Separating Pills in a pharmacy

Blunting Addiction’s Impact

With America’s deadly drug crisis looming large for years to come, public health officials say charting a path to nationwide recovery requires a multipronged approach, from treating those already addicted to tackling the epidemic’s root causes.

Around 2 million Americans are addicted to opioids, and more than 350,000 others have died of opioid-involved overdoses during the last two decades. Some became hooked via widely available prescription painkillers like OxyContin, which emerged in the 1990s, while heroin and illicit fentanyl have driven the mounting crisis in recent years.

Understanding how the current crisis developed is key to measuring which interventions are working to curb addiction and which efforts are falling flat. It also can help the country prepare for the inevitable next stage in its ever-evolving pattern of substance abuse.

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Father playing with his kids

New US Survey Shows Some Progress Against Opioid Crisis

Figures from a U.S. government survey released Friday show some progress in the fight against the ongoing opioid addiction crisis with fewer people in 2017 using heroin for the first time compared to the previous year.

The number of new users of heroin decreased from 170,000 in 2016 to 81,000 in 2017, a one-year drop that would need to be sustained for years to reduce the number of fatal overdoses, experts said.

Fewer Americans are misusing or addicted to prescription opioid painkillers. And more people are getting treatment for heroin and opioid addiction, the survey found.

The Trump administration said the positive trends show government efforts are working.

Messages are reaching people about the dangers of heroin and the deadly contaminants it often contains on the street, Dr. Elinore McCance-Katz, an administration health official, said in a video presentation released with the figures.

Among the other findings:

—Marijuana use climbed in all age groups except young teenagers, with 2.5 percent of those 26 and older, or 5.3 million adults, reporting they use marijuana daily or almost daily last year.

—Methamphetamine and cocaine use climbed in young adults, ages 18 to 25. The uptick may indicate that users are shifting from opioids to other drugs, said Leo Beletsky, a public health policy expert at Northeastern University in Boston.

Bottle of Spilled Pills

—Young adults have increasing rates of serious mental illness, major depression and suicidal thoughts.

—The number of new heroin users in 2017 — 81,000 — was lower than the numbers in most years from 2009 to 2016. But it was similar to the numbers of new heroin users in 2002 through 2008.  Experts said there’s still work to be done before success can be declared.

“Taken together, this does not look like the portrait of a nation with improving mental health and addiction issues,” said Brendan Saloner, an addiction researcher at Johns Hopkins Bloomberg School of Public Health. “It’s hard to look at this and not think we need to be doing a better job than we’re doing now.”

Earlier this month, the Centers for Disease Control and Prevention released preliminary figures that appear to show a leveling off in overdose deaths in late 2017 and the first two months of this year.

Health officials have said it’s too soon to say whether the nation’s drug crisis has peaked. But in an interview with The Associated Press this week, U.S. Health and Human Services Secretary Alex Azar said several measures of the crisis are improving.

“We are making progress,” he said. “We are seeing a flattening of our deaths from overdose.”


AP Medical Writer Mike Stobbe in New York contributed to this report. Follow AP Medical Writer Carla K. Johnson on Twitter: @CarlaKJohnson

The Associated Press Health & Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Copyright 2018 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Dopesick Author Interview: “We Need to Treat Addiction as the Medical Problem It Is”

Your new book, Dopesick: Dealers, Doctors and the Drug Company That Addicted America, details the opioid crisis in the U.S. When did you first start to look at the opioid epidemic?

I was a newspaper reporter in 2012, in Roanoke, Va. I had done reporting about what happens in communities when all the jobs go away. You had these poor, distressed places where people were not only becoming addicted to painkillers, but also starting to sell them as a way to pay their bills. And then you had the same thing happening in the wealthier neighborhoods.

Why do you think it took America so long to wake up to the crisis?

I think, partly, the media sort of abandoned rural America just when they needed us most. The newspaper where I worked for many years, the Roanoke Times, slowed down coverage of rural areas. We weren’t telling this story because we didn’t even know it was going on.

Do you think people fully understand the epidemic?

A lot of people still don’t know about the connection between opioid pills and heroin and fentanyl. Doctors are way better about not giving kids 30 OxyContin for wisdom teeth anymore, but I tell everyone I know: Just be really careful.

Do you think the conversation is changing around medication-assisted treatment (MAT)? [This method uses medication to temper cravings instead of demanding abstinence.]

The rehab industry grew up treating alcoholism as abstinence-only. Most treatment centers don’t allow MATs. People assume they don’t want to get better, but I see attitudes starting to change.

Author Beth Macy

Do you think people should be incarcerated for using drugs?

No, I don’t. There are places in the world that have responded with decriminalization and have gotten their arms around their opioid problems. Look at Portugal. They’ve done a lot with expanding buprenorphine providers and cutting regulations, and they’ve cut overdose deaths by quite a lot. We have more than 2 million people with opioid-use disorders in the U.S. Now, do the doctors need to prescribe less? Yes. But the horse is already out of the barn. We need to treat addiction as the medical problem that it is.

Serious man looking away denim jacket urban street

Op:Ed – The Opioid Crisis Has a Solution, Here it is

I recently attended a symposium examining how medical schools can prepare future doctors to deal with the continuing opioid crisis. I joined over 90 educators from 30 medical schools at the Warren Alpert Medical School of Brown University to discuss devising a curriculum based on a successful model that Brown has created.

The curriculum on opioids is designed to accomplish two objectives:

First, teaching medical students how to identify and properly treat pain. In the past, medical students have been notoriously undereducated when it comes to pain and pain management. They have over-prescribed opioids because of pressure from drug companies and patients. Now newly minted doctors will manage multidisciplinary teams to properly manage pain without opioids whenever possible.

At the groundbreaking symposium at Brown I joined former U.S. Surgeon General Dr. Vivek Murthy on stage to interview him and discuss key issues involving opioid addiction. Over lunch before the session, Murthy – who was surgeon general from December 2014 until April 2017 – and I discovered we have some things in common.

Vivek Murthy

Both of us are internists and are married to doctors who serve as medical mentors. And both of us believe firmly that the primary responsibility for causing the opioid problem lies in the hands of over-prescribers.

“We are the ones who hold the prescribing pen,” I told Murthy. I told him that my wife, a neurophysiologist and back pain specialist, almost never prescribes opioids. Instead, she prescribes muscle relaxants, non-steroidal patches, heat and physical therapy for most back pain.

Murthy agreed with this approach. And I agreed with his view that opioids alone aren’t the problem, but are instead part of a cascade of widely used addictive substances. In addition to opioids (both prescribed and illicit), these substances include anti-anxiety medication, sleeping pills and alcohol.

In 2016 Murthy issued a report titled “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.” The report launched a community-based program to address the addiction epidemic in the U.S.

During my hour-long interview and discussion with Murthy attended by those at the symposium we talked about the need to better regulate and restrict opioid prescriptions with a federal monitoring program, along with the huge need for proper doctor education.

Proper pain identification and management, along with medically assisted therapy (including buprenorphine) has been shown to dramatically decrease the urge to use opioids.

In contrast, locking up addicts in jail and prisons instead of providing the treatment they desperately need is the wrong way to deal with the addiction epidemic, Murthy said. I wholeheartedly agree.

Everyone in the audience knew that Murthy and I come from opposite sides of the political aisle, with fundamental differences in terms of how we approach health policy. And yet, here we were, in a give-and-take discussion filled with agreement and common ground, with the ultimate shared goal of improving treatments for addicts to help them lead healthy and productive lives.

Murthy discussed the three main addiction centers of the brain, along with progress in research to create less addictive pain treatments.

U.S. Food and Drug Commissioner Dr. Scott Gottlieb told me in a recent interview for Fox News that new effective and less-addictive pain treatments are in the offing.

We can learn lessons about solving the opioid crisis in the world of public health.

Vaccines – the greatest public health advance of the 20th century – are most effective when everyone takes them, creating a herd immunity that protects society. Addiction should be viewed the same way.

run down part of cityThere is a high recurrence rate for opioid addiction even after the most effective rehab program. Murthy talked about an addict’s essential loneliness, and about the need for the entire community to come together to help addicts overcome the stigma and embarrassment of their predicament.

The former surgeon general applauded the efforts that have been made by his successor – Surgeon General Dr. Jerome Adams – and others to provide much wider access to naloxone – a life-saving drug that rapidly reverses an opioid overdose by blocking the effects of other opioids. Naloxone can quickly restore normal breathing to someone whose breathing has slowed or stopped as the result of an opioid overdose.

Doctors, nurses, law enforcement officers, families and friends of addicts must all have access to naloxone and learn how to administer the drug. It is available as a prepackaged nasal spray and in a prefilled auto-injection device that make it easy to administer.

Murthy believes – as I do – that funding for wider distribution of naloxone at a low cost must be preserved and extended at the federal, state and local level.

And of vital importance, we must improve our understanding of what works best to help addicts get off and stay off the substances they are addicted to.

We need to help addicts relearn a sense of their own usefulness and understand that addiction is more than a disease – it’s a form of emotional and physical paralysis.

Doctors, beginning with medical students, must play an essential role in understanding and treating not just pain, but the addiction that arises from a community culture of drug abuse. According to the National Survey on Drug Use and Health, an astounding 75 percent of opioid misuse begins with people taking medications that were intended for others. And close to 80 percent of heroin addicts begin with prescription painkillers.

The most effective place to address the opioid epidemic is not in the halls of Congress but in the doctor’s office. Doctors helped to cause this problem, and now we must help to cure it.

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Written by: Dr. Marc Siegel

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Opioid Crisis: What People Don’t Know About Heroin

In a society that’s lost its faith in religion and institutions of government, does the opiate of the masses become, simply, opiates? Drug overdoses are now the leading cause of death for Americans under 55 – and despite a push for reform, those numbers aren’t budging. Over the past 15 years, pharmaceutical opioids flooded the streets until a backlash resulted in dried-up supply lines – and countless new addicts eventually found their way to heroin. In this sense, the Pablo Escobar of opioids is no one person but an amalgamation of doctors, lobbyists and lawmakers whose actions, sometimes unwittingly, have brought about one of the worst drug epidemics in history.

There is nothing new about heroin: What has changed is the way that we consume, dispense and talk about it. Despite the rising rate of opioid abuse and overdose in this country, we continue to mischaracterize heroin, thereby neglecting to understand the indelible hold it has on users. Here’s an attempt to clear up some of the most common misconceptions.

Heroin Isn’t Always White Powder
Heroin generally comes in three different forms in the United States: powder heroin – which falls into two subcategories, brown and off-white – tar heroin and heroin pills. Historically, the Mississippi River has been the line of demarcation between the tar and powder markets. Off-white powder heroin, which originates in Southeast and Southwest Asia, is generally considered the most desirable kind. Powder, with its origins in Mexico, often carries a deeper, browner hue, and is usually less powerful. On the West Coast, heroin comes almost exclusively from Mexico and South America and is most often sold in tar form; little balls of goo that look like black earwax. The third, least common form of heroin is “pill” form. “Pills” refer to heroin often sold in gel capsules and mixed with other powders – be it cocaine, methamphetamine or the more common heroin adulterants like powdered lactose, quinine and baby laxative. Pills are usually the cheapest and lowest-quality form of the drug.

What Might Look Like an Opioid High Is Actually the Symptoms of Withdrawal
Outsiders often confuse withdrawal symptoms for the effects of the drug, because the effects of withdrawal are far more noticeable than the euphoria the drug produces. Dilated pupils, sweating, shaking, slurring and vomiting aren’t signs of being high; they’re signs of opioid withdrawal. Quitting heroin is often called “kicking” in reference to the tendency to kick out one’s legs in attempt to stretch away the discomfort.

During the 1960s, heroin use rose, in part, due to soldiers returning from Vietnam who were exposed to the drug overseas, and drug dealers in urban centers seized on this opportunity. Then, in the summer of 1969, when Nixon declared his war on drugs, he cited New York City’s heroin trade as the core of the problem. The speech apparently roused the NYPD, who proceeded to arrest some of the city’s biggest dealers.

Meanwhile, suppliers in Asia became concerned that they would lose their distribution. In response, they began setting up their own networks in America’s cities to establish a more discrete trade. Heroin sold in the U.S. saw a bump in purity around this time as a result of this more direct supply line. However, purity levels would soon skyrocket as the heroin market was about to become competitive.

Though Nixon targeted heroin in his speech, in practice the drug war mainly targeted toward marijuana. With cocaine, heroin and marijuana all categorized as Schedule I drugs, DEA agents opted to pursue the smelliest, bulkiest and most conspicuous of those three substances. Colombian and Mexican drug cartels, who had previously trafficked mainly in marijuana, switched to a product that was less noticeable and carried more value by weight. Ironically, it was the drug war itself that pushed the cartels into the heroin business.

Additionally, in the Eighties, crack appeared almost overnight – and authorities suddenly deprioritized heroin. Meanwhile, as a result of the tenfold rise in heroin purity between 1970 and 1990, nasal administration became a viable option for users. Mexican and Colombian cartels introduced the drug to suppliers and users who previously had only dealt with cocaine. The new, more socially acceptable method of use endeared the drug to an entirely new demographic of trendy, wealthy and often white cocaine users.

Heroin in Powder

The demographic that had previously been most afflicted by heroin addiction took a deliberate step away from the drug. In low-income urban centers, the fallout of the 1970s heroin explosion became a cautionary tale. A generation came up witnessing the long-term effects of the drug, which had hardly existed as a threat in rural and suburban America. “Young African Americans and young Latinos were not going into heroin because they saw the destruction that occurred in their families and in their neighborhoods and they didn’t want to go down that road,” says Philippe Bourgois, a cultural anthropologist and author of the book Righteous Dope Fiend. “It was seen as a loserly thing to do.”

Meanwhile, he says, working-class white people in rural areas – which in the past had not been as affected by drug epidemics – found themselves beset by poverty due to the shifting nature of the American economy. The groundwork was laid for a potential drug crisis.

The Pharmaceutical Companies Made it Worse
For a true public health crisis to occur, there first had to be an influx of opioids into the country, the likes of which no drug cartel could muster. Enter the major American pharmaceutical companies. In the late 1990s, the pharmaceutical companies successfully lobbied the Joint Commission, an organization responsible for accrediting American health care programs thereby essentially setting the standard for American health care programs, to accept the concept of pain as a vital sign. Before that, pain was a secondary consideration. But now, physicians would be required to ask about and treat their patients’ pain. In the decade that followed, sales of prescription opioids in the U.S. quadrupled. Roughly during the same time period, the overdose rates quadrupled as well.

The Pharmaceutical Companies Made it Worse
For a true public health crisis to occur, there first had to be an influx of opioids into the country, the likes of which no drug cartel could muster. Enter the major American pharmaceutical companies. In the late 1990s, the pharmaceutical companies successfully lobbied the Joint Commission, an organization responsible for accrediting American health care programs thereby essentially setting the standard for American health care programs, to accept the concept of pain as a vital sign. Before that, pain was a secondary consideration. But now, physicians would be required to ask about and treat their patients’ pain. In the decade that followed, sales of prescription opioids in the U.S. quadrupled. Roughly during the same time period, the overdose rates quadrupled as well.

Replacement and Maintenance Therapies Gets Results
Maintenance therapies like methadone and subutex have shown better results than non-medication-assisted treatments, both in cases of addicts seeking abstinence from opioids, and for those seeking simply to carry on living relatively normal lives. Replacement therapy with drugs like methadone, subutex, kratom and even cannabis have also shown major promise in helping addicts get clean.

The success rate of addicts getting clean without the help of replacement therapies has been stated to be as low as 3 to 5 percent and as high as 20 to 30 percent. Success rates amongst those using drugs like methadone and buprenorphine to help them taper off opioids have been cited as high as 60 to 90 percent. According to the California Society of Addiction Medicine, addicts who go cold turkey are significantly more likely to relapse than those who taper off with drugs like methadone or Suboxone.

Though Attorney General Jeff Sessions recently shared his opinion that most heroin addiction starts with marijuana “and other drugs too,” the benefits of marijuana as a potential treatment for opioid addiction have become the cornerstone of several controversial treatment modalities. Researchers also believe that painkillers derived from chemicals found in marijuana such as CBD could provide an effective and far less dangerous alternative to prescription opioids.

Safe-injection Sites Reduce Risk, Too
A 2005 study in Switzerland found greater reductions in opioid use and greater rates of complete abstinence among subjects who were given injectable heroin while supervised, over those who were given methadone over the same 12-month period. With the number of supervised injection sites around the world nearing 100, and showing promise in major cities like Sydney, Vancouver and Amsterdam, activists in major cities like New York have begun the fight to bring supervised injection sites to the U.S.

Addicts Aren’t So Easily Pegged
Mugianis believes that the biggest misconception about heroin addicts is that they are non-functional. During his time treating addicts, Mugianis says he’s seen heroin users with careers and families living what many would consider successful, fulfilling lives. The harm for them mainly came when they didn’t have access to the drug. “To say that people are totally dysfunctional on opiates as Americans, we’d have to discount all that active users have given to this culture, from Billie Holliday to Edgar Allan Poe to Jimi Hendrix; people who not only functioned but excelled and enriched our culture,” he says. “The people who made our culture were high.”

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JAMA Forum: A New Year’s Wish on Opioids

As overdose deaths mount, leading to a decline in US life expectancy 2 years in a row, my New Year’s wish is for more people to appreciate this statement: Not all well-intentioned approaches to addressing the opioid epidemic are good ideas. Some are based on evidence and experience, others on misunderstanding, blame, fear, or frustration. What’s needed in 2018 is the wisdom—and the courage—to tell the difference.

Addiction Treatment

The use of the opioid agonists methadone and buprenorphine reduces overdose, illicit drug use, crime, and transmission of infectious diseases. A common misconception, however, is that these medications are part of the problem. Even in the field of addiction treatment, many still believe that those who take methadone or buprenorphine are “trading one addiction for another,” “in bondage,” or taking a “cop-out.” The majority of privately funded treatment programs for opioid use disorder do not offer patients the chance to use medications. In addition, Narcotics Anonymous allows chapters to block people who take medications from telling their stories at support meetings. Some judges order patients off medications or allow social services agencies to remove children from parents doing well on medications in treatment.

The consequence of these attitudes and actions? More fatal overdoses. A must-read investigation by journalist Jason Cherkis, a finalist for the Pulitzer Prize, found that the ideology against medications can be so fierce that it leads some to shrug off a greater risk of death.

For 2018, I ask for greater understanding that medications can help—not hinder—an individual in taking responsibility for his or her own recovery. Indeed, many patients who take medication explain that it clears their mind of intense cravings and allows them to focus on making amends and rebuilding their lives. Programs such as the Hazelden Betty Ford Foundation that historically promoted “abstinence only” are now incorporating effective medications into their programs. This is not new ground: Medication use and personal responsibility coexist for many other conditions, from diabetes to nicotine addiction.

An expanded appreciation of the role of medications would support the growing bipartisan interest in broadening access to all of the FDA-approved options. Consistent with the approach taken by the Obama Administration, President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis emphatically endorsed treatment that includes medications, and US Food and Drug Administration Commissioner Scott Gottlieb recently testified: “We should not consider people who hold jobs, reengage with their families, and regain control over their lives through treatment that uses medications to be addicted. Rather, we should consider them to be role models in the fight against the opioid epidemic.”

Criminal Justice

It is now recognized by many across the political spectrum—including the Koch brothers—that the arrest and jailing of millions of Americans for their addiction has complicated efforts to address the opioid epidemic. Charging nonviolent individuals for possessing small amounts of drugs strains the courts and jails and tags people with addiction with criminal records that hinder recovery. Yet as overdoses have spiked—in large part due to heroin laced with fentanyl—several states have again increased penalties for possessing small amounts of drugs, and some prosecutors have turned overdoses into crime scenes, charging friends and family with murder. The instinct to “get tough” is understandable, but users rarely know the content of their drugs, and the result is likely to be fewer people calling for help.

There is also the very real danger of overdose after incarceration. In most jails across the country, individuals with an opioid use disorder are forced to endure a painful (and occasionally fatal) withdrawal. While incarcerated, they lose their tolerance to opioids, raising the chance of overdose when opioids become available again. Studies document up to 10-fold elevations of risk of death upon release from detention.

In 2018, I hope for far wider adoption of alternative approaches: fewer arrests for drug use and much greater access to treatment within the corrections system. There are some inspiring examples. Innovative police departments and prosecutors in Massachusetts, New York, Washington, Vermont, and elsewhere are diverting nonviolent users of drugs to treatment instead of detention. Initial results of some of these efforts show substantial declines in recidivism.

Young Man Hands Clasped In Front of Brick WallIn addition, states including Rhode Island and Connecticut are beginning to offer access to effective treatment with medications to detainees, with transitions to community care upon release—a promising approach supported by evidence from other countries and consistent with the recommendations of the President’s Advisory Commission.

Health Care System

There is now broad understanding that the overprescribing of opioids has contributed to today’s opioid epidemic. There is much less appreciation, however, that some responses to this insight can make the overdose problem worse. At a time when most insurers still do not provide adequate reimbursement for nonpharmaceutical approaches to pain or treatment for opioid use disorder, overly restrictive prescribing policies risk pushing patients with pain or addiction to illicit drugs, a transition many have made. A few distraught patients have even committed suicide.

The good news is that tools and evidence-based guidelines and coverage policies are available to reduce excessive prescribing of opioids, while preserving the ability to provide individualized care. In 2018, I hope that medical community rapidly adopts a recently released set of quality metrics that was designed to support these thoughtful approaches.

I also hope that in the new year, more health care organizations embrace their responsibility not only to cause less of the opioid problem (by reducing excessive prescribing for pain) but also to contribute more to the solution (by expanding access to addiction treatment). A randomized trial found double the rate of short-term treatment success when emergency departments offered buprenorphine therapy and a warm handoff to ongoing treatment. Similarly, starting treatment with medications on the wards is far better than the oft-provided “detox,” which is associated with a risk of death from overdose.

An inspiring example for the new year? Massachusetts General Hospital, which recently began training emergency department physicians to start treatment on the spot.

Looking to Evidence

On opioids, it can sometimes seem that there are 3 bad ideas for every good one. Public officials have supported limiting the number of naloxone resuscitations and afterwards letting people die, requiring drug testing before enrolling in Medicaid, and launching stigmatizing public relations campaigns that can reduce the chance people will seek treatment. Can we leave such approaches behind in 2017?

Various prescription bottles and pills

Worth holding onto are approaches by states like Rhode Island, where the Governor asked a team of local experts to listen to the public, consult the evidence, and provide recommendations for priority strategies. As one Rhode Island expert told an assembled group, “Our goal here is not to make everybody in this room happy. Our goal is to cut down on overdose deaths.” Three years later, after developing a terrific dashboard, investing in access to effective treatment, developing programs to improve prescribing of opioids and benzodiazepines, and setting standards for hospital activities, the state is one of a few actually seeing a decline in overdoses.

The sheer scale of the opioid epidemic is staggering. There needs to be much more work on understanding and addressing the root causes of this problem, as well as greater willingness to try out promising approaches to the emerging threats of fentanyl and related compounds.

To get started on the right foot in 2018, the opioid epidemic demands much more of what works, and much less of what does not—as do our friends, family, and neighbors who are struggling for their very lives.

About the author (pictured below): Joshua M. Sharfstein, MD, is Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is a consultant for Audacious Inquiry, a company that has provided technology services and other support to Maryland’s Health Information Exchange. A pediatrician, he lives with his family in Baltimore.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Link to the original article here: JAMA Forum: A New Year’s Wish on Opioids

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