Gavel and pills

Op-ed: The opioid epidemic’s untold story — enormous strain on courts

Last year, more Americans died of opioid overdoses than of many cancers, gunshot wounds, or even car crashes. In fact, by at least one metric, the epidemic is more dire for Americans than was the Vietnam War: while an average of 11 Americans died per day during the 14 years the U.S. was involved in Vietnam, nearly 120 Americans died per day of opioid overdoses in 2018 alone.

As families write obituaries, death notices are printed, and flowers are delivered to grieving loved ones, an important part of the story has gone largely untold. At some point, if they survive, most opioid abusers end up in court. Perhaps they have been arrested for stealing to feed their habits or perhaps an agency has deemed them unfit parents. Whatever the reason, one fact remains: the state court justice system is now the primary referral source for addiction treatment in the country.

This reality has put enormous strain on our nation’s state courts, many of which have been overwhelmed by growing dockets and shrinking resources. In a recent survey of chief justices and state court administrators, 55 percent ranked the opioid epidemic’s impact on the courts as severe. The survey results are unsurprising, given the complexity of opioid cases: it takes an enormous amount of time to figure out what’s best for people who are addicted, how to care for their children, and what resources are available for them. And those who are placed in a treatment program with court oversight may remain involved with the court for years.

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A Prescription for Change

Amidst the ongoing opioid epidemic in the United States, the assertion that “addiction is a disease” continues to dominate the public discourse surrounding substance use and drug policy. While the brain disease model of addiction is often credited with clearing the way for a more empathetic approach to treating and policing drug use, the work of many psychological scientists suggests that addiction may arise from the same basic psychological mechanisms that allow us to discover a passion for jogging, adapt to our environment, and feel loved.

When studies conducted in the 1960s indicated that lab rats would self-administer drugs even until death, many researchers took it as evidence of the inexorable appeal of substances like morphine and heroin. A decade later, Bruce Alexander’s series of “rat park” experiments at Simon Fraser University in British Columbia, Canada would turn this claim on its head.

Alexander’s rats, which were kept isolated in small metal cages with little else to do beyond sleep, eat, and wait, also filled their time by consuming large quantities of drugs. Not so for rats raised in a less traditional lab environment, however. Free to roam within the walls of a large plywood box painted with a forest scene and filled with others of their kind, more often than not the rats chose running in an exercise wheel, climbing wooden towers and tin cans, mating, and bonding with offspring over the temptation of a morphine drip. And when they did choose to partake, the social rats consumed far less than their isolated counterparts.

“They forgot to tell us the importance of the environment,” behavioral neuroscientist Carl Hart, chair of the Department of Psychology at Columbia University, said of earlier addiction studies. “They forgot to tell us that the rats or primates only had that lever leading to the drug administration, and if that’s the only thing they have in that cage, why are we surprised that’s the activity in which they engaged?”

Since learning about the findings of these early addiction studies as an undergraduate student at the University of Maryland in the 80s, Hart — an advocate for science-based drug policy who’s appeared everywhere from “Real Time with Bill Maher” to “The O’Reilly Factor” — has extended Alexander’s rat park findings to human participants. When offered a choice between $5 at the end of a study and a hit of crack cocaine worth more than $5 right then and there, only half of people known to be addicted to cocaine chose the drug, Hart said. In a similar study of 13 recreational methamphetamine users, participants abstained at even higher rates, choosing $5 over self-administering drugs 59% of the time over the course of five 2-day trials. When the incentive was raised to $20, they chose the substance over cash in just 17% of trials.

These findings, while observed in a small pool of participants, suggest that providing people with attractive alternatives removes much of the incentive to use, Hart said. Extrapolated to the real world, alternatives might not only increase access to meaningful employment and mental healthcare for individuals with substance use issues, but could also change the way society conceives of drug use.

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Dr and Patient

The Public Is Angry About the Opioid Crisis. We Need to Listen.

Chris McGreal, a veteran reporter for the Guardian, explores in his recent book American Overdose: The Opioid Tragedy in Three Acts how many Americans have been left feeling enraged by the people who caused the ongoing opioid crisis.

“They’re very angry at what they consider betrayal,” McGreal tells TIME. “Betrayal by the medical profession for having given them these drugs without the warnings of what might follow. Anger at the companies that marketed them. Anger at the government for ignoring them for a very long time whilst their communities were devastated.” The list continues of institutions that either didn’t appreciate the impact that opioids were having on American society, or didn’t act soon enough as the problem emerged.

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Nurse Signing Ipad In Office

This E.R. Treats Opioid Addiction on Demand. That’s Very Rare.

Every year, thousands of people addicted to opioids show up at hospital emergency rooms in withdrawal so agonizing it leaves them moaning and writhing on the floor. Usually, they’re given medicines that help with vomiting or diarrhea and sent on their way, maybe with a few numbers to call about treatment.

When Rhonda Hauswirth arrived at the Highland Hospital E.R. here, retching and shaking violently after a day and a half without heroin, something very different happened. She was offered a dose of buprenorphine on the spot. One of three medications approved in the United States to treat opioid addiction, it works by easing withdrawal symptoms and cravings. The tablet dissolved under her tongue while she slumped in a plastic chair, her long red hair obscuring her ashen face.

Soon, the shakes stopped. “I could focus a little more. I could see straight,” said Ms. Hauswirth, 40. “I’d never heard of anyone going to an emergency room to do that.”

Highland, a clattering big-city hospital where security wands constantly beep as new patients get scanned for weapons, is among a small group of institutions that have started initiating opioid addiction treatment in the E.R. Their aim is to plug a gaping hole in a medical system that consistently fails to provide treatment on demand, or any evidence-based treatment at all, even as more than two million Americans suffer from opioid addiction. According to the latest estimates, overdoses involving opioids killed nearly 50,000 people last year.

Woman staring out the window

By providing buprenorphine around the clock to people in crisis — people who may never otherwise seek medical care — these E.R.s are doing their best to ensure a rare opportunity isn’t lost.

“With a single E.R. visit we can provide 24 to 48 hours of withdrawal suppression, as well as suppression of cravings,” said Dr. Andrew Herring, an emergency medicine specialist at Highland who runs the buprenorphine program. “It can be this revelatory moment for people — even in the depth of crisis, in the middle of the night. It shows them there’s a pathway back to feeling normal.”

It usually takes many more steps to get someone started on addiction medicine — if they can find it at all, or have the wherewithal to try. Locating a doctor who prescribes buprenorphine and takes insurance can be impossible in large swaths of the country, and the wait for an initial appointment can stretch for weeks, during which people can easily relapse and overdose.

A 2015 study out of Yale-New Haven Hospital found that addicted patients who were given buprenorphine in the emergency room were twice as likely to be in treatment a month later as those who were simply handed an informational pamphlet with phone numbers.

After Dr. Herring read the Yale study, he persuaded the California Health Care Foundation to give a small grant to Highland and seven other hospitals in Northern California last year, in both urban and rural areas, to experiment with dispensing buprenorphine in their E.R.s. Now the state is spending nearly $700,000 more to expand the concept statewide as part of a broader, $78 million effort to set up a so-called hub-and-spoke system meant to provide more access to buprenorphine and two other addiction medications, methadone and naltrexone.

Under that system, an emergency room would serve as a portal, starting people on buprenorphine and referring them to a large-scale addiction treatment clinic (the hub), to get adjusted to the medication, and to a primary care practice (the spoke) for ongoing care. Dr. Herring is serving as the principal investigator for the project, known as E.D. Bridge. The $78 million is most of California’s share of an initial $1 billion in federal grants that Congress approved for states to spend on addiction treatment and prevention under the 21st Century Cures Act, enacted in 2016.

Suboxone wrapper next to lipstick

“At first it seemed so alien and far-fetched,” Dr. Herring said, noting that doctors are often nervous about buprenorphine, which is more commonly known by the brand name Suboxone. They need training and a special license from the federal Drug Enforcement Administration to prescribe it for addiction (it’s also used to treat pain), although E.R. doctors don’t need the license to provide doses of the medication to patients in withdrawal.

But lately, Dr. Gail D’Onofrio, the lead author of the Yale study, has been fielding calls every week from E.R. doctors interested in her hospital’s model.

Since the study was published, a few dozen hospital emergency departments, including in Boston, New York, Philadelphia, Brunswick, Me., Camden, N.J., and Syracuse, have also started offering buprenorphine.

“I think we’re at the stage now where emergency docs are saying, ‘I’ve got to do something,’ ” Dr. D’Onofrio said. “They’re beyond thinking they can just be a revolving door.”

As Dr. Herring’s shift began one Tuesday, a 30-year-old woman in a white baseball cap entered the E.R. She said she had been using heroin for the past three years, but had been taking opioids since a doctor prescribed her the painkiller Norco after a softball injury when she was 12. She had overdosed twice and had never stopped using for more than two months at a time. Most recently, she told the doctor, she had been snorting fentanyl from a dealer who gave it to her for free in exchange for meth provided by her friend.

She was talking fast about how she hadn’t been able to sleep for days. She had just moved into a sober-living house in Berkeley, about 20 minutes away, and withdrawal was kicking in. The manager of the house had sent her to Highland.

“My heart was just pounding,” the young woman, who asked to be identified only by her first name, Angelica, told Dr. Herring. “My stomach hurt from everything going straight through me. My body just won’t turn off.”

Sign in Drs office

Dr. Herring nodded. “It’s called wired and tired,” he said. A nurse brought her a buprenorphine tablet as they went over her history, and Dr. Herring told her to come to his addiction clinic in two days for a follow-up visit and more medication.

While the care provided in emergency rooms is particularly expensive, supporters of programs like E.D. Bridge say E.R.s are the best place for stabilizing any dangerously out-of-control condition, including addiction.

“We don’t think twice about someone having a heart attack, getting stabilized in the emergency department, and then getting ongoing care from the cardiologist,” said Dr. Kelly Pfeifer, director of high-value care at the California Health Care Foundation. “And the risk of death within a year after an overdose is greater than it is for a heart attack.”

She added that since E.R. visits like Angelica’s are usually brief and uncomplicated, they aren’t as expensive as many other types of E.R. care.

Here in Oakland, a city of 416,000, opioid addiction cuts across lines of race and ethnicity. Highland has provided buprenorphine to roughly equal numbers of blacks and whites, with Latinos, Asians and other ethnic groups filling out the rest. Many of those patients are homeless and most are on Medicaid, the government health insurance program for the poor that, crucially for Dr. Herring’s program, California expanded under the Affordable Care Act. Buprenorphine can cost more than $500 a month, putting it out of reach for many of the uninsured.

Since February 2017, Highland’s E.R. has offered buprenorphine to more than 375 emergency room patients. Two-thirds of them accepted it, along with an initial appointment for ongoing treatment at the hospital’s addiction clinic.

Many were in withdrawal. Some had infections from injecting opioids. Others were seeking help for an unrelated medical problem, like a broken arm, but disclosed that they were addicted to heroin or opioid painkillers.

Dozens have continued taking buprenorphine, a weak opioid that activates the same receptors in the brain that other opioids do, but doesn’t cause a high if taken as prescribed. Even if they reject the idea of starting treatment, those who try buprenorphine in the E.R. may be more likely to do so in the future, Dr. Herring said.

Patient and Doctor Talking

“You’ve given them a chance to test-drive it,” he said. “They’ll still remember in a month, in a year.”

At Highland, patients who get an initial dose of buprenorphine also usually get a prescription for Suboxone, which comes in strips that dissolve in the mouth and is harder to abuse, to last until they can get to an addiction clinic that Dr. Herring runs on Thursdays. There, he assesses their progress and often adjusts their dose on a weekly or biweekly basis until they can find a more permanent provider.

Dr. Herring has reached out aggressively to detox centers, where people often spend a few days withdrawing from heroin, and residential treatment programs. Although many such programs haven’t allowed residents to be on buprenorphine or methadone, California has started requiring them to.

Signs posted throughout the E.R.’s waiting area — “Need Help With Pain Pills or Heroin? We want to help you get off opioids” — have helped spread the word. That’s how a man named Abai found his way to Dr. Herring; his sister had come to the E.R. with a respiratory infection, seen the signs and told him about the program.

Abai, who is 35 and asked that his middle name be used to protect his privacy, had been released from federal prison six weeks earlier, and was trying hard not to return to heroin and other drugs that he had used incessantly before his 18-month sentence. He had been buying buprenorphine off the street, but now he had a job offer and wanted a more stable source of treatment.

“It keeps me away from doing any hard drugs and that’s really critical for me,” he said. “Being on federal probation, they have zero tolerance.”

About an hour later, after Dr. Herring briefly met with him, a nurse called Abai’s name and put a buprenorphine tablet under his tongue. He left after promising to come to Dr. Herring’s clinic the next morning.

An urban public teaching hospital like Highland, with lots of mission-driven doctors and a commitment to serving the poor, can do this — particularly in the Bay Area, where attitudes about addiction are among the most progressive in the country. But can every hospital? Given the choice, would they?

“You do hit sort of a culture clash,” said Arianna Sampson, a physician assistant at Marshall Medical Center in Placerville, Calif., about two hours northeast of Oakland in rural El Dorado County. Ms. Sampson worked with Dr. Herring to start an E.D. Bridge program there last year, and her emergency room has provided initial doses of buprenorphine to 41 patients since last August. But Ms. Sampson has had to work to overcome stigma about buprenorphine — that it’s just one opioid replacing another — in the community, she said.

The Placerville program refers patients to a local community health center that prescribes buprenorphine, where many have become regular patients.

Although Highland’s E.R. treats a fair number of opioid overdose victims — about 150 last year- — they aren’t usually candidates for starting buprenorphine on the spot, Dr. Herring said. Many have just been revived with naloxone, an injectable drug that reverses overdoses, and there isn’t enough data yet about the safety of giving them buprenorphine so soon afterward.

“Figuring out how to do that safely and effectively has to be one of our greatest priorities,” Dr. Herring said.

The efforts to help don’t always work. One afternoon in May, a homeless woman named Jessica came to the Highland E.R. with a festering abscess on her arm, the result of a heroin injection gone bad. She was thin, with a whispery voice. Waiting for help, she asked a nurse what month it was.

Dr Leaving Hospital

The staff had flagged her as a patient for Dr. Herring, and he learned she had been using for seven years. Because she had injected heroin just before coming to the E.R., she was not a candidate for an immediate dose of buprenorphine; people have to be in at least mild withdrawal to start taking it, otherwise it can throw them into full-fledged withdrawal. Christian Hailozian, the E.D. Bridge program coordinator, sat down next to her with a checklist of questions.

“So you live just by yourself, in your car?” he asked. “No friends or family with you?”

She nodded.

“Do you have a phone number I can reach you at? You don’t have a phone?”

“O.K. ma’am, we’re going to let the doctors treat your arm right now,” he went on. “But we’d really like you to come back tomorrow. O.K.? It would be really good to try and reduce the amount of heroin you’re doing and try to start on these meds. You’re going to have to put yourself in a little bit of withdrawal.”

Jessica was preoccupied with her swollen arm, staring past Mr. Hailozian. After her abscess was drained, she left in a hurry, scuffing across the floor in pink slippers.

That day was a long one for Dr. Herring, who met with Abai and Jessica in between a steady flow of emergencies, including a harrowing one involving a toddler who had stopped breathing. He worked until midnight.

The next morning, he arrived at the hospital early and hustled to the basement office where he holds his weekly clinic for patients who started buprenorphine in the E.R. Angelica and Abai were already waiting, as were a young homeless couple carrying all their belongings. Ms. Hauswirth was there, too, with a friend from her detox center, Christa Blackwell.

Ms. Hauswirth wasn’t feeling well. She had never let herself experience withdrawal before, scrambling to find heroin or pills before it kicked in. Although she was now taking 16 milligrams of buprenorphine daily, a healthy dose, she was still feeling sick by the end of each day.

“It’s a war within my body,” she told Dr. Herring.

He added a nighttime dose of eight milligrams to her regimen; she had used very heavily for several years and needed more help than some.

Ms. Blackwell, 42, was livelier, telling Dr. Herring that she was doing well on 16 milligrams of buprenorphine daily.

But Dr. Herring had a warning for her: “People can feel like they’re cured. So just keep taking it, like a vitamin.”

“You’ve torched everything, and the medication is letting it grow back, and it’s going to be beautiful,” he added. “But it’s going to take some time.”


Predicting, Preventing Spread of Opioid Epidemic in Rural and Micropolitan Areas

The rapid increase of opioid overdose deaths in rural communities across the country has far outpaced the overdose rate in urban areas, and an Iowa State University-led research team wants to know why.

The researchers’ goal is to identify prevention strategies and use big data to predict which communities may be at risk, said David Peters, an associate professor of rural sociology at Iowa State who is leading the five-year project. Andrew Hochstetler, a professor of sociology, and Eric Davis, an assistant professor of computer science, are working with Peters along with researchers from the University of Iowa and Syracuse University. The team received a grant from the U.S. Department of Agriculture to fund the work.

Rural areas hit hardest by the opioid epidemic have often experienced some type of economic shock, Peters said. In many cases, manufacturing plants have closed or farms have consolidated, resulting in a loss of jobs. Peters says such hardship does not automatically put a community at risk for increased opioid use, but there appears to be a connection between how the community responds to economic decline and its risk.

Graph Opioid Epidemic By The Numbers

“We think local action plays a role in why some of these communities are more resilient in the face of the opioid crisis and why others are not,” Peters said. “The opioid epidemic seems to be centered in areas where it’s not just economic decline, but there’s a decline in everything – infrastructure, buildings, quality of life. The community is a withering place.”

Learning from communities

There is limited research on the factors driving the opioid epidemic and no evidence-based strategies for how communities can minimize or prevent it, Peters said. Previous research of economically distressed communities shows residents tend to disengage and social networks start to break down. Hochstetler says residents may be less likely to monitor public spaces or work with police to reduce crime.

“With this level of disorganization we see a shift in cultural norms that makes a community less likely to condemn illicit behavior and prevent crime,” Hochstetler said. “If communities are not proactive and that economic shock leads to higher poverty and crime rates, graffiti, trash and abandoned buildings – you’re going to have more social problems.”

Researchers will work directly with those affected by opioids to collect data and identify what has and hasn’t worked in fighting the epidemic. They are developing an advisory panel, which will include law enforcement and court officials, public health experts, city and county leaders and medical professionals, as well as former addicts and family members, to help guide their research, Peters said.

The work will focus specifically on rural areas and micropolitan communities – populations between 10,000 and 50,000 – in different regions of the country. Researchers expect to find differences in rural areas driven by farming, forestry and mining, and want to develop appropriate strategies based on those economic factors.

Predicting risk with big data

A concern for researchers and communities alike is the lag time for data on opioid arrests and deaths, Peters said. The data can help identify potential problems, but the most recent statistics are often two years old. Researchers want to eliminate this barrier by using big data to develop a real-time opioid risk indicator for communities.

“To predict a community’s risk, we must understand the local dynamics, the community’s connectivity to other areas and the risks there,” Davis said. “We don’t yet know how all the indicators for opioids are linked, but we’re going to look at data on people, economic situations, previous risk in the area and potential trafficking patterns. All of this data combined should help form a picture of the local risk.”

The ability to predict is what will set this risk indicator apart from other data sources. If researchers are successful, communities can use the tool to identify the risk and take action before it becomes a larger problem. Researchers will test the tool in 12 communities as part of the five-year project.

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Two Men Listening to a woman

A Closer Look at How the Opioid Epidemic Affects Employment

The toll that the opioid epidemic has taken on the United States is undeniable. On average, 115 Americans die every day from a drug overdose involving an opioid, and even more suffer the debilitating effects of addiction. Despite state and federal efforts to curb the crisis, there is no sign that the epidemic is letting up. Whichever way the data is sliced, things look bad and are getting worse.

Inevitably, the effects of this crisis touch multiple aspects of people’s lives: their families, their communities, and, of course, their workplaces. One narrative suggests that addiction leads to job loss and lower labor force participation. In fact, the OECD recently stated that the opioid epidemic is responsible for recent declines in labor force participation in the U.S. At first glance this claim would appear to be supported by the data: a study by Alan Krueger at Princeton University showed that among prime-age white men who are out of the labor force, over 50% report taking prescription opioids daily.

Other data, however, points to a different reality. As the epidemic continues to rage, unemployment is at its lowest level in decades. Furthermore, the numbers suggest that many people taking opioids are actually employed: comprehensive prescription data reveals that nearly 85% of opioids prescribed for working age people are paid for by private health insurance, which is overwhelmingly employer provided. While not everyone who uses opioids gets them directly from a physician—some prescriptions are illegally ­diverted to other users and an increasing number of addicts turn to heroin or illicit fentanyl—the fact remains that many people who take opioids either begin by using or continue to use legally prescribed medications that are paid for by employer-provided health insurance.

So what’s the actual connection between prescription opioids and the labor market?

To answer this question, we analyzed data on all opioid prescriptions filled at pharmacies across the U.S. from 2006 to 2014. This data includes the gender, age group, residential zip code, and payer (public or private) for the prescription. We aimed to identify the causal effect of opioid prescriptions on employment—that is, getting beyond mere correlations—which is a difficult task for at least two reasons.

First, the areas that have been hardest hit by the opioid epidemic are different than areas that have seen less dramatic rises in opioid abuse for many reasons other than employment opportunities. For example, West Virginia has higher rates of both opioid abuse and unemployment than California. While opioid abuse and unemployment will therefore be correlated when comparing West Virginia to California, this does not mean that opioid use causes unemployment or vice versa. The two states are different for a variety of reasons, such as demographic composition and educational attainment. Any of these factors, or a combination of them, could really be to blame for both high substance abuse and poor labor market conditions.


Since areas are different, we examine how employment within an area changes as prescription rates fluctuate. That is, instead of comparing West Virginia to California at a given point in time, we compare West Virginia to West Virginia and California to California over time. Perhaps surprisingly, this within-location analysis shows that changes in opioid prescriptions per capita are not associated with changes in employment. That is, increases in opioid prescribing in a particular place don’t seem to reduce employment there.

Second, while this kind of analysis controls for any time-invariant differences across locations, another complication remains. Let’s say, for example, that Charleston, West Virginia, unveils a new public transportation system that safely and affordably connects the greater metropolitan area. This public transportation system allows those who were previously isolated to connect with employment opportunities, thereby increasing employment. It also reduces traffic accidents since fewer people opt to drive, thereby reducing opioids prescribed for post-accident pain. In this case we would find that opioid use and employment are correlated within West Virginia over time, although this relationship is still not causal: there’s really a third factor—the opening of the new public transportation system—that is behind the two.

To identify what’s really going on, we need to find something that affects opioid prescribing but has no independent effect on employment. To understand how this might work, imagine a helicopter drop of opioid prescriptions on a town. This drop will increase opioid consumption, but it will not have any effect on employment except through this channel. Measuring how employment changed as a result of this helicopter drop would therefore tell us how increasing opioid consumption causally affects employment.

In our analysis, we treat opioid prescriptions to adults 65 and older as this helicopter drop. Why? We found that doctors who have a high propensity to prescribe opioids to the elderly also on average have a high propensity to prescribe opioids to working age people – and opioid prescriptions to the elderly should have no direct effect on the employment of working age people. Even though some elderly people work, and opioids may have some impact on their employment, it is unlikely that competition from the elderly is a major factor affecting employment of prime age adults. We can therefore use fluctuations in prescriptions to the elderly to isolate changes in opioid consumption that are driven by fluctuations in local prescribing practices rather than by changes in local economic conditions. This methodology of finding shifting—or helicopter drop—variables is referred to as “instrumental variables.”

Our instrumental variables analysis demonstrates that there is no simple causal relationship between opioids and employment. While there is a positive, but small, relationship between changes in opioid prescribing and changes in employment for females in areas with low levels of education, this relationship disappears among women in counties with higher levels of education. Furthermore, regardless of local education, there is no systematic relationship between changes in opioid prescribing and changes in employment rates for men.

Many observers have noted that areas that experienced the largest increases in opioid use over the past decade, like Appalachia, have had persistently low employment. However, it is important to keep in mind that these areas had low employment for decades prior to the opioid epidemic. Our results indicate that the correlation between opioid use and low employment in these areas is largely a coincidence and could be due to other factors, such as the prescribing practice styles of physicians in those areas.

Similarly, some studies have found that a high fraction of people who are out of the labor force take pain medication. However, this does not prove that taking pain medication causes people to drop out of the labor force. For example, someone with chronic back pain might drop out of the labor force due to this condition and then be prescribed opioids. In this case, it would be the patient’s back pain, not their opioid use, that caused them to leave the labor force. More research is necessary into the reasons why chronic pain in middle age seems to be on the rise, as Angus Deaton and Anne Case have noted.

In short, while the opioid epidemic has caused wide-reaching devastation, aggregate employment appears not to be one of its victims. Furthermore, evidence suggests that poor economic conditions cannot be blamed for the crisis itself. What this means is that we must look at the opioid epidemic for what it is: a self-inflicted perfect storm that arose from a combination of newly available opioids, new attitudes about the importance of pain management, loose prescribing practices, and a lack of professional accountability. The solution to the problem must lie in addressing some of these root causes.

Original article here on Harvard Business Review.

By Janet Currie and Molly Schnell

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Dr's Lab Coat

America’s doctors can beat the opioid epidemic. Here’s how to get them on board.

 A primary care physician assistant’s work typically looks a lot like that of other providers in the field: conducting physical exams, administering tests and checkups, and taking other steps to ensure that a patient is generally in good health. But in the middle of America’s deadly opioid epidemic, Lindsay Fox has taken on another task too — figuring out how to treat patients in the throes of drug addiction.

“This is not an easy group of people to treat,” Fox, who sees patients at the Southwest Mesa Clinic in Albuquerque, told me. “However, to bear witness and share space with someone who … has been supported by their family and their clinic and their provider, and has really challenged themselves to transition off of opioids and find sobriety, that’s one of the most rewarding things I’ve ever witnessed as a provider. Looking back at all the stories, that’s really what keeps me going.”

In the US, though, most primary care providers don’t get past the initial hurdle that Fox mentioned — the potential difficulty presented by people with addictions. So many don’t even have the legal ability, as Fox does, to prescribe buprenorphine, one of the medications widely regarded as the gold standard for opioid addiction care.

Even as drug overdose deaths rose to a record 64,000 in 2016, at least two-thirds of which were linked to opioids, the statistics show that US doctors aren’t on board with fully dealing with this crisis: According to the White House opioid commission’s 2017 report, 47 percent of US counties — and 72 percent of the most rural counties — have no physicians who can prescribe buprenorphine. And only about 5 percent of the nation’s doctors are licensed to prescribe buprenorphine in the first place.If you talk to America’s leading drug policy experts, one of the most common solutions they point to in confronting the opioid crisis is fixing these numbers — to massively expand access to addiction treatment. Yet access remains a problem: Only 10 percent of people with a substance use disorder get specialty treatment, in large part due to a lack of affordable and available treatment options, according to a 2016 report from the surgeon general.

Doctors and Patients Talking

Doctors’ reluctance to provide opioid addiction care shouldn’t be due to the science. Buprenorphine and other medications like it, such as methadone, are well-studied and proven to be effective. Studies show the medications cut the mortality rate among opioid addiction patients by half or more and keep people in treatment better than nonmedication approaches.

In France, the government loosened the rules around doctors prescribing buprenorphine in response to an opioid epidemic in the 1990s — and overdose deaths declined by 79 percent from 1995 to 1999 as the number of people in treatment went up, according to a 2004 study published in the American Journal on Addictions.

I went to New Mexico to figure out what’s behind clinicians’ reluctance to offer addiction treatment. There, I met with medical providers taking part in a conference for an elaborate training and support program known as Project ECHO (Extension for Community Health Outcomes), which supports providers involved in, among other things, addiction treatment. I asked them about the hurdles that they faced before deciding to treat addiction in their practices.

Some providers complained about the legal obstacles to prescribing buprenorphine. In the US, federal laws impose special rules to prescribing buprenorphine — requiring eight hours of training for physicians and 24 hours of training for physician assistants and nurse practitioners to obtain waivers to prescribe the medication.

But many providers said that the initial barriers they faced were more complicated than just going through the training courses. There are real structural barriers, they said, particularly the fear that patients with addiction are more complicated than the typical patient, and that these providers, even if they want to treat those patients, won’t have the time and resources to do it.

It’s true that patients with addiction can be more complicated. Long neglected, or even rejected, by the health care system and society at large, people with addictions often have other medical conditions, including mental health issues, along with a variety of socioeconomic problems such as joblessness, homelessness, and family turmoil.

Doctor Kneeling Next to Patient

Most doctors have historically gotten zero to very little training on addiction in medical school, according to Anna Lembke, a Stanford psychiatrist and author of Drug Dealer, MD. And now treating these patients may involve expertise and issues beyond addiction care? It’s a big ask.

Dealing with all of these issues can create “time barriers,” Fox said. Treating addiction “requires a lot of patient education. It requires a lot of time spent with the patient getting a history — getting the history of the addiction, getting the history of the present illnesses. Basically, everything you do in an appointment but to a detail that you can identify the patient’s opioid use.”

The barriers exist, in part, because of expectations built into the health care system that push medical providers to see a lot of patients quickly, maximizing how many people and services can be billed. “That’s been a barrier — to try to convince employers that I needed extra time,” Fox said.

There are also trust issues. “It takes a while to build rapport with this population because substance abuse is a very personal topic,” Fox said. “We can’t treat it like toenail fungus or something that is very basic. It takes time for people to trust you, and to be able to reveal something that brings a lot of shame to people.”

And even once patients are on buprenorphine and stable, Fox said, that’ll only begin the process of solving other problems: “Now that you’re stable and not worried about having withdrawal effects and not worried about losing your job or losing your children, what do you want to do next?”

Altogether, treating a patient for addiction isn’t just treating the addiction — but the many other issues, from homelessness to mental health, that can affect a person’s wellness too. For health care providers, addressing all of this can be time-consuming and difficult, even outside of their personal expertise.

So how do you fix this? How do you get more health care providers like Lindsay Fox?

The answer, in short: If we expect doctors, physician assistants, nurse practitioners, and others in health care to help solve the opioid epidemic, they must be equipped with the resources, training, and backup to do so. Only then will enough providers feel comfortable taking on an overdose crisis that’s become the deadliest in US history.

Doctors are worried they can’t handle addiction patients

As I’ve asked health care providers around the country what it would take to get more of them on board with confronting the opioid crisis, I’ve heard the same story again and again. Lembke, the Stanford psychiatrist, summarized the general sentiment:

“I think too much is being asked of primary care doctors, who are already overwhelmed with high patient loads and minimal support to take care of multiple complex chronic illnesses.  They have good reason to be concerned about adding one more chronic illness – addiction – to their to-do list.  On the other hand, we do not have enough addiction medicine doctors to meet the need, so combating the opioid epidemic will require all hands on deck.”

That helps explain why the great majority of opioid overdose survivors, based on a recent study of Massachusetts survivors published in the Annals of Internal Medicine, aren’t prescribed medications for opioid addiction in the year following a nonfatal overdose.

It’s not simply because health care providers think medications like buprenorphine are ineffective. In a 2017 study published in the Annals of Family Medicine, rural doctors who had the credentials to prescribe buprenorphine but didn’t prescribe it said their biggest concerns were time constraints, lack of specialty backup for complex problems, lack of available mental health or psychosocial support services, fear of diversion, and the attraction of drug users to their practice. A 2014 study in Annals of Family Medicine of doctors, both urban and rural, in Washington state produced similar results.

“Our findings suggest that more than a training course is needed to convert trainees and primary care clinics into service providers in areas that have no access to buprenorphine,” the 2014 study concluded.

Doctor Answering Patients Question

Fox shared a story to put clinicians’ concerns in context. She was dealing with a very technical issue involving a patient’s buprenorphine — an issue so technical, she said, that she wouldn’t know how to handle it without outside help.

She had a patient in treatment for opioid addiction who needed a colectomy, a procedure to remove part of the colon (to treat, for example, cancer). It would require getting the patient on opioid painkillers temporarily for the surgery.

But buprenorphine, the patient’s anti-addiction medication and an opioid itself, can block the effects of other opioids. So Fox had to figure out how to temporarily wean the patient off buprenorphine — without triggering withdrawal, which can lead to a relapse — so the surgical team could properly administer opioid painkillers. And then, after all that, she would have to figure out how to get the patient off the new painkillers and back on buprenorphine.

“That’s pretty technical,” Fox said, “but it’s doable.”

Fox knew whom to call. She reached out to her colleagues at Project ECHO, an international program that uses teleconferencing technology to connect health care providers and specialists to make it easier to share previous lessons and expertise on all kinds of medical issues. They managed to guide Fox through the process, and the patient eventually ended back on buprenorphine with no major problems.

But what would happen if Fox didn’t have access to ECHO or any other kind of structural support for dealing with this kind of patient? What if she was out in rural West Virginia — without the resources to know how to deal with such a technical case, and without access to an ECHO program or anything like it?

“I don’t really know what I would do,” she said.

It’s that point of not knowing what to do where providers often end up or fear ending up — and so they decide that perhaps these patients aren’t really worth the hassle, or that they’re not capable of adequately serving these patients at all. And while Project ECHO is far from the only support program that can help these providers, it helps demonstrate some of the issues that need to be overcome to truly get the health care system on board with fighting the opioid crisis.

With backup, doctors can provide more addiction treatment

Project ECHO attempts to address some of the structural gaps in the health care system. Using teleconferencing tools, it aims to build capacity in underserved areas, from rural counties to minority communities. ECHO currently has at least 17,200 participating health care offices around the world.

Starting in New Mexico in 2003, ECHO first tried to link specialists and primary care providers to improve treatment for hepatitis C — through teleconferencing technology, primary care providers across the state could share information with one another about treatment and continue to stay connected on a regular basis

Studies of ECHO have shown promise, finding that, for hepatitis C, patients of ECHO providers saw similar health care outcomes as specialists’ patients. Over time, ECHO has expanded to address more medical conditions, including addiction.

ECHO should help address at least one of the big complaints from primary care providers about treating addiction: poor access to specialists who are more likely to know their way around complex problems. And a 2016 study published in Substance Abuse concluded that ECHO helped facilitate an expansion of clinicians providing buprenorphine to patients (but patient outcomes weren’t measured).

Here’s how it works: The program links specialists at a hub — say, a university, hospital, or other academic or medical setting — with primary care clinicians around a region, state, or country. During each meeting, a primary care provider (or more) shares a complex patient case. As everyone on the call provides feedback, people are not only helping solve the case but also effectively conveying lessons that they’ve gained from treating complicated patients throughout their own practices.

Additionally, a teleconferencing session can include a sort of webinar on an area of research, like new treatments or newly discovered medical conditions, to help providers continue their education on treatment after training.

In Albuquerque, I got to see several of these ECHO sessions in action. Before, it was hard for me to imagine how just one case study every week or two could impart much of an education for providers. But what stuck out to me is just how many lessons can stem from one case.

One of the patients discussed in a session was a law enforcement official, whose drug use — which included opioids, benzodiazepines, tobacco, and marijuana — had spiraled out of control as he and his clinicians attempted to deal with his chronic pain and depression. His marriage and job were strained as a result of the drug use, and the collapse of either would only worsen his situation, which was already mired by a lack of financial resources to obtain proper behavioral health care.

To make matters worse, the patient didn’t want to come to terms with his addiction. He saw himself as a masculine, self-reliant John Wayne kind of guy. The idea that his drug use might have gotten out of control — and turned into an addiction — was not something that he was willing to accept. The clinicians on the call viewed this as a self-stigmatization, but instead of dismissing it offhand, they talked about how to work around it.

Ultimately, the clinicians landed on emphasizing the risk of overdose rather than addiction. “You’re bending the truth, but you’re bending the truth for a good purpose,” Brant Hager, a psychiatrist based in Albuquerque, said during the call. That, they said, could help ease the patient into taking buprenorphine and tapering off other drugs.

In reaching this conclusion, a lot of topics were covered: not just opioid addiction but the stigma that can come with it, the opioid overdose antidote naloxone, the social and mental health contributors to addiction, the commonality and problems of someone using multiple drugs (which can interact in ways that make the drugs more dangerous), pain management, and even the possibility of medical marijuana. I learned a lot in under an hour.

The weekly or biweekly teleconferences, though, are only one part of ECHO. The program also provides more traditional training seminars, including the training sessions that providers need to get certified to prescribe buprenorphine. Fox, the physician assistant from Albuquerque, said ECHO helped her get her buprenorphine waiver “sooner rather than later.”

And crucially, ECHO also acts as a networking tool — giving clinicians and specialists a means to meet and, ultimately, collaborate. “That’s where Project ECHO has been very helpful,” Fox said. “It’s connected me with a community of people that are teachers and who have experience and that I can call or email and say, ‘Hey, I just want to run something by you.’”

Women in a meeting

In providing training and specialist backup, ECHO is trying to fill a medical education gap in the US for addiction treatment. ECHO’s leaders admit that they can’t possibly fill the whole gap, but they hope to at least help. “In no way does ECHO replace basic undergraduate or graduate medical education,” Miriam Komaromy, who oversees ECHO’s addictions program, told me. “ECHO really follows that.”

Project ECHO is not without its critics. After Congress passed a law in 2016 encouraging federal support for ECHO programs, Chris Langston, the vice president of health care services at the Aging in New York Fund, cautioned that there isn’t robust empirical evidence for ECHO and patient outcomes outside of hepatitis C care. In his view, we should demand much more research before expanding the model to help with other medical conditions.

Still, Langston said there is reason to believe ECHO could work for addiction as it worked for hepatitis C. A problem with hepatitis C treatment, Langston said, seemed to be that primary care providers simply didn’t believe it was in their wheelhouse to treat it — even if they knew what to do, they thought it should be left to specialists. ECHO may have changed this, Langston said, by legitimizing the treatment of hepatitis C in primary care — essentially, boosting providers’ self-efficacy.

“Nobody was treating hepatitis C at all outside the academic center at the University of New Mexico,” he said. “It wasn’t like people were doing it badly. I think the best interpretation was that the physicians didn’t think they were supposed to do this.”

That self-doubt has historically applied to many primary care providers when it comes to addiction, Langston said. It’s not because these providers aren’t aware of effective opioid addiction treatments like methadone and buprenorphine; they tend to believe those issues should be left to other providers. So, he said, perhaps Project ECHO could help boost self-efficacy among primary care providers and encourage them to treat addiction on their own.

But, again, Langston cautioned that more research into ECHO is necessary.

Mia Lozada, a doctor who treats opioid use disorder at the Indian Medical Center in Gallup, New Mexico, said that a boost in self-efficacy is part of what ECHO did for her. “When an individual doesn’t feel as isolated — doesn’t feel as if you’re an island trying to treat opioid use disorder — that confidence will beget more confidence in a given clinic, a given hospital, or a given region,” Lozada said. And that confidence, she added, will make doctors more likely to treat addiction.

To address the opioid crisis, doctors need a lot more institutional support

As Komaromy acknowledged, ECHO can’t address all the problems providers face. It is, after all, just one program trying to address a slice of a systemic problem.

“Addiction has typically fallen between the cracks of behavioral health and physical health, and no one has really wanted to own it as a problem,” Komaromy said.

Some of that is caused by stigma and misconceptions about addiction. After decades of the US treating addiction as a criminal justice problem instead of a public health concern, much of the public, including health care providers, still views addiction as an issue that demands a punitive response, and sees those with addiction as part of the problem instead of people who need help.

For example, a prominent belief about patients with addictions is that they’re more likely to lie to clinicians. The reality is that all kinds of patients lie to their providers to some extent — to avoid shame and embarrassment. But to the extent that this is true for addiction patients in particular, it may be a survival mechanism in the face of a society that often stigmatizes people who use drugs.

Doctor On Comp

“If you think about how hard it is to be addicted and struggling, those behaviors are coping strategies that have been developed by people who have been using illicit substances in order to survive,” Komaromy said. “They’re afraid of being rejected in the medical setting, and they often have had very bad experiences working with doctors and other health care providers. So their first instinct is to sort of say what they think the provider wants to hear. Then when the provider realizes that’s not true, the whole relationship breaks down.”

There’s also the idea that addiction patients are particularly hard to treat. While people with addiction do often present other complex problems, that may be a part of a vicious cycle — a result of the health care system failing to treat people with addiction in the first place.

“If you only saw breast cancer after it metastasized, you would think breast cancer is very, very hard to treat,” Leslie Hayes, a family physician in Española, New Mexico, who was named a “Champion of Change” by the White House in 2016, told me. “That’s what we’re doing with substance use disorder. We’re not diagnosing alcoholism until patients come in with end-stage cirrhosis. We’re not diagnosing opioid use disorder until they’ve overdosed several times. We’re not diagnosing it soon enough.”

To the extent that patients with addiction are more complicated, programs like ECHO can help. But it can’t address the full scope of the problem; as the 2017 study of rural doctors found, concerns beyond having access to specialty backup include time constraints and a lack of available mental health or psychosocial support services.

Addressing these kinds of issues will simply require more people involved in addiction work — staff to help a clinician handle more patients, and staff or referrals that can offer mental health and psychosocial services. “Physicians just need more support,” Holly Andrilla, a co-author of the study on rural doctors, told me.

Vermont — with its innovative “hub and spoke” system, which works to integrate addiction treatment into the rest of health care — has attempted to address concerns about poor support for providers. To make addiction treatment more accessible, the state offers providers teams, made up of a nurse and a behavioralist, that handle the extra workload that comes with addiction patients, while the clinician can continue to focus on treating the condition itself.

Echo building

When I checked out Vermont’s hub and spoke system in 2017, providers consistently emphasized how crucial those teams were to the program. Heather Stein, a primary care doctor at the Community Health Center in Burlington, said the teams alone made a huge difference in her practice. Before, she felt she couldn’t take more patients, “because I felt like there were so many i’s I had to dot and t’s I had to cross in every office visit.” But now her team calls the patients, makes sure they’re seeing a therapist, and gets them to come in for pill counts. “All I’m really having to address is their medical symptoms and their medical issues,” she said. “It made me able to take on a larger panel of patients.”

There are also broader structural issues with health care costs. For example, health insurers often impose barriers to avoid fully paying for addiction treatment. This makes addiction treatment more expensive for patients, but it also discourages health care providers from offering addiction treatment. For providers, it’s a simple calculation: Why treat people who will have complicated medical conditions if you can accept far fewer patients who will take less time yet reliably pay at the same or higher rates?

There are ways around this problem as well. Virginia, for instance, in 2017 boosted reimbursement rates for addiction providers through its Medicaid program. While the results are early, independent evaluations from researchers at Virginia Commonwealth University have already found some promising results: The number of clinicians who provided addiction care went up, the number of Medicaid members receiving treatment also rose, and the number of emergency department visits related to opioid use disorder declined. Looking at these results, other insurers, public and private, could boost their own reimbursement rates for addiction care.

Beyond encouraging existing providers, more could be done to bring in new clinicians to addiction care. Lembke of Stanford told me of her potential solution to the problem — what she called AmeriCorps for addiction treatment: “Why don’t we recruit these young people and say, ‘Hey, we’ll pay back your med school loans, in part, if you spend a couple years in rural West Virginia treating people with addiction’? We need to come up with creative ways like that to bring people into the workforce.”

There are also legal barriers. Besides the training requirements that health care providers need to meet to prescribe buprenorphine, the federal government also sets caps on how many patients each provider can prescribe the drug to. The cap can be raised, but only by meeting additional hurdles. These are barriers that aren’t in place for a lot of other drugs — not even opioid painkillers, the initial cause of many patients’ addiction.

Providers told me that some rules are needed (since buprenorphine is an opioid that can be diverted for misuse). But they argued that the current rules are tilted too far in a burdensome direction. Congress could loosen the restrictions — just as France relaxed its rules for buprenorphine prescribers in the 1990s, and subsequently saw big drops in drug overdose deaths.

So while there are structural issues, they’re not insurmountable — whether it’s through a program like ECHO, a systemic approach like Vermont’s hub and spoke system or Virginia’s Medicaid reforms, legal changes, or, more likely, all of the above and more. There just needs to be a demand for such reforms, from providers and the public, to treat addiction as a health care problem — and not just for opioids, since the next addiction crisis may very well involve a whole different class of drugs.

In the end, this could help health care providers treat the patients they’re already seeing. After all, more than 20 million people in America have a substance use disorder of any kind, from alcohol to opioids. Chances are providers who don’t treat addiction are already seeing some of these patients, even if they’re not formally diagnosed yet.

As Hayes put it, before she got her buprenorphine training, “I was already taking care of all of these patients anyway. I just wasn’t able to treat their opioid use disorder.”

Original article here posted on

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The Per Capita Cost of the Opioid Crisis

The opioid epidemic has hit West Virginia, Washington D.C., and New Hampshire the hardest in terms of costs per capita, according to a new analysis released Tuesday by the American Enterprise Institute.

The new study breaks down costs identified by the White House Council of Economic Advisors, which estimated the opioid epidemic cost the country $504 billion in 2015 alone in mortality costs as well as health, productivity losses and criminal justice costs. The estimate is based on “local wages, health care costs and criminal justice costs along with variation in opioid-related death and addiction rates, and average age-adjusted value of statistical lives lost,” according to the report.Homeless Man Injecting Heroin

Of the lower 48 states and Washington D.C., West Virginia by far had the highest total per-capita burden at $4,378, followed by Washington, D.C. ($3,657); New Hampshire ($3,640); Ohio ($3,385) and Maryland ($3,337). Meanwhile, Iowa ($705), Mississippi ($703), Texas($653), Montana ($596) and Nebraska experienced the lowest cost per capita, with Nebraska’s the lowest at $394. Alaska and Hawaii were not included in the analysis due to difficulties in obtaining consistent data.

“The misuse and abuse of prescription opioids as well as the addiction and abuse of heroin in the United States imposes incredible hardship on those who are addicted, their families, communities, and the economy more broadly,” the report concludes. ” As overdose deaths and costs associated with opioid abuse rise, policymakers are increasingly looking for ways to stem the epidemic. Identifying the local per capita economic burdens should inform policymakers in this effort.”Opioid Per Capita Cost

The working paper, to be published next week, was released a day after President Donald Trump announced his administration’s most comprehensive agenda to combat the opioid epidemic since he declared it a public health emergency in October 2017. His plan includes policies for increased treatment availability, lowering the number of prescriptions and increased penalties for drug dealing and trafficking, including minimum sentences and in some cases the death penalty. 
More than 42,000 Americans died of opioid-related overdoses in 2016, according to the Centers for Disease Control and Prevention, and the National Institutes on Drug Abuse estimates that more than 115 people die daily from using prescription opioids, heroin and fentanyl – more than the number of deaths linked to guns, car crashes, or the HIV/AIDS epidemic.

By Katelyn Newman , Digital Producer, Staff Writer |March 20, 2018

Original article here originally posted on
Broken Metal Chain

What You Should Know Before You Say ‘Addiction Is A Choice’

I do not understand the belief held by some that one chooses to become addicted. If addiction is defined as a compulsion to do something or behave a certain way repetitiously regardless of the negative consequences, I find little logic in anyone doing this by choice. Especially if it interferes with the well being of one’s life or hurts the ones we love.

My education and experience tells me addiction doesn’t start out as an act beyond our control. It begins in a slow, progressive notion and we often don’t even recognize its enormous growth until well beyond the awareness of many of those around us. Which, for a time at least, we will adamantly deny.

At first, we try something meant to give us a pleasurable experience and we enjoy the way it makes us feel. We like the giddiness of that first glass of wine after a stress filled day, or that rush of excitement in a winning hand at blackjack. And then we do it again and achieve the same results. And eventually, like it enough to create meaning around it.

We organize birthday barbecues and football parties where consuming large amounts of alcohol is an acceptable way to “celebrate” the occasion. We plan “family” trips to Vegas yet don’t see the outside of those dark walls for days because we are one step away from hitting the jackpot.  Euphoria and fulfillment and the broken promise of happily ever after are just beyond our reach.

We ignore the onlookers who frown at our behaviors and we discount their judgment as simply not knowing how to “have fun” or live on the edge. What we don’t realize is our behaviors have stopped being “fun” long ago, and we are wickedly close to falling off the edge, but we are forever chasing that euphoric feeling that swept us off our feet in the honeymoon phase of our distorted relationship with addiction.


What we also fail to recognize in our blindness of addiction is that not only are we continuing to do it because of the the way it makes us feel, we are equally doing it for the way it makes us not feel.  Research is only growing about addictions being a common yet detrimental escape from the unwelcomed experiences of our past. An incomplete mourning for the loss of something or someone meaningful to us that subsequently changes the direction of our life path.

An unexpected death of a close family member or friend, a difficult divorce, an unwanted move or loss of a job can all take considerable chunks of well being out of a previously unscathed being. These adverse experiences can happen in our childhood or as an adult and can weaken our whole existence and life motivation. Especially when those around us are equally effected and unable to help mend our pain because of their own.

It is of no surprise anxiety and depression frequently intertwine in the tumultuous relationship with addiction. And so begins the infinite cycle of turning to our addictions to numb the pain, which further inflames the anxiety of our choices and fuels our depressed state of being. Only causing us to turn toward our addiction all the more.

Soon we learn to escape our fears and insecurities with our addiction because we feel forcefully giddy and excited about what we are doing at that moment that brings us pleasure. And we create misconceptions — that somehow we will achieve ultimate satisfaction and perpetual happiness. Or at least we won’t think about the pain. At least not today.

Eventually this relationship with addiction evolves from giving pleasure and avoiding pain to becoming a necessary evil to merely exist. The compulsion sets in and our minds become fixated on our unquenchable urge for that next drink. Oftentimes, our bodies develop a physical dependence we can no longer ignore. So we drink to stop our hands from shaking. We do it to feel “normal” again, at least enough to function in our daily routine. We gamble away that last dollar to suffice the unattainable desire to double our wins. To win back that lost tax return that was meant to pay our mortgage. To get back that feeling of euphoric satisfaction and enjoyment we felt when we first met our addiction.

In the end and without help beyond ourselves, addiction overpowers us with a curse that becomes so strong, nothing and no one in our own innately selfish-driven world can stop us from it. Not our spouses, our children, our parents, our failing health or our careers. Not one thing can stand between our addiction and our mind. We have succumbed to a curse that is larger than us and it becomes stronger than our ability to make any choice to stop. We stand to lose it all and that still might not be enough to stop the insanity. The curse destroys all that was good in our lives and renders us hopeless for a better tomorrow.

Therefore, what they should say…

Addiction is a disease that needs help to recover.

According to multiple health reports published within the National Institute of Drug Abuse and Harvard Health Publications, researchers now recognize addiction as a chronic and reoccurring disease that changes both neurological brain structure and overall cognitive function. This transformation happens as the brain experiences a series of chemical changes, beginning with recognition of pleasure and the lessening of its effect with continued use of that which once gave us enjoyment, and ending with a drive toward compulsive behaviors attempting  to sustain it.

What we once found to be pleasurable in its infancy is altered within our brains to result in a compulsion for utter destruction in the part of our brain we rely on for emotion and pleasure. Our brain is no longer functioning the same way as before we became addicted. So we act on our compulsions because pleasure becomes impossible without intensifying our addictive tendencies.

This alteration in our brain and resulting compulsion is real, and when intermingled with the weakening grip on our addiction and all that once had meaning in our lives, it destroys. And it knows no social, racial or economic barriers.  It can creep into the least expecting community, impact whole cultures and span multiple generations.  Whether it be personally impactful, or through the far reaching ripple effect that results because of it. Ultimately, no one escapes unharmed. Addiction is that strong.

But there can be hope. Hope that there can be change.

To say addiction is a choice and not a disease that needs help is only further perpetuating the stigma that has carried on for decades, and for many, has contributed to loss of time spent having a life worth living. Or worse, of living any life at all.

Recognizing addiction as a potentially life threatening disease that requires continuous effort to recover successfully can allow us to make a much needed paradigm shift in our morally judgmental way of thinking. And to dispel the assumption that all those who suffer continue to do so by their own choosing, can begin to awaken the possibility that recovery exists. But it can not be done without a sincere commitment to end the stigma that at times prevents many from venturing toward the narrow path of healing.

I believe this commitment may include reaching beyond the current treatment models with floundering success rates and incorporating additional unorthodox and holistic methods that are slowly gaining more acceptance in the professional recovery communities. We can begin to focus on tailored recovery modalities because no longer can we assume that the traditional ways will always work for everyone.

My personal and still very raw experience with addiction and recovery has yet to be shared, but there is no doubt in my forever recovering mind the addiction that was in my path was not there by any ounce of my own choosing. My path to destruction came upon me as the horrific and overpowering curse that it was and mentally stole a mother from her children for 18 months of their lives I can never get back. It rendered me helpless for weeks on end and ultimately ended the career I had spent 15 years building for the person I mistakenly thought I wanted to be. It swallowed my joy and buried deep into my unconscious mind all that I once loved. It changed the unscathed child I yearned to be and morphed me into a monstrous entity my conscious mind will never want to know.

Regardless of what society continues to say about addiction, my personal truth will always be I didn’t willingly choose addiction. Rather the disease of addiction chose me. And it was only through the brokenness of my entire being and the insanity of my disastrous mind that I found the miraculous help and saving grace that gave me strength to overcome my addiction that almost became stronger than my will to survive.

Original article here written by Kelly Hubbard or “Kel B”, article also published on

To understand why America’s opioid epidemic keeps getting worse, just look at this map

America’s opioid epidemic keeps getting worse, with the latest data showing that drug overdose deaths in the US climbed by roughly 21 percent between 2015 and 2016 — from a record high of more than 52,000 to a new record of nearly 64,000. About two-thirds of those overdoses were linked to opioids.

To understand how this crisis keeps growing, take a look at an insightful map by amfAR, an advocacy group dedicated to the fight against HIV/AIDS. The map shows three things: the availability of facilities that treat drug addiction, the facilities that provide at least one medication for opioid addiction (marked as MAT, or medication-assisted treatment, on the map), and the facilities that provide all three kinds of medications for opioid addiction.

Map of US States Per County For MAT

Clearly, there are a lot of gaps in coverage. In a post on Health Affairs, Austin Jones, Brian Honermann, Alana Sharp, and Gregorio Millett of amfAR looked at 2016 data from the Substance Abuse and Mental Health Services Administration and found that only 41.2 percent of the more than 12,000 drug addiction treatment facilities in the US offered at least one kind of medication for opioid addiction. Only 2.7 percent offered all three.

These medications are widely considered by experts to be the gold standard in opioid addiction care. Studies, including systematic reviews of the research, have found that opioid addiction medications in general cut all-cause mortality among opioid addiction patients by half or more. The Centers for Disease Control and Prevention, National Institute on Drug Abuse, and World Health Organization acknowledge their medical value. That doesn’t mean these medications are for everyone (they’re not), but there’s a lot of good evidence for their general efficacy.

 So it is pretty bad that a majority of addiction treatment facilities don’t provide access to any of these medications. It is similarly bad that even more of these facilities don’t offer access to more than one kind of medication; the individual types of medications don’t work for everyone — nothing in addiction treatment does — so it’s important to provide multiple options.

We are, as a country, nowhere close to that goal.

If the US isn’t making good use of even the bare minimum of evidence-based treatment, it’s no wonder the opioid crisis keeps getting worse.

One caveat: The map likely understates the amount of addiction treatment that is available in some parts of the US. For one, physicians can gain the ability to prescribe buprenorphine through a special waiver, but those kinds of practices wouldn’t appear in a map solely dedicated to drug addiction treatment facilities. Still, other data collected by amfAR shows that there are big swathes of the country without doctors who can prescribe buprenorphine.

There’s also other data that exposes America’s big gaps in addiction treatment. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country lacking affordable options for any treatment — which can lead to waiting periods of weeks or even months.

The map exposes America’s inaction in the opioid epidemic

More than showing the specific counties and states that don’t have access to some kinds of treatment and medications, amfAR’s map shows that America isn’t truly serious about dealing with its opioid epidemic.

Given that we know these medications are highly effective for opioid addiction, providing access to them should be the low-hanging fruit for dealing with a drug overdose epidemic fueled by opioids. Coverage remains sparse, and there’s been little attention to changing that.

 A major reason for that is stigma. These medications are often characterized as “replacing one drug with another” — say, replacing heroin use with methadone use.

This fundamentally misunderstands how addiction works. The problem is not drug use per se; most Americans, after all, use caffeine, alcohol, and medications without major problems. The problem is when drug use becomes a personal or social burden — for example, putting someone at risk of overdose or leading someone to commit crimes to obtain drugs.

Medications for opioid addiction, by staving opioid withdrawal and cravings without leading to a significant risk of overdose, mitigate or outright eliminate those problems — treating the core concerns with addiction.

 Another reason for the treatment gap is a lack of federal attention. In the past few years, for example, the only new federal effort to dedicate a serious amount of money to the opioid crisis was the Cures Act, which committed $1 billion over two years.

Even that sum fell woefully short of the tens of billions annually that experts argue is necessary to deal with the opioid epidemic. For reference, a 2016 study estimated the total economic burden of prescription opioid overdose, misuse, and addiction at $78.5 billion in 2013, about a third of which was due to higher health care and addiction treatment costs. So even an investment of tens of billions could save money in the long run by preventing even more in costs.

As Stanford drug policy expert Keith Humphreys previously told me, “Crises in a nation of 300 million people don’t go away for $1 billion. This is the biggest public health epidemic of a generation. Maybe it’s going to be worse than AIDS. So we need to go big.”

America has not gone big, at least yet. So the opioid epidemic continues, killing tens of thousands of people in the process every single year.

By German Lopez on January 10, 2018

Link to interactive map here: Opioid and Health Indicators Database

Link to original article here: To understand why America’s opioid epidemic keeps getting worse, just look at this map