Trainspotting in the 21st Century
The United States is facing a massive health crisis in the face of epidemic opioid addiction rates. But what are we doing about it?
“Max” was happily married when he became addicted. He got a prescription for Vicodin for a back injury. Before long, he was taking twice the amount he was prescribed. Max liked how the drug made him feel. He was more relaxed and was able to worry less. But he was also tired more often, and had to drag himself around some days.
Eventually, Max’s prescription ran out and he got sick. He sweated profusely, despite it being December. His body was racked with pain and he was scared. He started doctor shopping to get more prescriptions. He would lie about fictitious pains and fill the prescriptions at different pharmacies. Max would sometimes drive hours to faraway pharmacies so as not to be discovered as a fraud. He began ignoring his business and his marriage suffered. But the only thing he was focused on was getting more Vicodin.
One day, Max was a pharmacy with his wife when the computer flagged him. The pharmacist said they would not fill the prescription because he just had several filled in short succession in the area. He was busted, and now his wife knew the truth. Yet in spite of this, Max’s biggest fear was the withdrawal he would now go through.
The pharmacist gave Max the number to an addiction hotline. They told him that he could get help for his problem. Had he been alone, Max would have thrown the number away. But his wife pushed him, and with her support, Max got the help he needed and he is now clean and sober. Yet there are thousands upon thousands of Maxes in the United States right now, and many of them are not getting the help that they need.
Opioid addiction is killing over 30,000 Americans each year. According to the U.S. Department of Health and Human Services (DHHS), drug overdose deaths are the leading cause of injury death in the United States and opioid abuse alone has reached epidemic proportions. Which begs the question, “Why aren’t we making more noise about this?”
Abuse of opioids can begin when a patient is given a valid prescription for painkillers for a legitimate reason.
An opioid is a substance which is able to bind to the opioid receptors of the brain. An opiate is a specific substance derived from naturally occurring opium. While opioids have been used medicinally for nearly 5,500 years, their modern uses include treating extreme pain resulting from severe injury or surgery and chronic pain resulting from ailments such as cancer. Opioids include drugs such as morphine, codeine, hydrocodone (Vicodin), oxycodone (Percocet), and fentanyl/carfentanil.
Abuse of opioids can begin when a patient is given a valid prescription for painkillers for a legitimate reason. These medications, however, can still put the patient at risk. Some patients may continue to take the medication for its euphoric effects long after their legitimate need for it has passed. This paves the way for addiction.
When drugs are used repeatedly, the body can build up a tolerance to them while simultaneously developing a dependence on them. Tolerance is when the body needs more of the drug to produce the same effect. Dependence is when the body needs the drug to prevent unwanted withdrawal symptoms. During an opioid overdose, a person may lose consciousness and stop breathing. Combining opioids with alcohol or other drugs, such as Xanax, Valium, or other sedatives, can increase the risk of an overdose.
Until the late 1900’s, doctors worried that patients could and would become addicted to these powerful medications…
Approximately 22% of patients list chronic pain as a symptom when they visit their doctor. It was not until recently that doctors began using opioid drugs to treat non-cancer pain. Until the late 1900’s, doctors worried that patients could and would become addicted to these powerful medications, would overdose on them, or would become tolerant of them, thereby lowering their effectiveness. In fact, just a century ago, doctors believed that pain actually made people stronger.
This philosophy began to change in the 1980’s, when the medical culture shifted towards a policy of eliminating pain altogether. Doctors began to receive backlash in the medical community if their patients experienced any pain. This led to an increase in prescribing opioids for pain management without carefully considering the risk of overuse, abuse, and risk of overdose. In fact, doctors were being taught that as long as a patient was responding to opioids, no dose was too high. So if they developed a tolerance to a particular amount, the doctor simply increased that amount. There was no cap to say how much was too much.
In 1991, doctors wrote 76 million prescriptions for opioid painkillers. By the early 2000’s, patients could tell a doctor a number on a pain scale and usually walk away with some type of opioid. So unsurprisingly, the number of prescriptions written for opioid painkillers had nearly tripled by 2011, when doctors wrote 219 million prescriptions. While addiction and overdose rates increased parallel to the increase in prescriptions, the medical community was nevertheless slow to react.
Alexander Walley, a physician and director of addiction consultation services at Boston Medical Center, told The Guardian, “The simplistic idea was, ‘Oh, this is all about prescription opioids, and therefore that’s all we need to do: reduce the supply of prescription opioids and we’ll reduce all these deaths and people won’t become addicted.” But as federal and state restrictions on opioid prescriptions were tightened, those seeking relief turned to heroin, which is a cheaper but deadlier alternative. “What we’re seeing now is that even as you reduce access to prescription opioids, you’re seeing an explosion of heroin use and heroin overdoses,” said Dr. Walley.
Central Appalachia appears to have been ground zero for the overdose crisis.
This epidemic has affected every racial demographic, although Whites and Native Americans have the highest death rate. Oddly enough, racial stereotypes may be a factor in why the death rates in African –American and Hispanic communities are lower. The New York Times found that doctors were more reluctant to prescribe opioids to these minority patients out of fear that they would either sell them or become addicted to them. Although there is no clear geographic pattern for high levels of opioid prescriptions, there is speculation that the variances are more a matter of doctors disagreeing about how much pain medication to prescribe than anything else.
Central Appalachia appears to have been ground zero for the overdose crisis. This area is predominantly rural, and most of its employers specialize in physically demanding industry, such as mining, agriculture, and logging. Such work is rife with injury, making its workforce highly susceptible to being prescribed opioid painkillers. Michelle Lofwall, associate professor at the Center on Drug and Alcohol Research at the University of Kentucky School of Medicine, told The Guardian, “At the time, it wasn’t understood how addicting these prescription pain medications were.”
Utah tried to quell its opioid addiction problem early on. In 2007, the state enacted a two-year public health-based program to eradicate abuse of prescription painkillers. This program was based on researching causes of drug abuse and educating the public about how to avoid addiction. It worked initially, resulting in a 25% decline in overdose deaths. But with a meager $300,000 budget, funding soon ran out and overdose deaths began to increase again. Six years later, the Utah legislature declared drug overdose deaths to be a public health emergency and passed new measures, including a needle-exchange program, to battle its epidemic.
In New England, the stakes are even higher. Not only are those states dealing with people abusing pills, there has been a rise in the abuse of fentanyl as well. Fentanyl is 50-100 times stronger than morphine, and is the strongest opioid pain reliever approved for human use. Fentanyl is often cut into regular heroin, leaving users buying a drug that may be lethal due to its strength. New Hampshire saw a rise in fentanyl-related deaths between 2013 and 2014. Fentanyl was a factor in over 1,300 opioid-related deaths in Massachusetts in 2015.
Fentanyl has become more prevalent in other states as well, including Ohio and Florida. Florida, once known for its “pill mill” clinics, began cracking down on doctors who were writing prescriptions for large amounts of opioid painkillers. For a short time, the overdose death rates in the Sunshine State were dropping. But they soon began to rise when, as in Utah, treatment funding was cut. James Hall, an epidemiologist at Florida’s Nova Southeastern University, told The Guardian, “Florida did a good job of cracking down on the supply side, but at the same time they actually cut treatment funding. Not addressing the demand side of the problem has contributed to the continuing of the epidemic.”
North Carolina is not immune to this problem. A 2016 article posted by WNCN reported that North Carolina has four of the Top 25 cities for opioid addiction. These cities were, by rank in the 25, Fayetteville (18), Jacksonville (12), Hickory (5), and Wilmington (1). The stories of those addicted mirror those in other states: most started out using validly prescribed painkillers. Eventually, these prescriptions ran out but the addiction remained. The patient – still needing the drug – shifted to heroin, and the problem was compounded. Tessie Castillo is an employee at the North Carolina Harm Reduction Coalition. She told WNCN that most of the people her organization treats come from all ages, races, and economic backgrounds and would never have used illegal drugs. “[These people say] they would never use a syringe, sometimes they’re afraid of needles, but little by little as that addiction becomes more severe, they start doing things they said they’d never do before,” she said.
“People have views still that being addicted is your own fault, that it’s a spiritual flaw, that you should be able to stop on your own.”
In the face of this epidemic, first responders have wider access to Naloxone, a drug that can reverse opioid overdoses. Naloxone – sold commercially as Narcan – essentially kicks the opioids out of the opioid receptors of the brain. This “opioid antidote” can be administered through a subcutaneous injection or a nasal spray. It usually works within about 5 minutes, allowing an overdosing person to begin breathing more normally and avoiding brain damage by a lack of oxygen. Narcan usually wears off completely after about 90 minutes, but by this time, the body has been able to process enough of the opioids that the person is unlikely to stop breathing again.
Still, Narcan only treats the physical overdose. It does nothing to address the underlying problem of addiction. That’s where long-term treatment and solutions come in. Yet access to adequate treatment and the stigma of addiction is still a large hurdle for those who want to get help. As Professor Lofwall said, “People have views still that being addicted is your own fault, that it’s a spiritual flaw, that you should be able to stop on your own.” While treatment is available, many people may not be able to afford it. With 19 states refusing to expand Medicaid, those who need treatment most may not get it. The future of those who can hangs in the balance with the Republican-proposed repeal/replacement of the Affordable Care Act.
It is time for us as a nation to face this problem and to provide adequate resources to the thousands of Maxes out there. As Murray Penner wrote in 2015, “People with substance use disorders are our spouses, children, parents, brothers, sisters, co-workers, and friends who have a right to high quality, culturally competent, and client-centered services. In a nation with as many resources as the U.S., it shouldn’t take…[a] rash of opioid related overdoses for us to address the… needs of many U.S. residents.”