The Opioid Epidemic

Our country is currently gripped by a crisis most commonly referred to as the Opioid Epidemic. In 2017 alone, the Federal Government estimated a death total of roughly 72,000 people. This total indicates that nearly 200 people are dying each day as a result of opiate overdose. By September of 2017, synthetic opioid overdose deaths were estimated at almost 29,000. By March of 2018, the synthetic opioid death toll rose to 30,000. By all indications, synthetic opioid deaths will continue to trend upwards while painkiller and heroin overdose deaths are beginning to trend downward. While these numbers are staggering, they indicate that the opioid epidemic is showing no signs of slowing down. So let’s ask the question…

Who is to blame for the rise of opiate use in the United States?

If you’re anything like me, you have been devastated by the impact of the opioid epidemic, and the far-reaching implications it has on a larger scale. You might also be seeking an opportunity to place blame or exact retribution on those responsible for such a devastating evil. However, before jumping to conclusions, it’s important to consider as many facets to this problem as possible in order to gain a better understanding of the problem. Additionally, it is necessary to research what we need to do to enact long-lasting, positive change.

The Doctors

Growing up in a family of doctors has given me profound confidence in the medical field. That being said, my intent is not to sully an entire field of study over a few bad eggs. However, the more I continue to work in the industry of mental health, the more I recognize a glaring problem within the field of medicine. My criticism is rooted in the over-prescription of opioids to treat pain in patients. One cited culprit for the over-prescription of opioids is the recommendation of several professional organizations to make pain “the fifth vital sign.” This propagates a widely held belief by physicians that opioids are the most effective analgesics known to treat a patient’s pain.

Simply put, the majority of physicians that I continue to encounter in the medical field, almost always resort to putting a patient on opioids in order to treat their pain. Even after receiving prior knowledge that the patient is currently in treatment for addiction to opiates, the physician will still administer and prescribe these drugs to the patient. To me, this is totally insane.

I can see the conversation happening in my mind. “You have a hurt ankle? Here are some opiates; Hurt shoulder? Take some of these pills; Stomach ache? Pop a few of these and let’s check back in a week.” You get the picture. This one-track minded solution is devastating to addicts in recovery and has caused treatment centers like Stonegate Center to work tirelessly to save lives devastated by this flawed practice. The physician is regarded as the professional, and a drug like hydrocodone is considered acceptable because it was prescribed by the doctor. What causes this? Incompetence, ignorance, or an intent to do harm? We’ll let you be the judge.

The Pharmaceutical Companies

Who else is at fault? The low-hanging fruit is the pharmaceutical industry. Companies like Purdue Pharma aggressively marketed the drug OxyContin, and are now facing a plethora of lawsuits. Evidently, whether through subversive advertising or a the company’s inability to realize how powerful this pill was, Purdue Pharma laid the foundation for the opioid epidemic.

With any basic knowledge of how the FDA or pharmaceutical industry works to get a drug onto the open market, most would consider the introduction of such an addictive medication unlikely, right? The FDA is there to protect us from certain instances like that. However, a new report by the Justice Department asserts that Purdue Pharma not only knew about the drug’s potential for abuse within the first several years of the drug’s introduction but they concealed it.

According to a study conducted by the Tufts Center for the Study of Drug Development, the cost to introduce a new drug is roughly $2.7 billion dollars – a whopping expense. Even though some experts disagree on the exact amount of money required to get a new drug on the market, it is certain that the cost can be staggering. Therefore, it’s reasonable to infer that certain information related the addictive nature of a drug could be concealed in order to ensure the production, sale, and eventual profitability of the drug.

In 2012, a new drug by the name of Subsys was introduced to the market by a company called INSYS. This drug was developed and approved by the FDA as a highly potent opioid painkiller. Shortly thereafter, a physician by the name of Steven Chun was fiercely pursued by the INSYS to prescribe the new drug to his patients. According to one report, 95% of the Medicare patients Dr. Chun saw in 2015 were prescribed the painkiller. Stuff like this sounds fictional – and that makes the reality of it hard to stomach.

Furthermore, Dr. Chun became a spokesperson for INSYS, and within one year of his involvement with the company, their sales skyrocketed by more than 1000% grossing a little less than $100 million. After facing a lawsuit over “widespread billing schemes” intended to defraud the government, Steven Chun would later pay $750,000 to the Department of Justice to resolve the claims. It is important to recognize that Steven Chun was never charged with a crime, and also that he denies all wrongdoing.

This short but cautionary tale exemplifies the influence that pharmaceutical companies have on prescribing physicians. Not since 2008, has the phrase “Too Big to Fail” taken on such a significant meaning as it did with the rise and subsequent fall INSYS. Early on, the only patients that would qualify to receive a prescription of the drug were cancer patients in a significant amount of physical pain.

Soon thereafter, in an effort to boost profits, companies like INSYS strongly influenced physicians to prescribe the drug more often to treat less intense conditions. The doctors were assured by pharmaceutical companies since the late 1990’s that their patients would not become addicted to opiates. While investors made millions on the sale of the addictive opioid, Subsys, others languished in the throes of addiction as a result of its availability on the open market.

The Federal Government

The Federal Government has been harshly criticized for not doing enough to curb or altogether stop the opioid epidemic. An epidemic that has only increased in severity and scope over the last 18 years has led to the opioid-induced overdose death of 300,000 citizens. But for the first time in nearly 2 decades, the Federal Government has taken action to curb the opioid epidemic. In 2017, the HHS outlined its five-point Opioid Strategy listed below:

• Improve Access to Support Services, such as prevention, treatment, and recovery-support organizations aimed at preventing the social, economic, and health consequences associated with opioid addiction. Through this, the HHS is hoping to enable individuals to achieve long-term recovery.
• Provide Overdose-Reversing Drugs to ensure that more people are adequately equipped to respond to an overdose. In particular, they are increasing the availability of the opioid-curbing medicines with a particular focus on high-risk populations.
• Strengthen Public Health Data Reporting and collection in order to improve the timeliness of data and to evoke real-time health responses as the opioid epidemic involves. Accurate data is key to cost-effective counter measures.
• Support Cutting-Edge Research that advances our understanding of pain and addiction. By doing so, we’ll better be able to develop new treatments and help identify effective public health intervention to reduce opioid-related health hazards; and,
• Advance the Practice of Pain Management to enable access to high-quality, evidence-based pain care and reduce the burden of physical pain for individuals, families, and society. This will also reduce the inappropriate use of opioids and opioid-related harms.

For the first time in a long time, the government has done more than just “talk” about what it plans to do in order to curb or eradicate the opioid crisis by putting its money where its mouth is. In 2017, SAMHSA administered State Targeted Response (STR) grants that provided more than $485 million of support to the U.S. The intended purpose of these grants are to provide greater access to treatment by reducing unmet treatment needs and reducing opioid-related overdose deaths.

More recently in 2018, HHS has asked for more than $800 million in efforts to combat this crowing opioid crisis. While the vast majority of public funding seems to be directed to Medication Assisted Treatment (MAT) programs, several within the treatment industry wonder what, if any impact this public funding will have on the day-to-day operations of substance abuse treatment centers nationwide. Further research, assessment, and longitudinal outcome studies are necessary in order to provide a more accurate indicator of the best way to allocate public funds. On an optimistic note, it is nice to see the federal government funding something that might actually benefit the well-being and health of its citizens.

The Drug Dealers

Perhaps the most obvious offender to blame for the opioid crisis are the drug dealers that peddle their wares on a daily basis within this country. Most opioid users start with hydrocodone or other prescription pills until they come to the conclusion that $40 to $50 dollars per pill is not sustainable for anyone’s addiction budget. After the opioid addict reaches this conclusion, they begin using heroin because it is much cheaper, and available on the street. Heroin does not require a prescription, and pain management issues only lead to a higher incidence of heroin usage given the fact that the only thing that exists beyond pain management is drug addiction.

A factor that cannot be underestimated when thinking about the rise in opioid-related overdose deaths within the U.S. is the introduction of fentanyl and carfentanil to the black market. Dealers often use cut their heroin with fentanyl which is 50-100 times more potent than morphine in order to increase the power of their batch. Scary, huh?

Another drug known as carfentanil was designed as an anesthetic for large animals. This elephant tranquilizer has recently been introduced on the black market as yet another means of cutting heroin. With a potency 10,000 times higher than morphine, a piece of carfentanil smaller than a grain of sand is enough to send an individual into overdose or death immediately.

The modern heroin user is clueless to the exact quantity of carfenanil or fentanyl they just purchased. And that’s a deadly predicament to be in. Even with fentanyl-related overdoses, and deaths on the rise, users continue to look for heroin that has been cut with this deadly chemical agent in order to achieve a high that is now unattainable to them given their current level of tolerance. The profitability of heroin has also increased due to the influx of fentanyl and carfentanil. Dealers now have the ability to “cut” or “step on” their heroin even more, thus increasing the potency and quantity of their batches. More product = more money.

Incarceration

One factor not often considered is how the prison system at large plays into the opioid epidemic in the United States. There has been much discussion, debate, and discourse about the failed “drug war” in the United States. However, the majority of research and documentaries have centered on the injustice of mass incarceration for non-violent crimes. This is certainly a problem that needs to be addressed. According to the Federal Bureau of Prisons,“46% of inmates are currently doing time for non-violent drug offenses or 77,649 individuals total.” For the purpose of this post, I would rather examine what effect incarceration has on opioid addicts leaving prison.

A commonly held belief is that incarceration is somehow a solution to the drug problem as a whole in the United States. However, the vast majority of data since Ronald Reagan was knocking down walls in Berlin does not support this conclusion. In fact, a study published in 2007 by The New England Journal of Medicine found that former inmates are 129 times more likely to die from a fatal overdose than the general population in the first two weeks after their release from prison. Worldwide, the newly released prisoner is at the highest-risk.

While some professionals consider Medical Assisted Treatment (MAT) to be the “Gold Standard” to treat opioid addiction, only 22 states offer opioid-addiction medications. Of the 22 that allow opioid addiction medications, Rhode Island is the only state that offers all three forms of opioid addiction medications including: Buprenorphine, Methadone, and Naltrexone. And even this treatment option is under scrutiny – just ask those in the recovery community. However, within the prison system, a lack of treatment opportunity, and insufficient aftercare planning further exacerbates the problem of relapse and recidivism.

This can be attributed to the fact that most inmates return to the same exact using environment that led them to drug usage, and crime in the first place. Even if the inmate is able to stay clean while incarcerated, they face an uphill battle upon release as a result of limited economic opportunity, a legal record, and an overall lack of social support. As they struggle to find a decent job because of their legal record, they often resort back to old patterns of behavior which may include illegal activities. This Catch-22 is another reason why the opioid crisis continues hurling forward with very little end in sight.

Time to Take Action

Much like any good therapist, I hate offering a problem without also proposing a solution. And, that holds true even for the opioid epidemic. I think there are several actions we can take in order to overcome the opioid epidemic. Below I have outlined a few tips about what you can do to help those gripped with the disease of opioid addiction.

• Educate Yourself. The best way to treat a problem is to first understand it. I hope that this blog entry has, in some way helped to better understand the issue of opioid addiction. Another great resource to further understand addiction is the “Big Book” of Alcoholics Anonymous. While this text pertains more directly to alcoholics, it also does a fantastic job of providing insight into the repetitive cycle of drug addiction.
• Don’t Judge Others. Seems simple enough, right? Matthew 7 Verse 1 tells us, “Don’t judge others, and God will not judge you.” A barrier to recovery for many is the shame and guilt directed at those struggling with opioid addiction. Please do not hamper someone’s ability to pursue a life of recovery by shaming them. Not only is this ineffective, it can also be deadly in the long-term.
• Look for The Signs. Look for signs in your loved one such as: increased suicidal comments, impaired visual acuity, dry mouth and nose, marks on veins, emotional distress caused by family and relationship issues, financial instability, legal issues due to drug-related crimes, homelessness, and work or school-related issues.
• Don’t Be Afraid to Ask for Help. Don’t be afraid to ask those around you for help if you are battling an addiction to opioids or any other substances. There is absolutely no shame in receiving help whether that be in the form of inpatient treatment or a local AA Group.
• Don’t be Afraid to Have Difficult Conversations. Have boldness when speaking with others about your addiction is key. If you happen to see signs and symptoms of opioid abuse present in your loved one, SPEAK UP. The fear of the reaction can disable us from having the hard conversations with those we love.
• Call Your Senator and Demand Better Treatment Options. Identify and call your local representatives to demand more affordable treatment options. Request better funding for the local programs in your area. If you aren’t sure who your local representatives are, follow this link listed below to identify them and get in contact with them:
  https://www.house.gov/representatives/find-your-representative

Solution

In closing, there are many different philosophies regarding the proper treatment of opioid addiction. Some favor harm-reduction methods such as providing clean syringes or Medication Assisted Treatment (MAT), while others like Stonegate Center offer a 12-Step solution-focused program meant to address the underlying issues that maintain the addiction. Call me a cynic or a pessimist, but I have very little trust in the pharmaceutical companies to get us out of a problem that they themselves created. In my mind, this is akin to me smashing out a neighbor’s car window, and then coming over the very next morning to fix it for a reasonable fee.

The profit motive is an ugly reality of treating opioid addiction that cannot be understated or ignored. It is up to the people within the industry of chemical dependency treatment to stand up and fight for those that are not able to help themselves.

As a treatment center, Stonegate Center has done an excellent job of not only providing highly-individualized care for those struggling with opioid addiction, but we have also recognized when a client might not be a fit for our program. We hope that every addict or alcoholic is a fit for our program, but we also understand our own limitations. It is imperative that the treatment centers work together in a collaborative effort to combat this ugly crisis facing our nation. Without unity, we do not have a chance to face and overcome this deadly epidemic.