a patient’s history of controlled substances within seconds while formulating a treatment plan. Also, our patient-provider agreements and consents are stored electronically so anyone who cares for that patient can see it, review it and update it as appropriate.

At the same time, we can use the electronic medical record to gather data so that we truly understand current practice – What type of patients are being prescribed narcotics? Which departments prescribe opioids most often? – then use that data to standardize care across the system.

Cleveland Clinic Statistic 2

Here are a few more approaches we’re using at Cleveland Clinic:

A Twist on “Just Say No”: Saying “no” to patients who are seeking narcotics for pain relief is difficult. That’s why we’ve instituted training courses for physicians on how to decline opioid requests from patients, with an emphasis on being compassionate. These are difficult conversations and the stakes are high. We must help our physicians navigate this by giving them the skills, strategy and practice to show empathy while managing emotion, setting boundaries and employing de-escalation tactics when needed.

Getting Back on TREK: Back pain strikes about 31 million Americans at some point during their lives. All too often, the first-line treatment is surgery or pain killers. At Cleveland Clinic, we are offering a different approach. Back on TREK (Transform Restore Empower Knowledge) is a pilot program treating patients with chronic low back pain (with or without leg pain), with the goal of restoring function through non-surgical treatment approaches and providing patients with tools to manage their pain without narcotics. The program utilizes a combined treatment approach of psychologically informed physical therapy; pain neuroscience education and behavioral medicine sessions utilizing cognitive behavioral therapy and psychological education techniques. More than 60 percent of patients showed significant improvement in pain and disability; over half demonstrated significant reduction in fatigue, pain interference, and overall physical health.

Painless mastectomy: An experimental drug, Exparel, is a local, time-released anesthetic used after a mastectomy to help patients with the worst of the pain — the first four days — so patients can avoid opioids.

Narcotic-free colorectal surgery: A program at Cleveland Clinic Akron General replaces narcotics with pre-surgical pain management, peripheral nerve blocks during procedure, and encouragement for the patient to get out of bed and move around within 4 to 6 hours of getting to the recovery floor. Of 80 patients in the program, one-third avoided narcotics. As a result, readmission rates and surgical costs dropped, hospital stays were shortened by 50 percent, risk of complications were reduced, and recovery improved with less pain.

New “ERAS” of recovery: Several medical centers, including Cleveland Clinic, have been developing the concept of “fast-track” or “enhanced” recovery after surgery. Recently, comprehensive research has indicated that an ERAS (“Enhanced Recovery After Surgery”) methodology that permits patients to eat before surgery, limits opioids by prescribing alternate medications, and encourages regular walking reduces complication rates and accelerates recovery after surgery. ERAS can reduce blood clots, nausea, infection, muscle atrophy, hospital stay and more. Patients are also given a post-operative nutrition plan to accelerate recovery, and physicians are using multi-modal analgesia, limiting the use of narcotics.

The good news is that the fight against the opioid epidemic is moving in the right direction. Everyone – hospitals, physicians, lawmakers, law enforcement and the general public – see this as the national emergency that it is.

By leveraging the tools at our disposal – or by creating new tools – we can save lives.

Link to original article here: Healthcare Providers Helped Bring About the Opioid Epidemic; Now It’s Time to Help End It

How to Be Human: Talking to People with Addiction or Substance Use Disorders

Shifting our perspective from ourselves to them

When it comes to addiction, using people-first language doesn’t always cross everyone’s mind. In fact, it hadn’t actually crossed mine until recently. Several years ago, many close friends experienced addiction and substance use disorders. Others in our extended friend group overdosed and died.

Before working at Healthline, I worked as a personal care assistant for a woman with disabilities throughout college. She taught me so much and brought me out of my able-bodied ignorance — teaching me how much words, no matter how seemingly small, can affect someone.

But somehow, even when my friends were going through addiction, empathy didn’t come so easily. Looking back, I’d been demanding, self-centered, and at times mean. This is what a typical conversation looked like:

“Are you shooting up? How much do you do? Why won’t you return my calls? I want to help you!”

“I can’t believe they’re using again. That’s it. I’m done.”

“Why do they gotta be such a junkie?”

At the time, I was having a hard time separating my emotions from the situation. I was scared and lashing out. Thankfully, a lot has changed since then. My friends stopped misusing substances and got the support they needed. No words can convey how proud I am of them.

But I hadn’t really thought about my language — and others’ — surrounding addiction until now. (And maybe getting out of your early 20s helps, too. Old age brings wisdom, right?) I cringe at my actions, realizing that I’d been mistaking my discomfort for wanting to help.

Many people frame well-intended conversations wrong, too. For example, when we say, “Why are you doing this?” we really mean, “Why are you doing this to me?”

This accusatory tone stigmatizes their use — demonizing it due to stereotypes, belittling the actual brain changes that make it difficult for them to stop. The overwhelming pressure we then place on them to get better for us actually debilitates the recovery process.

Maybe you have a loved one who had or is currently experiencing a substance or alcohol use disorder. Believe me, I know how hard it is: the sleepless nights, the confusion, the fear. It’s OK to feel those things — but it’s not OK to act on them without taking a step back and thinking about your words. These linguistic shifts may seem awkward at first, but their effect is enormous.

DEPENDENCE VS. ADDICTION

Not everything is an addiction, and not all ‘addictive’ behaviors are the same

It’s important not to confuse these two terms so we can fully understand and talk clearly to people with addictions.

 

Term Definition Symptoms
Dependence The body becomes used to a drug and usually experiences withdrawal when the drug is stopped. Withdrawal symptoms can be emotional, physical, or both, like irritability and nausea. For people withdrawing from heavy alcohol use, withdrawal symptoms can also be life-threatening.
Addiction The compulsive use of a drug despite negative consequences. Many people with addiction are also dependent on the drug. Negative consequences can include losing relationships and jobs, getting arrested, and doing harmful actions to get the drug.

Many people may be dependent on a drug and not realize it. And it’s not just street drugs that can cause dependence and addiction. People prescribed pain medications can become dependent on the meds, even when they’re taking them precisely as told by their doctor. And it’s completely possible for this to eventually lead to addiction.

First, let’s establish that addiction is a medical problem

Addiction is a medical problem, says Dr. S. Alex Stalcup, medical director of New Leaf Treatment Centerin Lafayette, California.

“All of our patients get an overdose kit on their first day. People thought it was creepy at first, but we give Epi-Pens to people with allergies and devices for people who are hypoglycemic. This medical device is for a medical disease,” he says. “It’s also another way of explicitly stating this is a disease.”

Since New Leaf started providing overdose kits, deaths have also been averted, says Dr. Stalcup. He explains that folks who carry these kits are really just dealing with major risk factors until they get better.

What you call someone with an addiction can bring unfair biases

Certain labels are charged with negative connotations. They reduce the person to a shell of their former self. Junkie, tweaker, drug addict, crackhead — using these words erase the human with a history and hopes, leaving behind a caricature of the drug and all the prejudices that come with it.

Man-Painted-Blue-Tattoos

These words do nothing to support people who need help getting away from the addiction. In many cases, it only prevents them from getting it. Why would they want to make their situation known, when society judges them so harshly? Science backs up these prejudices in a 2010 study that described an imaginary patient as a “substance abuser” or “someone with a substance use disorder” to medical professionals.

Researchers found that even medical professionals were more likely to hold the individual to blame for their condition. They even recommended “punitive measures” when they were labeled as an “abuser.” But the imaginary patient with a “substance use disorder”? They didn’t receive as harsh of a judgment and would probably feel less “punished” for their actions.

Never Use Labels
  • junkies or addicts
  • tweakers and crackheads
  • drunks or alcoholics
  • “abusers”

MAINTAINING RESPECT AND DIGNITY

A person is a person is a person:’ Labels aren’t your call to make

But what about when people refer to themselves as a junkie? Or as an alcoholic, like when introducing yourself in AA meetings?

Just like when talking to people with disabilities or health conditions, it’s not our call to make.

“I’ve been called a junkie a thousand times. I can refer to myself as a junkie, but no one else is allowed to. I’m allowed to,” says Tori, a writer and former heroin user.

“People throw it around… it makes you sound like s***,” Tori continues. “It’s about your own self-worth,” she says. “There are words out there that hurt people — fat, ugly, junkie.”

Amy, an operations manager and former heroin user, had to balance burdensome cultural differences between her first-generation self and her parents. It was difficult, and still is to this day, for her parents to understand.

“In Chinese, there are no words for ‘drugs.’ It’s just the word poison. So, it literally means you’re poisoning yourself. When you have that harsh language, it does make something seem more severe,” she says.

“Connotations matter,” Amy continues. “You’re making them feel a certain way.”

“Language defines a subject,” says Dr. Stalcup. “There’s a huge stigma attached to it. It’s not like when you think of other conditions, like cancer or diabetes,” he says. “Close your eyes and call yourself a drug addict. You’ll get a barrage of negative visual images you can’t ignore,” he says.

“I feel strongly about this… A person is a person is a person,” Dr. Stalcup says.

Don’t say this: “She’s a junkie.”

Say this instead: “She has a substance use disorder.”

CLEAN VS. DIRTY

How racism and addiction play into language

Arthur*, a former heroin user, also shared his thoughts on the language surrounding addiction. “I have more respect for dope fiends,” he says, explaining that it’s a hard road to travel and understand if you haven’t gone through it yourself.

He also alludes to racism in addiction language, too — that people of color are painted as addicted to “dirty” street drugs, versus white people dependent on “clean” prescription medications. “People say, ‘I’m not addicted, I’m dependent cause a doctor prescribed it,’” Arthur adds.

Perhaps it’s no coincidence that there’s growing awareness and empathy now, as more and more white populations are developing dependency and addictions.

Empathy needs to be given to everyone — no matter race, sexuality, income, or creed.

We should also aim to remove the terms “clean” and “dirty” altogether. These terms hold belittling moralistic notions that people with addictions were once not good enough — but now that they’re in recovery and “clean,” they’re “acceptable.” People with addictions aren’t “dirty” if they’re still using or if a drug test comes back positive for use. People shouldn’t have to describe themselves as “clean” to be considered human.

Don’t say this: “Are you clean?”

Say this instead: “How are you doing?”

Just like with the use of the term “junkie,” some people with use disorders may use the term “clean” to describe their sobriety and recovery. Again, it’s not up to us to label them and their experience.

ONE DAY AT A TIME

Change won’t come overnight — we’re all a work in progress

“The reality is and will remain that people want to sweep this under the rug,” says Joe, a landscaper and former heroin user. “It’s not like it’s going to change overnight, in a week, or in a month,” he says.

But Joe also explains how quickly people can change, like his family did once he began treatment.

It may seem that after a person has overcome their substance use disorder, everything will be fine going forward. After all, they’re healthy now. What more could anyone want for a loved one? But the work doesn’t stop for the former user.

As they say in some circles, recovery takes a lifetime. Loved ones need to realize this is the case for many people. Loved ones need to know they themselves need to continue to work to maintain a more empathetic understanding, too.

“The aftermath of being a drug addict is sometimes the hardest part,” explains Tori. “To be honest, my parents still don’t understand… [Their language] was just really technical, medical language, or that I had a ‘disease,’ but to me, it was exhausting,” she says.

Dr. Stalcup agrees that the language families use is absolutely critical. While it’s wonderful to show an interest in your loved one’s recovery, he stresses that how you do it matters. Asking about their progress isn’t the same as if your loved one has diabetes, for example.

With addiction, it’s important to respect the person and their privacy. One way Dr. Stalcup checks in with his patients is asking them, “How’s your boredom? How’s your interest level?” He explains that boredom is a big factor in recovery. Checking in with specific questions catered to your friend’s interests will show you understand while making the person feel more comfortable and cared for.

Don’t say this: “Have any cravings lately?”

Say this instead: “What have you been up to, anything new? Wanna go on a hike this weekend?”

TAKEAWAY

Language is what allows compassion to thrive

When I started working at Healthline, another friend began her recovery journey. She’s still in treatment, and I can’t wait to see her in the new year. After talking to her and attending a group meeting at her treatment center, I now know I’ve been dealing with addictions in a totally wrong way for years.

Now I know what I, and other people, can do better for their loved ones.

Uphold respect, compassion, and patience. Among the people I talked to about their addictions, the single biggest takeaway was the power of this sensitivity. I’d make the argument that this compassionate language is just as important as the medical treatment itself.

“Treat them how you’d want to be treated. Changing the language opens doors to different ways of behaving,” Dr. Stalcup says. “If we can change the language, it’s one of the fundamental things to lead toward acceptance.”

No matter who you’re talking to — whether to people with health conditions, people with disabilities, transgender people or nonbinary folks — people with addictions deserve the same decency and respect.

Language is what allows this compassion to thrive. Let’s work on breaking these oppressive chains and see what a compassionate world has in store — for all of us. Doing this will not only help us cope, but help our loved ones actually get the help they need.

The behaviors of a person with an active substance use disorder may make you not want to be compassionate. But without compassion and empathy, all we’re left with will be a world of hurt.

*Name has been changed at the request of the interviewee to preserve anonymity.

A very special thank you to my friends for giving me guidance and their time to answer some hard questions. Love you all. And very big thank you to Dr. Stalcup for his earnestness and dedication. — Sara Giusti, copy editor at Healthline.


 

Link to original article here: How to Be Human: Talking to People with Addiction or Substance Use Disorders

Suboxone Is Sober: 4 Myths That Keep Heroin And Pain Pill Users From Trying This Life-Saving Treatment

Suboxone (the popular name brand of medication buprenorphine/naloxone) reduces cravings and the withdrawal effects from heroin and pain pills. Any heroin or pain pill user knows that a fear of the horrible physical and emotional opiate detox can keep us using long after we want to quit. Even if we’ve tried to quit (and I’m speaking from experience), we might end up using again because we can’t make it through those first brutal days of detox.

Suboxone helps you survive opiate detox, and stabilizes you for life sober. Brand names Suboxone, Zubsolv, and Bunavail (different forms of the same medications, buprenorphine/naloxone) are expert-backed options categorized as medication-assisted treatment for opiate addiction. They’re medications that, with counseling, act as treatment to help you stay sober. Thus, medication-assisted treatment.

Large expert organizations like SAMHSA, NIDA, and the World Health Organization agree that medication-assisted treatment decreases opioid use, opioid related-deaths, and increases success in treatment. This isn’t up for debate, studies show medication-assisted treatment saves lives, and keeps people sober.

It should be a no brainer, right? If medication-assisted treatment like Suboxone works, and we’re in the midst of an opioid epidemic, you think it would be welcomed with open arms. You’d be thinking wrong. Less than ½ of privately funded treatment centers offer medication-assisted treatment, and less than ⅓ of patients struggling with opiate misuse ever receive it. (source)

A sponsor told me a long time ago, “Just because you’re an addict, doesn’t mean you have to be in pain.” I’ve carried that belief with me, and I believe it to be true for all opiate users who are struggling to quit today. Let’s bust four myths about Suboxone and other types of medication-assisted treatment, that keep many addicts in pain today.

1. Myth: A drug is a drug is a drug.

This is a response to Suboxone heard in Narcotics Anonymous meetings. A drug is a drug is a drug, and if you’re on one, you aren’t sober. But this simply isn’t true. You know it, and I know it. All drugs aren’t created equal. Street drugs cut with fentanyl can kill you, and can make you so high you fall asleep eating ice cream in your bed, or worse. Suboxone, or other forms of buprenorphine/naloxone, can reduce the likelihood that you’ll relapse and die. When taken as prescribed, then can improve your quality of life and chances of long-term recovery. That’s seriously sober to me. (source)

2. Myth: Suboxone makes you high.

This myth stems from Suboxone’s medication-assisted treatment precursor, methadone. Methadone can create a slight euphoric effect, and it can make you tired. But Suboxone is a partial opioid agonist, with a weaker side effects than heroin or methadone. It has a “ceiling effect” meaning if you do feel any sort of buzz (which most users don’t report, a switch from heroin or pain pills to Suboxone is not pleasant – trust me, I’ve done it), it will level off even if you increase your dose. Meaning that by definition, you won’t be able to get high. You’ll be stabilized. (source)

Suboxone different packets

3. Myth: Suboxone is trading one addiction for another.

There’s a big difference between addiction and dependence. Physical dependence is an aspect of taking certain drugs. Antidepressants like SSRI’s, certain blood pressure medications, and epilepsy medications all cause physical dependence. This means that if you stop taking these medications, you with experience some type of withdrawal from them. Does this mean we’re all addicted to our antidepressants? Nope. It means our bodies have adapted to them.

But addiction is a brain disease, characterized by compulsive drug use despite harmful consequences. This means if you can’t stop taking antidepressants despite the fact that you’ve spent all your money on them, your friends and family have told you they can’t stand to be around you when you’re on them, and you’ve missed a ton of work because of them, but still, you crave them like crazy and stay up at night taking just another Effexor, Cymbalta… that would be addiction. This is not what happens with medication-assisted treatment, or antidepressants, or plenty of other doctor-prescribed medication when we take it as prescribed. With Suboxone, just the opposite happens. Cravings decrease, and you can focus on daily living free of addiction. (source)

4. Myth: Suboxone is mood-altering, so you can’t take it and be sober.

Outside of any 12-step meeting, you might find some folks vaping and chugging Monster Energy drinks. All that nicotine, caffeine, and sugar is mood-altering. But it’s a certain kind of socially acceptable, so we encourage it. Living Sober, the Alcoholics Anonymous guide on how to get through early recovery, recommends reaching for something sugary to beat cravings. What is that sugar doing? It’s altering your mood. We need to think past the mood-altering rule and into a more personal and private decision of self-care. What works for you? What doesn’t work for you?

cigarette and cup of coffee

The reality is, opiate addiction is mood-altering, even after you quit using. When you misuse opiates long-term, you throw your brain chemicals off balance. That imbalance can lead to Post-Acute Withdrawal Syndrome, with depression, cravings, and sleep disturbances continuing long after short term withdrawal has ended. You feel funky, and your mood is altered. This can stack the decks against you. Because your brain is trained to turn to a single solution when you feel bad: USING OPIATES. Suboxone solves this problem by giving your brain back the chemicals your opiate addiction depleted, while also keeping you from getting high.

Is it easier, in the world of drug addiction, to categorize all drugs as bad? It might be, on the surface. But that sort of black and white thinking doesn’t serve us in recovery. It’s tempting, as we all point fingers at big pharma, to tell everyone to screw all meds. To say, “Just suck it up. Stop using, without any help.” But it sounds easy until you’ve been there. We’d all gladly kick opiates without any help if we could. But there’s a solution that makes the process of opiate addiction a little less painful. So let’s start treating it like one. Suboxone isn’t the enemy here. Heroin and pain pill addiction is.

Link to original article: Suboxone Is Sober: 4 Myths That Keep Heroin And Pain Pill Users From Trying This Life-Saving Treatment

Heroin-addicted cry out for treatment now, but help can be slow

An average of nearly 500 calls a day rang into Cincinnati’s Center for Addiction Treatment (CAT) in September. The website caught 1,100 visits a day.

The phone and web traffic for CAT’s services are two measures of how many people want help for heroin addiction. Problem is, immediate treatment is hard to get.

“We are not close to treatment-on-demand ability,” said Sandi Kuehn, CEO of the West End-based center.

Offering services when people want them would put Cincinnati among the national leaders in the battle against heroin addiction. Experts cannot name a city that has all forms of treatment on demand.

Addiction doctors say that the Cincinnati region does not have enough treatment facilities for everyone who needs the help. Many who want treatment do not know how to get what is available, and many who are addicted do not have the means, including transportation or a phone, to find treatment.

Cincinnati skyline river

Treatment on demand for heroin addiction usually means quickly providing medication to stop a patient’s cravings and help stabilize them, then finding long-term treatment that includes counseling.

Addiction experts say it’s important to give people treatment when they ask for it because people may want treatment one minute, but succumb to heroin the next.

Not having treatment on demand is “like denying treatment to a person with advanced heart disease,” said Linda Richter, director of policy research and analysis for the National Center on Addiction and Substance Abuse.

One user’s story: No phone, no treatment

Justin Warfield, 30, is in the Hamilton County jail awaiting treatment. He thinks being in jail is the only way he can get help.

When he was homeless in July, he said he’d tried to get residential treatment but abandoned the idea because it seemed impossible to do.

“You have to call every day,” he said. “I don’t have a phone. I can’t even call my mom.”

Justin Inmate Prison

Even if he’d had a phone and a way to charge it, Warfield said he’d probably call a heroin dealer before he’d keep in touch with a treatment center.

“It’s hard-wired into my brain at this point,” Warfield explained.

His mother, Colleen Owens of Camp Washington, has seen her son vacillate between wanting treatment and refusing it over the years.

“When they want help, they need to be able to get help then, not later,” Owens said. She sobbed, adding, “Later might be too late.”

While Greater Cincinnati and Northern Kentucky aren’t able to promise treatment on demand yet, we are getting closer.

More help faster, but without a bed

Addiction treatment is becoming more available in the Cincinnati area, with outpatient clinics and programs “popping up all the time,” said Nan Franks, CEO of the Addiction Services Council, a Greater Cincinnati nonprofit.

But while the clinics have shorter wait times than inpatient treatment, clinic treatment usually requires an appointment. The clinics mostly offer FDA-approved medications buprenorphine and injectable naltrexone for opioid addiction. They match medication with counseling.

BrightView Health has four locations in Southwest Ohio “with more under development,” said founder Dr. Shawn Ryan, a certified addiction expert. The first opened in 2015. “We’ve gone from zero- to about a 1,000-patient capacity,” Ryan said.

His clinics offer same-day and next-day treatment. People can walk in and get what they need, Ryan said. Patients are given buprenorphine as soon as they are medically approved for it. “That can be within hours,” he said.

The Center for Addiction Treatment opened its outpatient clinic in September, which is when calls nearly doubled. Kuehn said clients can get treatment in 24 to 48 hours.

In Northern Kentucky, Dr. Michael Fletcher, a certified addiction expert, has openings in his Chemical Addiction Network clinic. And St. Elizabeth Physicians just expanded its Journey Recovery clinic to try to meet the demand.

Going from ER directly to treatment

One way to get more people treatment when they are likely to want it is by offering it in emergency rooms to overdose survivors, rather than handing them a resource list and watching them walk out the door.

St. Elizabeth Healthcare recently brought the concept to our region. On Oct. 1, it started a pilot program at its Edgewood hospital to try to get OD patients into treatment before they leave the hospital.

Syringe on Ground

The St. E “bridge” program provides an addiction medication, buprenorphine, to overdose survivors and a peer recovery specialist to guide people into treatment.

It’s a form of treatment on demand that’s gaining favor across the nation.

Dr. Ross Sullivan pioneered his program in Syracuse in 2016 as an emergency doctor at Upstate University Hospital. He prescribed buprenorphine to patients who’d overdosed. Within months, he had approval to start a clinic for the ER patients. Like at St. E, a peer recovery specialist secures full treatment for the patients.

As of his last count, Sullivan had 165 patients referred by the ER. Of those, 132 showed up to their clinic appointment, and from there, 86 percent were linked to treatment.

It’s difficult for families, but hopsitals can’t coerce patients into treatment, said Dr. Leana Wen, Baltimore’s health commissioner, who has gained national attention for her city’s “kitchen sink” response to heroin.

 In Baltimore, four hospitals offer buprenorphine induction, but all hospitals connect overdose survivors with an outreach worker. That social worker “follows them out the door,” Wen said, staying in touch with them until they are ready to get treated.

One user’s story: Arrested to get treated

Katerra Jervis of Elsmere, a longtime heroin user, knew she wanted help. The only way she knew how to get it was to get herself arrested. So that’s what she did on March 22.

“I just wanted help so bad I didn’t care what I had to do,” said Jervis, 29.

She made her decision after a friend sent her a link to an Enquirer story about the jail’s evidence-based treatment program.

She showed up at the Campbell County jail, and Newport police cited her for public intoxication. Jervis says she “faked” her way into the citation. A police report states she had “pinpoint” pupils and was “a danger to herself, others and public property.”

The officer stated that Jervis “wanted to get help to end her addiction to heroin” and that “she wanted court-assisted addiction help.”

She pleaded guilty to disorderly conduct and got in. She graduated from the program Aug. 28 and took a two-year follow-up program option.

“It’s the best thing that ever happened to me,” Jervis said.

Jason Merrick, director of an addiction services program at the Kenton County jail, wasn’t surprised at Jervis’ story, adding that such situations “probably occur more often than we would admit or know.”

Helplines work, if people know about them

For those who can call, the Cincinnati area has two 24-7 heroin helplines staffed with addiction counselors who are finding treatment fast for people who need it.

 

“We probably have access every day,” said Addiction Services Council’s Franks.

The council’s staff is tapped into the treatment community and can cut through the runaround that so many describe they face when searching for help.

But not everyone knows about the helplines.

Amanda Cicchinelli of Loveland, whose son, Austin, struggled with heroin addiction for three years, said she was unaware of a helpline. Over the years, she said, she hunted for treatment repeatedly for her son.

”We made countless phone calls through the years,” Cicchinelli said. “It was a never-ending cycle of walls and barriers. Waiting lists and restrictions. Desperation became the deciding factor in where he went – not the program or treatment offered.”

Austin Cicchinelli, like most people with heroin addiction, wanted and didn’t want treatment. He cycled in and out of programs, his mother said, propelling her into a frantic search for help for him again and again.

Amanda Austin mother son

He kept a diary in 2016 that chronicled his thoughts about addiction, his wish to help others, his own need for help and, ultimately, his hopelessness.

July 23: “I wish I could build a time machine and stop myself from all of the choices.  I would show myself the things I was too naive and blind to see.  I would stop myself from ever even buying my first bag of weed.”

Aug. 21: “A woman I met on the streets overdosed. I bet people just look at her and think she’s just another addict. Nobody cares about an addict. No one contemplates that she is her parents’ daughter.”

Oct. 4: “I’m one shot away from being another T-shirt.”

Cicchinelli used heroin for the last time on June 26 this year.

“He was 21 when he died at his grandparents’ house, down the road from me, in Loveland,” his mother said.

Why can’t we get on-demand treatment?

How much more addiction treatment is needed isn’t clear, because the size of the opioid problem isn’t known.

Health officials in the region say they can’t provide an educated guess about the number of people who use heroin and other opioids, much less an actual count of the population. The research and data just aren’t there.

Vine St Over The Rhine Cincinnati

“If folks don’t come into the picture because of criminal justice, treatment, emergency types of reasons, we don’t know they exist,” explained Jennifer Mooney, the family health division director for Cincinnati Health Department.

Nationally, the federal Substance Abuse and Mental Health Services Administration estimates one in 10.8 people who need addiction treatment get it at a specialty program. Put another way, that’s roughly 2.3 million of the 21.7 million who reported in a 2015 survey that they needed treatment.

Even if the size of the problem were clear, there are other barriers to treatment and removing them “is complicated,” said Kenton County’s Merrick, who also is board president of the Kentucky chapter of People Advocating Recovery.

One problem, for example, is that insurance companies often require pre-authorization for treatment. People Advocating Recovery plans to ask the Kentucky legislature to hasten the process.

“If they could figure out a way to do this, we could give people treatment immediately,” Merrick said.

Another problem: Money.

Often, those who ask for treatment don’t have insurance. They have to get signed up, and that represents a delay. Beyond that, Merrick said, most treatment centers are understaffed and underfunded, making it difficult to provide immediate treatment.

Dr Mina Kalfas with patient

A final barrier is the misunderstanding that those who are addicted don’t want help, said Dr. Mina “Mike” Kalfas, a Northern Kentucky addiction specialist who has more than 200 heroin patients.

“Just about everybody I know battling addiction falls into one of two categories: Those that want help and those that have given up,” he said.

How to get help for yourself or somebody else

For 24-7 help, call the Addiction Services Council:

• Cincinnati area: 513-281-7880
• Northern Kentucky: 859-415-9280

The Social Life of Opioids

New studies strengthen ties between loss, pain and drug use

In the story of America’s opioid crisis a recent tripling in prescriptions of the painkillers is generally portrayed as the villain. Researchers and policy makers have paid far less attention to how social losses—including stagnating wages and fraying ties among people—can increase physical and emotional pain to help drive the current drug epidemic.

Man pondering Sea

But a growing body of work suggests this area needs to be explored more deeply if communities want to address the opioid problem. One study published earlier this year found that for every 1 percent increase in unemployment in the U.S., opioid overdose death rates rose by nearly 4 percent.

Another recent study from researchers at Harvard University and Baylor College of Medicine reported U.S. counties with the lowest levels of “social capital”—a measure of connection and support that incorporates factors including people’s trust in one another and participation in civic matters such as voting—had the highest rates of overdose deaths. That review of the entire U.S. mined data from 1999 through 2014 and showed counties with the highest social capital were 83 percent less likely to be among those with high levels of overdose. Areas with low social capital, in contrast, were the most likely to have high levels of such “deaths of despair,” with overdose alone killing at least 16 people per 100,000

Overdose is now the nation’s leading cause of death for people in the prime of life. And suicide- and alcohol-related deaths have also risen—most dramatically in regions with the highest levels of economic distress. “It will be hard to address the addiction and overdose crisis without better understanding and addressing the neurobiology linking opioids, pain and social connectedness,” says Sarah Wakeman, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School.

Connecting opioid use to social stress is not a new idea. Forty years ago the late neuroscience pioneer Jaak Panksepp first proposed the now widely accepted hypothesis that our body’s naturally produced opioids—endorphins and closely related enkephalins—are critical to the nurturing bonds that develop between parents and offspring and also between monogamous mates in mammals. Panksepp’s work and that of others showed that blocking one opioid system in the brain—which relies on the mu-opioid receptor—increased the distress calls of infants separated from their mothers in species as varied as dogs, rats, birds and monkeys. Giving an opioid drug (in doses too low to produce sedation) reduced such cries.

Panksepp also observed similarities between maternal love and heroin addiction. In each situation animals would persist in a behavior, despite negative consequences, in order to gain access to solace from the partner—or the drug. But, as Panksepp (who died in April) said in an interview several years ago, major journals rejected his paper in the 1970s because editors said the idea that motherly love was similar to heroin addiction was “too hot to handle.”

Since then, however, data supporting the link between opioids and bonding has only grown. It has been expanded on by researchers including Thomas Insel, former head of the National Institute on Mental Health; Robin Dunbar at the University of Oxford; and Larry Young, professor of psychiatry at Emory University.

Young showed that oxytocin, a hormone previously linked mostly with labor and nursing, is crucial to the formation of pair bonds as well as bonds between parents and infants. “The feelings that infants or adults feel when being nurtured—warmth, calmness and peacefulness—come from a combination of opioids and oxytocin,” he says. “These are the same feelings that people who take opioids report: a feeling of warmth and being nurtured or loved.” When a social bond is formed, oxytocin reconfigures the mu-opioid system so that a loved one’s presence relieves stress and pain—and that person’s absence, or a threat to the relationship, increases distress. For example, Young’s research shows normally monogamous prairie voles do not develop pair bonds with their mates if their mu-opioid system is blocked; other studies have found that mice genetically engineered to have no mu-opioid receptors do not prefer their mothers to other mice the way normal baby mice do.

A paper Young published this month, in collaboration with researchers at the University of Tsukuba in Japan, found prairie voles that have bonded with a mate not only experience more anxiety when separated from their partners—they also experience more physical pain during the separation, by various measures including response to a painful injection and pain from heat. “Bonding somehow changes your pain threshold—so if you lose that bond, then your pain reduction and natural analgesia is lost,” he says. This paper did not measure mu-opioid receptor binding, but other work with humans strongly suggests it is involved.

Recent human studies have specifically found that a partner’s presence can reduce pain, and supportive touching such as hugging is linked to activation of mu-opioid receptors in the brain. In addition, a study published last year found that administering an opioid blocker decreased people’s feelings of social connectedness—both when they were in the lab receiving e-mails of support from close friends or relatives and when they were at home during the four days they took the drug—compared with when they took a placebo. And, whereas the drug reduced overall levels of positive emotion, it had a larger effect on positive emotions related to feeling connected and loved.

All of this suggests that recognizing the connections between bonding, stress and pain could be critical to effectively addressing the opioid crisis. “Understanding the biology and commonalities between trusting social relationships and the opioid system can change the way we think about treatment,” Young says, noting that neither the punitive approach of the criminal justice system nor harsh treatment tactics are likely to increase connectedness. In essence, if we want to have less opioid use, we may have to figure out how to have more love.

Link to original article here: The Social Life of Opioids

Written by:  Maia Szalavitz

Ex-DEA agent: Opioid crisis fueled by drug industry and Congress

Whistleblower Joe Rannazzisi says drug distributors pumped opioids into U.S. communities — knowing that people were dying — and says industry lobbyists and Congress derailed the DEA’s efforts to stop it.

In the midst of the worst drug epidemic in American history, the U.S. Drug Enforcement Administration’s ability to keep addictive opioids off U.S. streets was derailed — that according to Joe Rannazzisi, one of the most important whistleblowers ever interviewed by 60 Minutes. Rannazzisi ran the DEA’s Office of Diversion Control, the division that regulates and investigates the pharmaceutical industry. Now in a joint investigation by 60 Minutes and The Washington Post, Rannazzisi tells the inside story of how, he says, the opioid crisis was allowed to spread — aided by Congress, lobbyists, and a drug distribution industry that shipped, almost unchecked, hundreds of millions of pills to rogue pharmacies and pain clinics providing the rocket fuel for a crisis that, over the last two decades, has claimed 200,000 lives.

Ex DEA agent and 60 mins correspondent

JOE RANNAZZISI: This is an industry that’s out of control. What they wanna do, is do what they wanna do, and not worry about what the law is. And if they don’t follow the law in drug supply, people die. That’s just it. People die.

“This is an industry that allowed millions and millions of drugs to go into bad pharmacies and doctors’ offices, that distributed them out to people who had no legitimate need for those drugs.”

Joe Rannazzisi is a tough, blunt former DEA deputy assistant administrator with a law degree, a pharmacy degree and a smoldering rage at the unrelenting death toll from opioids.  His greatest ire is reserved for the distributors — some of them multibillion dollar, Fortune 500 companies. They are the middlemen that ship the pain pills from manufacturers, like Purdue Pharma and Johnson & Johnson to drug stores all over the country. Rannazzisi accuses the distributors of fueling the opioid epidemic by turning a blind eye to pain pills being diverted to illicit use.

JOE RANNAZZISI: This is an industry that allowed millions and millions of drugs to go into bad pharmacies and doctors’ offices, that distributed them out to people who had no legitimate need for those drugs.

BILL WHITAKER: Who are these distributors?

JOE RANNAZZISI: The three largest distributors are Cardinal Health, McKesson, and AmerisourceBergen. They control probably 85 or 90 percent of the drugs going downstream.

BILL WHITAKER: You know the implication of what you’re saying, that these big companies knew that they were pumping drugs into American communities that were killing people.

JOE RANNAZZISI: That’s not an implication, that’s a fact. That’s exactly what they did.

In the late 1990s, opioids like oxycodone and hydrocodone became a routine medical treatment for chronic pain. Drug companies assured doctors and congressional investigators — as in this 2001 hearing — that the pain medications were effective and safe.

Purdue Executive to Congress in 2001: Addiction is not common, addiction is rare in the pain patient who is properly managed.

DEAarticle2
Rannazzisi accuses distributors of fueling the opioid epidemic by turning a blind eye to pain pills being diverted to illicit use.

With many doctors convinced the drugs posed few risks, prescriptions skyrocketed and so did addiction.

Many people who’d become addicted to painkillers turned to shady pill mills — pain clinics with rogue doctors to write fraudulent prescriptions and complicit pharmacists to fill them — one-stop shopping for controlled narcotics.

JOE RANNAZZISI: Pain clinics overnight popping-up – off an entrance ramp, or an exit ramp on an interstate. And all of a sudden there’s a pain clinic there.

BILL WHITAKER: Had you ever seen anything like that before?

JOE RANNAZZISI: Never. In fact– it was my opinion that this made the whole crack epidemic look like nothing.

JOE RANNAZZISI These weren’t kids slinging crack on the corner. These were professionals who were doing it. They were just drug dealers in lab coats.

BILL WHITAKER: You know what a chilling picture that paints?

JOE RANNAZZISI: I do, ’cause I watched them get arrested, and I was the one who approved the cases.

Despite arrests of unscrupulous purveyors, opioids kept flooding the black market.  The death toll kept rising. This map shows the U.S. death rate from drug overdose in 1999. By 2015, the map looked like this. Most of these deaths were opioid related. Joe Rannazzisi told us prosecuting crooked doctors and pharmacists wasn’t stemming the epidemic, so he decided to move up the food chain.

JOE RANNAZZISI: There had to be a choke point. And the choke point was the distributors.

Ex DEA Agent and 60 mins correspondent walking in front of Capitol Building in DC

BILL WHITAKER: What took you so long to go to that choke point of the distributors?

JOE RANNAZZISI: This was all new to us. We weren’t seeing just some security violations, and a few bad orders. We were seeing hundreds of bad orders that involved millions and millions of tablets. That’s when we started going after the distributors.

A distributor’s representative told us the problem is not distributors but doctors who overprescribe pain medication, but the distributors know exactly how many pills go to every drug store they supply.  And they are required under the Controlled Substances Act to report and stop what the DEA calls “suspicious orders” — such as unusually large or frequent shipments of opioids. But DEA investigators say many distributors ignored that requirement.

JIM GELDHOF: They had a business plan. Their plan was to sell a lotta pills and make a lot of money. And they did both of those very well.

“All we were looking for is a good-faith effort by these companies to do the right thing. And there was no good-faith effort. Greed always trumped compliance. It did every time.”

Jim Geldhof, a 40-year DEA veteran, ran pharmaceutical investigations from dea’s detroit field office. Frank Younker supervised the agency’s operations in Cincinnati.  Joe Rannazzisi was their supervisor. They saw distributors shipping thousands of suspicious orders. One example: a pharmacy in Kermit, West Virginia, a town of just 392 people, ordered nine million hydrocodone pills over two years.

JIM GELDHOF: All we were looking for is a good-faith effort by these companies to do the right thing. And there was no good-faith effort. Greed always trumped compliance. It did every time. But don’t sit here and tell me that, “Well, we’re not sure what a suspicious order is.” Really? I mean this– this co– this pharmacy just bought 50 times an amount that a normal pharmacy purchases and they are in a town of 5,000 people.  You don’t know that that’s suspicious? I mean at some point you’re just turning a blind eye to it.

BILL WHITAKER: These companies are a big reason for this epidemic?

JIM GELDHOF: Yeah, absolutely they are.

JIM GELDHOF: And I can tell you with 100 percent accuracy that we were in there on multiple occasions trying to get them to change their behavior. And they just flat out ignored us.

In 2008, the DEA slapped McKesson, the country’s largest drug distributor, with a $13.2 million dollar fine. That same year, Cardinal Health paid a $34 million fine. Both companies were penalized by the DEA for filling hundreds of suspicious orders — millions of pills.

Over the last seven years, distributors’ fines have totaled more than $341 million. The companies cried foul and complained to Congress that DEA regulations were vague and the agency was treating them like a foreign drug cartel.  In a letter, the healthcare distribution alliance, which represents distributors, told us they wanted to work with the DEA. Effective enforcement, they wrote, “must be a two-way street.”

BILL WHITAKER: Frank, you said you were tough but fair. The industry says you guys were unfair. That you were taking unfair hits at them.

FRANK YOUNKER: Tell that to the people who lost their sons and daughters. See how fair they think it is.

In 2011, more than 17,000 Americans died from opioid prescription overdoses.  That same year Cardinal Health, the second largest distributor, started pushing back at Joe Rannazzisi.  The companies’ attorneys went over his head and called his bosses at the Justice Department, who called in Rannazzisi to have him explain his tactics.  

JOE RANNAZZISI: And it in– infuriated me that I was over there, trying to explain what my motives were or why I was going after these corporations? And when I went back to the office, and I sat down with my staff, I basically said, “You know, I just got questioned on why we’re doing– why we’re doing what we’re doing. This is– this– this is– now this is war. We’re going after these people and we’re not going to stop.

BILL WHITAKER: Do you really think you were getting this pushback because you were going after big companies, Fortune 500 companies?

JOE RANNAZZISI: I have no doubt in my mind.  So the question is, why would it be any different for these companies as compared to the small mom-and-pops that we had done hundreds of times before.

BILL WHITAKER: What’s the difference?

JOE RANNAZZISI: The difference is, is they have a lot of money, and a lot of influence. And that’s the difference.

Rannazzisi says the drug industry used that money and influence to pressure top lawyers at the DEA to take a softer approach.  Former DEA attorney Jonathan Novak said it divided the litigation office. He said in 2013, he noticed a sea change in the way prosecutions of big distributors were handled. Cases his supervisors once would have easily approved, now weren’t good enough.

JONATHAN NOVAK: We had been achieving incredible success in an almost unstoppable wave, and then suddenly it stopped.

Novak prosecuted cases brought to him by Joe Rannazzisi’s investigators. He said his caseload started to slow down dramatically.

JONATHAN NOVAK: These were not cases where it was black — where it was grey… These were cases where the evidence was crystal clear that there was wrongdoing going on.

He said his bosses started to bog down the system, demanding ever more evidence.

JONATHAN NOVAK: But now, three undercovers by four officers over three months, that wouldn’t be enough. Maybe we need an expert to explain how recording equipment works. Maybe we need an expert to explain– the system for prescribing. What’s a prescription? It felt honestly confusing and almost insane. Where was this coming from?

Jim Geldhof says his investigations were getting bogged down too. He was looking into one mid-sized distributor that had shipped more than 28 million pain pills to pharmacies in West Virginia over five years.  About 11 million of those pills wound up in Mingo County, population 25,000. Suddenly, he said, he ran into roadblocks from one of attorney Jonathan Novak’s bosses.

JIM GELDHOF: “I spent  a year working on this case. I sent it down there and it’s never good enough. Every time I talked to this guy he wants something else. And I get it for ’em and that’s still not good enough.” You know? And this goes on and on and on.  When this– these roadblocks keep– get thrown up in your face, at that point you know they just don’t want the case.

BILL WHITAKER: But this is the DEA. That’s what you’re supposed to do.

FRANK YOUNKER: Yeah.

JIM GELDHOF: You would think.

DEAarticle4

The DEA’s toughest sanction is to freeze distributors shipments of narcotics — a step they haven’t taken in almost two years.

JONATHAN NOVAK: I mean there’s no denying the numbers. At the height of the opioid epidemic, inexplicably, they slowed down.

He said one big reason for the slowdown: DC’s notorious revolving door. Novak said he saw a parade of DEA lawyers switch sides and jump to high-paying jobs defending the drug industry. Once they’d made the leap, they lobbied their former colleagues, novak’s bosses, and argued the dea’s cases were weak and ultimately would lose in court. It had a chilling effect on dea litigators.

JONATHAN NOVAK: Some of the best and the brightest former DEA attorneys are now on the other side and know all of the — the — the weak points. Their fingerprints are on, memos and policy and — and — and emails going out where you see this concoction of what they might argue in the future.

BILL WHITAKER: You and the other attorneys had been winning these cases.

JONATHAN NOVAK: All of the time.

The Justice Department is the agency that oversees the DEA. A senior attorney at the department at the time, told us in a statement, ”Department of Justice leadership was not advised that DEA had changed enforcement strategies…Any significant policy shift should have been brought to [our] attention.”

FRANK YOUNKER: There was a lotta pills, a lotta people dyin’, and– and we had tools in our toolbox to try to use and stem that flow. But it seemed down in headquarters that that toolbox was shut off.

BILL WHITAKER: You’re watching an out of control epidemic and yet you both feel that at the height of this epidemic your– your– your hands were being tied?

FRANK YOUNKER: Yeah, if it’s a war on drugs then treat it like a war.

JOE RANNAZZISI: Addiction rate was still increasing. The amount of people seeking treatment was still increasing. It was all increasing. Still, the amount of prescriptions were increasing. And we started slowing down.

As cases nearly ground to a halt at DEA, the drug industry began lobbying Congress for legislation that would destroy DEA’s enforcement powers. That part of the story when we return.

In 2013, Joe Rannazzisi and his DEA investigators were trying to crack down on big drug distributors that ship drugs to pharmacies across the country.  He accused them of turning a blind eye as millions of prescription pain pills ended up on the black market.  Then, a new threat surfaced on Capitol Hill. With the help of members of Congress, the drug industry began to quietly pave the way for legislation that essentially would strip the DEA of its most potent tool in fighting the spread of dangerous narcotics.

JOE RANNAZZISI: If I was gonna write a book about how to harm the United States with pharmaceuticals, the only thing I could think of that would immediately harm is to take the authority away from the investigative agency that is trying to enforce the Controlled Substances Act and the regulations implemented under the act. And that’s what this bill did.

The bill, introduced in the House by Pennsylvania Congressman Tom Marino and Congresswoman Marsha Blackburn of Tennessee, was promoted as a way to ensure that patients had access to the pain medication they needed.

Jonathan Novak, who worked in the DEA’s legal office, says what the bill really did was strip the agency of its ability to immediately freeze suspicious shipments of prescription narcotics to keep drugs off U.S. streets — what the DEA calls diversion.

JONATHAN NOVAK: You’re not gonna be able to hold anyone higher up the food chain accountable.

BILL WHITAKER: Because of this law?

JONATHAN NOVAK: Because of this law

BILL WHITAKER: How hard does it make your job in going after the wholesale distributors?

JONATHAN NOVAK: I would say it makes it nearly impossible.

This 2015, Justice Department memo we obtained supports that. It states the bill “could actually result in increased diversion, abuse, and public health and safety consequences.”

JONATHAN NOVAK: They are toothless. I don’t know how they stop this now. It’s a very sad state of affairs.

Who drafted the legislation that would have such a dire effect? The answer came in another internal Justice Department email released to 60 Minutes and The Washington Post under the Freedom of Information Act: “Linden Barber used to work for the DEA. He wrote the Marino bill.”

Ad: Hi, My name is Linden Barber. I’m the director of the DEA litigation and compliance practice at Quarles and Brady’s Health Law Group. 

Barber went through the revolving door. He left his job as associate chief counsel of the DEA and within a month joined a law firm where he lobbied Congress on behalf of drug companies and wrote legislation. He advertised what he could offer a client facing DEA scrutiny.

Ad continued: If you have a DEA compliance issue, or you’re facing a government investigation, or you’re having administrative or civil litigation involving the Controlled Substances Act, I’d be happy to hear from you. 

JONATHAN NOVAK: It’s not surprising that this bill, that has intimate knowledge of the way that DEA, you know, regulations are enforced, the way that those laws work, was written by someone who spent a lot of time there, charged a lot of cases there.

BILL WHITAKER: Knew the workings?

JONATHAN NOVAK: Very much so.

Eric Holder was the attorney general at the time, he warned the new law would undermine law enforcement efforts to ”prevent communities and families from falling prey to dangerous drugs.”  The major drug companies — distributors, chain drug stores and pharmaceutical manufacturers — mobilized too. According to federal filings, during the two years the legislation was considered and amended, they spent $106 million lobbying Congress on the bill and other legislation, claiming the DEA was out of control, making it harder for patients to get needed medication.

Ex-DEA agent Joe Rannazzisi

A particular thorn for the drug industry and the bill’s sponsors was Joe Rannazzisi. He had been a witness before Congress more than 30 times and was called on again to testify about this bill.

JOE RANNAZZISI: 16,651 people in 2010 died of opiate overdose. OK. Opiate-associated overdose. This is not a game. We are not playing a game.

MARSHA BLACKBURN: Nobody is saying it is a game, sir. We’re just trying to craft some legislation. Let me ask you… 

Rannazzisi, who admits to having a temper, felt so strongly about the damage the bill could do, he lashed out at Marino’s committee staffers.

TOM MARINO: It is my understanding that Joe Rannazzisi, a senior DEA official, has publicly accused we sponsors of the bill of –quote supporting criminals –unquote. This offends me immensely.

BILL WHITAKER: Congressman Marino from Pennsylvania said that you accused him of helping criminals.

JOE RANNAZZISI: I’ve never accused Congressman Marino of helping criminals. I said that this bill is going to protect defendants that we have under investigation. And if Congressman Marino thinks I accused him of something, I don’t know what to tell you.

But a week after the hearing on legislation that would hobble the DEA’s enforcement authority, Marino and Blackburn wrote the inspector general for the Justice Department, demanding that Rannazzisi be investigated for trying to quote “intimidate the United States Congress.”

MATT MURPHY: There were people in industry that didn’t care much for Joe Ranazzisi, wanted him silenced, or wanted him outta the way. Basically unceremoniously kick him to the curb.

After almost 30 years with the DEA, Matt Murphy, Rannazzisi’s lieutenant, became a consultant for the drug industry — an industry with which he’s now disillusioned. He said he was shocked at the animosity he witnessed toward his friend and former boss.

MATT MURPHY: My theory is that the industry through lobbying groups donated — a certain amount of money to politicians to get a law passed that favored the industry. And also maybe using those political ties to have Joe removed.

BILL WHITAKER: Congress launched an investigation of him?

MATT MURPHY: Right.

BILL WHITAKER: And he was out?

MATT MURPHY: Yeah, pressure was put on for him to be moved out. I’m pretty confident of that. There was no reason to take the guy who was the most qualified person in DEA to run the Office of Diversion Control out of the Office of Diversion Control.

The investigation requested by Congressman Marino against Rannazzisi went nowhere, but soon after, Rannazzisi was stripped of his responsibilities. He says he went from supervising 600 people to supervising none — so he resigned.

JOE RANNAZZISI: We were totally focused on all these people dying and all these drugs being diverted. And we were not really looking at our flanks, waiting for somebody to come after us. So maybe that was my fault. And I just never realized that that was something that would have occurred.

In the end, the DEA signed off on the final version of the “Marino bill.” A senior DEA representative told us the agency fought hard to stop it, but in the face of growing pressure from Congress and industry lobbyists, was forced to accept a deal it did not want.  The bill was presented to the Senate in March of 2016.

Majority Leader Mitch McConnell introduced the legislation and it passed the Senate through unanimous consent with no objections and no recorded votes.

It passed the House the same way, with members of Congress chatting away on the floor.

A week later, with no objections from Congress or the DEA, President Barack Obama signed it into law without ceremony or the usual bill signing photo-op. Marino issued a press release the next day claiming credit for the legislation.

The drug distributors declared victory and told us the new law would in no way limit DEA’s enforcement abilities. But DEA chief administrative law judge, John J. Mulrooney, who must adjudicate the law, wrote in a soon-to-be-published Marquette Law Review article we obtained, that the new legislation “would make it all but…impossible” to prosecute unscrupulous distributors.

JOE RANNAZZISI: I just don’t understand why Congress would pass a bill that strips us of our authority in the height of an opioid epidemic in places like Congressman Marino’s district and Congressman Blackburn’s district. Why are these people sponsoring bills, when people in their backyards are dying from drugs that are coming from the same people that these bills are protecting?

BILL WHITAKER: Why do you think that is?

JOE RANNAZZISI: Because I think that the drug industry — the manufacturers, wholesalers, distributors and chain drugstores — have an influence over Congress that has never been seen before. And these people came in with their influence and their money and got a whole statute changed because they didn’t like it.

Seven months after the bill became law, Congressman Marino’s point man on the legislation, his Chief of Staff Bill Tighe, became a lobbyist for the National Association of Chain Drug Stores.

Since the crackdown on the distributors began, the pharmaceutical industry and law firms that represent them have hired at least 46 investigators, attorneys and supervisors from the DEA, including 32 directly from the division that regulates the drug industry.

Mike Gill, chief of staff for the DEA administrator, was hired by HDJN, one of the country’s largest healthcare law firms.

And most recently, Jason Hadges, a senior DEA attorney overseeing enforcement cases during the slowdown, joined the pharmaceutical and regulatory division of DC-based law firm Hogan Lovells. He declined to speak with us.

AmerisourceBergen and McKesson declined our requests to appear on camera.

So did Cardinal Health, which three months ago hired the author of the bill, Linden Barber, as senior vice president. With Scott Higham and Lenny Bernstein of the Washington Post, we called the head of public relations of Cardinal and asked to speak with Barber.

BILL WHITAKER: This is Bill Whitaker I’m a correspondent with 60 Minutes, I was calling to see if, um, we could speak with Linden Barber.

We were told the company would not make him available.

We also tried for several months to speak to Congressman Marino. Finally, we went to his DC office.

BILL WHITAKER: Hello. I’m Bill Whitaker with, uh, 60 Minutes.

MARINO STAFFER: Yes.

BILL WHITAKER: And we’d like to speak with Congressman Marino if we could.

MARINO STAFFER: I’m going to have to refer you to our Chief of Staff.

We were told he was not available…

MARINO CHIEF OF STAFF: Can you please turn the camera off and we have to ask the camera to leave the office.

His staff then called the Capitol Hill Police on us.

CAPITOL POLICE: Just accept the uninvite and leave the area.

When Joe Rannazzisi looks back he has one regret.

Joe Rannazzisi:  You know all these people that died happened under my watch. The one thing I wanted to do, the one thing that I just thought would have the most impact, is to lock up, arrest one of these corporate officers. You arrest a corporate officer. You arrest somebody that’s involved in the decision process, knowing what the law is. If you make that arrest, then everybody sits up and takes notice because three-piece-suit guys just don’t do well in prison. They don’t.

Joe Rannazzissi now consults with state attorneys general who have filed suit against distributors for their role in the opioid crisis. Tennessee Congresswoman Marsha Blackburn is running for the Senate. As for Congressman Marino, he was just nominated to be President Donald Trump’s new drug czar.

Link to original article here: Ex-DEA agent: Opioid crisis fueled by drug industry and Congress

Completely Unexpected Benefits of Being Sober

Better skin, more energy, good night’s sleep, money-saving – these are all popular benefits of being sober. As wonderful as they all are, there’s actually several more advantages to sobriety that are often overlooked…and they’re some of the best ones!

Lucy Rocca, the founder of the incredible alcohol addiction and abuse support network Soberistas, joins me in this article to discuss her experiences of the amazing advantages of choosing a sober lifestyle.

You’ll discover new personality traits

Drinking alcohol can blind, and even repress, our true personality traits. One of the most incredible things about being sober is you’ll really discover who you are and where your true potential lies.

For Lucy, it was discovering she is more of an introvert than she initially imagined. “I’m a bit shier than I ever thought I was – particularly in big groups. It took me a few years to recalibrate I think, after quitting drinking. At first I became a bit of a hermit but gradually I’ve merged the best bits of the old Lucy with the best bits of the new version. And finally, aged 41, I think I’m ok – that’s a novelty still, actually thinking I’m ok. I think having a positive mental outlook on life has been the biggest change in me.”

This is one of life’s greatest gifts – to see yourself for who you really are. Many people discover they’re more reserved when they stop drinking. This in itself can be a wonderful attribute. It’s easy to understand why a lot of people realise they’re introvert as an adult, because the chances are we probably started drinking in our teenage years and never really got to know ourselves as adults.

Eliminating alcohol from the equation brings a fresh new perspective on ourselves as adult individuals. Some even discover they’re a natural extrovert and didn’t even need alcohol in the first place. It doesn’t matter if you learn that you’re a peaceful introvert, a charming extrovert or even a split balance – knowing yourself is one of the keys to happier, healthier life.

Man Jumping a Rock

No more ‘alcohol anxiety’

Long gone are the days when you wake up worrying about what you said and did the night before. Instead, you get to wake up hangover-free and ready to enjoy your day. You might also find you’re far less likely to cancel on friends, skip the gym or shun work responsibilities.

Not only is sobriety great for your physical health, it can boost other aspects of your life such as your career, relationships, mental well being and so much more.

Strong relationships with the people who matter the most

When you first cut down on alcohol or quit altogether, you’re likely to distance yourself from those who seem to be the ‘bad influences’ in your life. I’m talking about friends you only hang out with in the pub – the type of people you only seem to spend time with if alcohol is involved.

Without the negative influences in your life – who are you left with? The people that truly love and care about you and like you for you! This is one of my favourite benefits of being sober – I know who I can trust and I know who’s going to be in my life all through the ups and downs!

And don’t forget all the new friends you’re going to make along the way – especially those also building a new sober lifestyle!

Time is a powerful thing

I won’t say being sober and staying sober gets easier over time, but time does seem to play a factor in successfully adjusting to a sober lifestyle. So one of the major perks of being sober is your mindset is more likely to change over time and your willpower could improve.

Lucy explained, “I do think it’s possible to rewrite your mental make-up, so things that once constituted a trigger for alcohol alter, your associations begin to change. For instance, if I’m stressed these days I go for a run, I never think “Oh, I’d kill for a drink right now!”. A sunny day makes me think about taking the kids somewhere for a lovely picnic, or going surfing, not getting trashed in a pub beer garden. Time does heal, I firmly believe that.”

There is such a thing, a ‘healthy hedonism’

You can have so much fun without drink – it seems crazy, right? Healthy hedonism is an especially rewarding benefit of sobriety if you’re noticing a shift in your mindset.
Healthy hedonism is different for everyone – you might be more active and take up some very interesting sports such as rock climbing to get that adrenaline pumping. Or you might find your creativity has rocketed through the roof and you spend days at a time painting, writing, playing guitar – anything that feeds your soul or gives you a natural high.

And that’s what healthy hedonism is all about. Pursuing activities that give you natural pleasure.

“For me, it’s running, surfing, skiing, trying new things, never stagnating, seeing life as a really exciting journey that I can now travel, totally unencumbered by alcohol or any other addiction,” said Lucy, “The world opened up to me when I stopped drinking, I haven’t looked back and wished I could still drink for many years. When I drank, I lived a dull life, it was Groundhog Day. Life sober is a really good life, I am a million times happier now than I ever was when I drank.”

Father playing with his kids in a field with sunlight

You’re in good company

This is one of the most overlooked benefits of sobriety – there are so many amazing role models out there. I know becoming sober has its obstacles, but realising there are so many inspirational people out there is one of the best benefits of sobriety.
Lucy, although one of the best role models I know, also looks up to several people, “It’s got to be Anthony Kiedis of the Red Hot Chili Peppers and the late Johnny Cash. And all of the many inspiring, strong and amazing people who make up the Soberistas community – they inspire me every day!”

Dr Bunmi Aboaba
bunmi@thesoberadvantage.com

Link to original article:  Completely Unexpected Benefits of Being Sober

Study highlights unmet treatment needs among adults with mental health and substance use disorders

Despite current treatment guidelines, fewer than 10 percent of adults with co-occurring mental health and substance use disorders receive treatment for both disorders, and more than 50 percent do not receive treatment for either disorder. The findings highlight a large gap between the prevalence of co-occurring disorders and treatment rates among U.S. adults and the need to identify effective approaches to increasing treatment for those with these conditions. An analysis of data from U.S. adults with both a mental health disorder and a substance use disorder indicates that only 9.1 percent of those adults received both types of care over the past year, and 52.5 percent received neither mental health care nor substance use treatment.

Crumpled Paper Taped Brain

The study, based on data collected from the 2008-2014 National Survey on Drug Use and Health, reports that 3.3 percent of the adult U.S. population, or some 7.7 million individuals, suffers from both a mental health and substance use disorder. Those adults with co-occurring disorders who did receive both types of treatment tend to have more serious psychiatric problems and accompanying physical ailments and were more likely to be involved with the criminal justice system compared to individuals who did not receive both types of care. The primary reasons for not seeking care were inability to afford treatment, lack of knowledge about where to get care, and a low perceived need among those with both disorders.

For more information about mental health and substance use disorders, go to: https://www.drugabuse.gov/related-topics/mental-health.

Link to article here: Study highlights unmet treatment needs among adults with mental health and substance use disorders

Here’s The Real Reason Why Some People Become Addicted to Drugs

Why do they do it? This is a question that friends and families often ask of those who are addicted.

It’s difficult to explain how drug addiction develops over time. To many, it looks like the constant search for pleasure. But the pleasure derived from opioids like heroin or stimulants like cocaine declines with repeated use. What’s more, some addictive drugs, like nicotine, fail to produce any noticeable euphoria in regular users.

So what does explain the persistence of addiction? As an addiction researcher for the past 15 years, I look to the brain to understand how recreational use becomes compulsive, prompting people like you and me to make bad choices.

Myths about addiction

There are two popular explanations for addiction, neither of which holds up to scrutiny.

The first is that compulsive drug taking is a bad habit – one that addicts just need to “kick.”

However, to the brain, a habit is nothing more than our ability to carry out repetitive tasks – like tying our shoelaces or brushing our teeth – more and more efficiently. People don’t typically get caught up in an endless and compulsive cycle of shoelace tying.

Another theory claims that overcoming withdrawal is too tough for many addicts. Withdrawal, the highly unpleasant feeling that occurs when the drug leaves your body, can include sweats, chills, anxiety and heart palpitations.

For certain drugs, such as alcohol, withdrawal comes with a risk of death if not properly managed.

The painful symptoms of withdrawal are frequently cited as the reason addiction seems inescapable. However, even for heroin, withdrawal symptoms mostly subside after about two weeks. Plus, many addictive drugs produce varying and sometimes only mild withdrawal symptoms.

This is not to say that pleasure, habits or withdrawal are not involved in addiction. But we must ask whether they are necessary components of addiction – or whether addiction would persist even in their absence.

Pleasure versus desire

In the 1980s, researchers made a surprising discovery. Food, sex and drugs all appeared to cause dopamine to be released in certain areas of the brain, such as the nucleus accumbens.

Rat Receiving Brain Transmissions

This suggested to many in the scientific community that these areas were the brain’s pleasure centres and that dopamine was our own internal pleasure neurotransmitter. However, this idea has since been debunked. The brain does have pleasure centres, but they are not modulated by dopamine.

So what’s going on? It turns out that, in the brain, “liking” something and “wanting” something are two separate psychological experiences.

“Liking” refers to the spontaneous delight one might experience eating a chocolate chip cookie. “Wanting” is our grumbling desire when we eye the plate of cookies in the centre of the table during a meeting.

Dopamine is responsible for “wanting” – not for “liking.” For example, in one study, researchers observed rats that could not produce dopamine in their brains. These rats lost the urge to eat but still had pleasurable facial reactions when food was placed in their mouths.

All drugs of abuse trigger a surge of dopamine – a rush of “wanting” – in the brain. This makes us crave more drugs. With repeated drug use, the “wanting” grows, while our “liking” of the drug appears to stagnate or even decrease, a phenomenon known as tolerance.

In my own research, we looked at a small subregion of the amygdala, an almond-shaped brain structure best known for its role in fear and emotion.

We found that activating this area makes rats more likely to show addictive-like behaviors: narrowing their focus, rapidly escalating their cocaine intake and even compulsively nibbling at a cocaine port. This subregion may be involved in excessive “wanting,” in humans, too, influencing us to make risky choices.

Involuntary addicts

The recent opioid epidemic has produced what we might call “involuntary” addicts. Opioids – such as oxycodone, percocet, vicodin or fentanyl – are very effective at managing otherwise intractable pain. Yet they also produce surges in dopamine release.

Most individuals begin taking prescription opioids not for pleasure but rather from a need to manage their pain, often on the recommendation of a doctor. Any pleasure they may experience is rooted in the relief from pain.

However, over time, users tend to develop a tolerance. The drug becomes less and less effective, and they need larger doses of the drug to control pain. This exposes people to large surges of dopamine in the brain. As the pain subsides, they find themselves inexplicably hooked on a drug and compelled to take more.

The result of this regular intake of large amounts of drug is a hyperreactive “wanting” system. A sensitised “wanting” system triggers intense bouts of craving whenever in the presence of the drug or exposed to drug cues.

These cues can include drug paraphernalia, negative emotions such as stress or even specific people and places. Drug cues are one of an addict’s biggest challenges.

These changes in the brain can be long-lasting, if not permanent. Some individuals seem to be more likely to undergo these changes.

Research suggests that genetic factors may predispose certain individuals, which explains why a family history of addiction leads to increased risk. Early life stressors, such as childhood adversity or physical abuse, also seem to put people at more risk.

Addiction and choice

Many of us regularly indulge in drugs of abuse, such as alcohol or nicotine. We may even occasionally overindulge. But, in most cases, this doesn’t qualify as addiction. This is, in part, because we manage to regain balance and choose alternative rewards like spending time with family or enjoyable drug-free hobbies.

Girl Overlooking Skyline

However, for those susceptible to excessive “wanting,” it may be difficult to maintain that balance. Once researchers figure out what makes an individual susceptible to developing a hyperreactive “wanting” system, we can help doctors better manage the risk of exposing a patient to drugs with such potent addictive potential.

In the meantime, many of us should reframe how we think about addiction. Our lack of understanding of what predicts the risk of addiction means that it could just as easily have affected you or me.

In many cases, the individual suffering from addiction doesn’t lack the willpower to quit drugs. They know and see the pain and suffering that it creates around them. Addiction simply creates a craving that’s often stronger than any one person could overcome alone.

The ConversationThat’s why people battling addiction deserve our support and compassion, rather than the distrust and exclusion that our society too often provides.

Article written by: Mike Robinson, Assistant Professor of Psychology, Wesleyan University.

Link to article: Here’s The Real Reason Why Some People Become Addicted to Drugs

What It Feels Like To Have An Opioid Addiction

We are in the midst of an epidemic of opioid addiction and death. Almost everyone knows someone living an opioid addiction or who has died from one. And they all have the same question: why can’t we, didn’t we, stop?

Why, they wonder, do we hock, trade, sell everything we own; why do we steal and hurt the ones we love just to get our roxies, dilaudid, our heroin? But the answer to that question is really very simple.

I started using heroin in 1976 when I was 20 years old. For the next 13 years I used occasionally, never enough to become addicted. I earned a B.A. in psychology, a masters in experimental psychology, and a doctorate in bio-psychology. After I completed the doctorate in 1987 I was awarded a national institute on drug abuse post-doctoral fellowship in the pharmacology and toxicology department at the University of Arkansas for medical sciences.

My area of research was behavioral pharmacology which is the study of how drugs affect the brain and behavior. During all of this time I was still, on occasion, using. In April of 1989 I got into a bottle of methadone hydrochloride from the behavioral pharmacology lab and the whole time I was shooting that methadone I told myself that I would stop. And I believed that. Until I couldn’t.

For the next 22 years I lived the life of opioid addiction. The last year and a half of my addiction I was homeless, living on the streets and sleeping on the ground, homeless shelters, and people’s floors. The last time I used an opioid was December 11, 2011.

I am sharing this because I want you to know that I understand what your child, what your loved one, experiences in their addiction. I have lived it. And that because of my education and research, I also understand the neurocircuitry, neuropharmacology, and behavioral aspects of opioid addiction.

I believe in science. I believe in its truth. And science has shown that opioid addiction is a disease of brain structure and, thus, function. The continual intake of these opioids, day after day, year after year, alters the brain on a cellular, molecular basis. These alterations are opioid addiction. And they are manifested as behavior directed toward the survival of the individual.

The neurobiological explanation of this illness is beyond the scope of this article. But maybe this will help.

Let’s say that you haven’t had anything to eat for three or four days. You are starving. Can you feel it? What it’s like to be really starving? What would you be thinking about? You would be thinking about food. You would be needing, craving food. This craving that you feel is the brain’s mechanism that drives you to survive. Its purpose is to make everything else fall away and to force you to focus solely on acquiring what you have to have to live.

Young man in the dark with hands clasped together

Now, let’s go further. Let’s say that food is restricted. There’s a famine or some kind of government control that limits the amount of food. There are no soup kitchens; there are no food banks. And no one will give you any food because they don’t have enough for themselves. There is, however, a black market in food. But the food in this black market is scarce and expensive. And it is illegal. It is against the law to buy food in this black market. What would you do if you were starving? Would you break the law? Would you steal to eat and to live? How much of yourself would you sacrifice? How much of who you are and what you are would you let go of to survive?

This craving for food is measured in days. Our craving for opioids is measured in hours. Four to five hours after our last use we begin to starve. And we crave. Everything but our need for these opioids falls away. And we focus solely on what we have to do to survive. We don’t have a choice. We really don’t.

Please understand I’m not trying to excuse our behavior. I am, though, trying to help you to see why we do these things. I know it may be difficult to believe that even when we stole from you, were verbally and maybe even physically abusive, we loved you. We are not narcissistic hedonists. When we hurt you we hurt too. We do these things not because we want to do them, but because we have to survive. We become desperate, and in our desperation we do things that we know are wrong; we do things that we know are not us. But this doesn’t mean we don’t care. If you are starving, you still love. What it does mean is that we are so desperate in our starvation that we will hurt the ones we love to end that hunger.

What is sad is that we don’t understand why we are hurting the ones we love. And because we don’t understand, we can’t explain it to you. We can’t explain why we are hurting you. And this lack of understanding can rip a family apart. It can replace love with resentments and anger. On both sides. And in this pain, in this lack of understanding, we lose each other.

The knowledge that I hope you take away from this article is that your child or your loved one did not hurt you so that they could go out and buy roxies, dilaudid, or heroin. What they bought was their survival.

For those of you that have lost a child or loved one to overdose and addiction, I hope this article will help you to understand that there is no blame here. Whatever you did, however you tried to help the one you loved, you did your best. Because that’s what love does. And I hope you also understand that your child or your loved one also did their best. They fought, they struggled, they did all they could to stop. But, ultimately, their disease took their life.

Understanding and knowledge is power. The lack of it is confusion and helplessness.

 

Sam Snodgrass, Contributor

PhD. Board of Directors, Broken No More/GRASP

Link to article here: What It Feels Like To Have An Opioid Addiction