tag:theconversation.com,2011:/ca/topics/opioids-special-43052/articlesOpioids special – The Conversation2017-11-02T23:42:04Ztag:theconversation.com,2011:article/867212017-11-02T23:42:04Z2017-11-02T23:42:04ZTo stop the opioid epidemic, the White House should embrace prevention<figure><img src="https://images.theconversation.com/files/192895/original/file-20171101-19900-1lm4225.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An emergency overdose kit in Providence, Rhode Island.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Emergency-Overdose-Box/d6ebcd4c107a45339590c854532c9e21/13/0">Michelle Smith/AP</a></span></figcaption></figure><p>There’s an old adage that states “An ounce of prevention is worth a pound of cure.” </p>
<p>President Donald Trump declared a <a href="https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html?_r=0">public health emergency</a> on opioid use on Oct. 24. He outlined several strategies to address <a href="https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html">the crisis</a>, including plans to establish drug courts in every federal judicial district; to adjust reimbursement rates for addiction treatment; and to streamline federal funding for drug treatment programs. </p>
<p>These plans focus primarily on treating opioid addiction after the problem is detected. In our response to the opioid crisis, the “pound of cure” is prominent. But where can we find the ounce of prevention?</p>
<p>Any comprehensive response to a health issue must consider those who have not developed the problem. When public health and medical professionals responded to the H1N1 crisis several years ago, for example, a great deal of time and resources were devoted to teaching people how to avoid contracting this potentially life-threatening disease.</p>
<p>People are dying from the opioid overdose epidemic, and we must mount an aggressive response in order to save lives. But let’s not forget the needs of those who haven’t developed opioid addiction, or those who are at risk for addiction. Their life trajectories could be changed with the support of timely and responsive prevention efforts. </p>
<h2>Why prevention matters</h2>
<p>What does <a href="http://dx.doi.org/10.1177/0011000000286001">prevention</a> entail? At a basic level, prevention means stopping a behavior, like opioid abuse, from ever occurring in the first place. To experts in public health and related professions, it can also entail delaying the onset of that problem behavior or reducing its impact. </p>
<p>Most importantly, prevention also means strengthening individual and community-level health and resilience, as well as promoting policies that improve physical, social and emotional well-being.</p>
<p>Research clearly shows that prevention is effective at enhancing human functioning and <a href="http://dx.doi.org/10.1037/1522-3736.5.1.515a">reducing psychological and physical distress</a>. <a href="https://www.ncbi.nlm.nih.gov/books/NBK44233/">Prevention services</a> help to further the health and well-being of both individuals and entire communities across many areas – for example, reducing the negative consequences of alcohol abuse, sexually transmitted infections, diabetes and many other conditions.</p>
<p>There’s clear evidence that <a href="http://dx.doi.org/10.1037/0003-066X.60.6.601">expanding preventive services</a> reduces the costs of substance abuse and mental health care. Prevention allows health care workers to address problems early, before costly treatment is necessary. </p>
<p>Prevention policies have been effective in reducing death rates. For example, states that <a href="http://www.thecommunityguide.org/mvoi/mvoi-AJPM-evrev-alchl-imprd-drvng.pdf">raised the legal drinking age</a> to 21 saw a 16 percent median decline in motor vehicle crashes.</p>
<p>Prevention services can also mitigate the consequences of health issues that may disproportionately affect demographic groups by race, gender, disability, socioeconomic class and other factors. </p>
<p>The importance of prevention is affirmed by the U.S. <a href="https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html">National Prevention Strategy</a>, a government initiative that aims to shift our nation’s focus from sickness and disease to wellness and prevention.</p>
<h2>Preventing opioid abuse</h2>
<p>With regard to prevention strategies for opioid abuse and addiction, the federal government has laid out some potentially promising strategies. However, the current opioid emergency response places most of the federal focus – and, likely, available funding – on the needs of a relatively small segment of the population: those with existing opioid use disorders and addiction.</p>
<p>A much larger segment of the population is affected in other ways. Many may have a family member or friend experiencing such addiction. Or they may themselves be at risk of starting to abuse opioids. These people need help to ensure that opioid use problems do not develop in the first place.</p>
<p>There are a few ways that the government can ensure that its current plan addresses the need for prevention. </p>
<p>The White House commission addressing the opioid abuse issue recommended a system for distributing federal funding. This system mirrors the process for obtaining <a href="https://www.samhsa.gov/grants/block-grants">block grants</a>, allocations to states to support substance abuse services. While this recommendation is encouraging, we should ensure that some of these funds are designated to address the needs and build the strengths of individuals and communities who have not yet been affected by the opioid crisis.</p>
<p>The commission also plans to coordinate with private sector and nonprofit groups to implement a national media campaign. This campaign will address addiction stigma and the danger of opioids. As part of this recommendation, it would be important to include messaging indicating that most members of the population do not use opioids, as well as specific steps that communities can take to remain healthy and drug-free.</p>
<p>Finally, the government says it will implement policies that ensure patients are adequately educated about the risks, benefits and alternatives of taking opioids before receiving an opioid prescription for chronic pain. Just as important is the provision promoting the use of nonpharmacological alternatives for pain management by health care professionals.</p>
<h2>A comprehensive approach</h2>
<p>A comprehensive public health-informed approach to address the opioid crisis may involve responses that affect an entire population, offer early intervention for people who may be at risk for opioid abuse and provide treatment and referral for individuals with already established opioid addiction.</p>
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<span class="caption">Mapping a comprehensive approach to the opioid crisis.</span>
<span class="attribution"><span class="source">M. Dolores Cimini and Estela M. Rivero</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>As a psychologist who works in alcohol and drug abuse prevention, I believe that public health professionals need to better understand what makes some individuals gravitate to opioid abuse and addiction. Such findings can help to develop strategies to promote health and resilience.</p>
<p>What’s more, we need to expand federal funding to support research across the spectrum of substance use. <a href="http://abcnews.go.com/US/addiction-america-numbers/story?id=39934007">Substance abuse in all its forms</a> compromises the health and welfare of millions across our nation. President Trump’s heartfelt comments about his brother, Fred, who died as a result of his addiction to alcohol, underscored this point.</p>
<p>One individual and community at a time, we must focus on supporting the millions of people who haven’t developed opioid addiction. That way, we can stem the tide associated with this devastating public health crisis.</p><img src="https://counter.theconversation.com/content/86721/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>M. Dolores Cimini has received funding from National Institutes of Health, Substance Abuse and Mental Health Services Administration, Office on Violence Against Women, U.S. Department of Justice, U.S. Department of Education, New York State Office of Alcoholism and Substance Abuse Services, and Transforming Youth Recovery.
</span></em></p>The White House has laid out a plan to address the opioid crisis. But people suffering from opioid addiction aren’t the only ones who need help.M. Dolores Cimini, Director for Behavioral Health Promotion and Applied Research, University at Albany, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816012017-10-05T00:56:11Z2017-10-05T00:56:11ZThe opioid epidemic in 6 charts<figure><img src="https://images.theconversation.com/files/188871/original/file-20171004-11777-9931ii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Michelle Holley holds a photograph of her daughter Jaime Holley, 19, who died of a heroin overdose in November 2016.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioids-Cycle-Of-Fraud/d3321ee9fb0d40e9b0c551e5d743fd1f/1/1">Lynne Sladky/AP Photo</a></span></figcaption></figure><p>Drug overdose deaths, once rare, are now <a href="https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?_r=0">the leading cause</a> of accidental death in the U.S., surpassing peak annual deaths caused by motor vehicle accidents, guns and HIV infection.</p>
<p>As a former public health official, clinician and researcher, I’ve been engaged in efforts to control the opioid addiction epidemic for the past 15 years. </p>
<p>The data show that the situation is dire and getting worse. Until opioids are prescribed more cautiously and until effective opioid addiction treatment becomes easier to access, overdose deaths will likely remain at record high levels.</p>
<h1>How the crisis started</h1>
<p>Opioids are drugs that stimulate the brain’s opiate receptors. Some are made from opium and some are completely synthetic. In the U.S., the most commonly prescribed opioids are hydrocodone and oxycodone, which are classified as semi-synthetic because they are synthesized from opium. Heroin is also a semi-synthetic opioid. The effects of hydrocodone and oxycodone on the brain are indistinguishable from the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787689/">effects produced by heroin</a>. </p>
<p>Opioids are essential medicines for palliative care. They are also helpful when used for a couple of days after major surgery or a serious accident. Unfortunately, <a href="http://annals.org/aim/article/2646632/prescription-opioid-use-misuse-use-disorders-u-s-adults-2015">the bulk of the opioid prescriptions</a> in the U.S. are for common conditions, like back pain. </p>
<p>In these cases, opioids are more likely to harm patients than help them because the risks of long-term use, such as addiction, outweigh potential benefit. Opioids have not been proven effective for daily, long-term use. Evidence suggests that chronic use of opioids can even make pain worse, a phenomenon called <a href="https://books.google.com/books?hl=en&lr=&id=_VrvBQAAQBAJ&oi=fnd&pg=PP1&dq=opioid+hyperalgesia&ots=D2aeoQx3T3&sig=TZVXFcavoT5xbd0pOomTurcAhxE#v=onepage&q=opioid%20hyperalgesia&f=false">hyperalgesia</a>. </p>
<p>Over the last two decades, as prescriptions for opioids began to soar, rates of addiction and overdose deaths increased in parallel. </p>
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<p>The increase in opioid prescription was fueled by a <a href="http://archive.jsonline.com/watchdog/watchdogreports/painkiller-boom-fueled-by-networking-dp3p2rn-139609053.html/">multifaceted campaign</a> underwritten by pharmaceutical companies. Doctors heard from their professional societies, their hospitals and even from state medical boards that patients were suffering needlessly because of an overblown fear of addiction. </p>
<p>The campaign minimized opioid risks and exaggerated the benefits of using opioids over the long term for chronic pain. Several states and counties have recently filed <a href="https://theconversation.com/a-look-inside-ohios-lawsuit-against-opioid-manufacturers-79322">lawsuits against opioid manufacturers</a> for the role they played in causing the opioid addiction epidemic by misleading the medical community.</p>
<h1>The rise of heroin</h1>
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<p>Until 2011, most opioid overdose deaths involved prescription opioids. Then prescription opioid overdose deaths leveled off, while overdose deaths involving heroin began to soar. </p>
<p>Why did this happen? A common misconception is that so-called “drug abusers” suddenly switched from prescription opioids to heroin due to a federal government “crackdown” on painkillers. </p>
<p>There is a kernel of truth in this narrative. It’s true that the vast majority of people who started using heroin after 1995 switched from prescription opioids because heroin was easier to obtain. But heroin use among young whites has been increasing since before 2011. From the beginning of the opioid crisis, young adults who became addicted to prescription opioids would <a href="https://source.wustl.edu/2014/05/drug-users-switch-to-heroin-because-its-cheap-easy-to-get/">switch to heroin</a>, a less expensive option. </p>
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<span class="attribution"><a class="source" href="https://www.samhsa.gov/data/sites/default/files/2014_Treatment_Episode_Data_Set_National_Admissions_9_19_16.pdf">Substance Abuse and Mental Health Services Administration</a></span>
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<p>As young people switched to heroin, the heroin supply also became more dangerous. This caused the sharp increase in heroin overdose deaths in 2011. Increasingly, <a href="https://www.cdc.gov/mmwr/volumes/66/wr/mm6634a2.htm">fentanyl</a>, a potent and inexpensive synthetic opioid, was <a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">mixed with heroin</a> or sold as heroin. </p>
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<p>Until 2013, medical examiners didn’t routinely test heroin overdose victims for the presence of fentanyl, but once they did, an alarming trend appeared. Preliminary data indicate that, in 2016, <a href="https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html">deaths involving fentanyl</a> surpassed deaths involving prescription opioids and heroin. </p>
<h1>Treating the crisis</h1>
<p>There’s another reason not to believe the narrative about a “crackdown” on painkillers leading to a sudden shift to heroin: There hasn’t been a crackdown on prescription opioids. Despite some slowdown, the medical community continues to overprescribe opioids.</p>
<p>In fact, U.S. per capita opioid consumption is much higher than other developed nations. Our oxycodone consumption has started to decline, but it remains much higher than oxycodone consumption in Europe.</p>
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<p>To bring the opioid addiction epidemic under control, the medical community must be more cautious about prescribing opioids. Federal and state governments also have to ensure that the millions of Americans now suffering from opioid addiction can access effective addiction treatment.</p>
<p>Buprenorphine and methadone maintenance – also known as medication-assisted treatment – are preferred <a href="http://www.bmj.com/content/357/bmj.j1550">treatments for opioid addiction</a>. When patients with addiction take these medications, they are able to function and have an improved quality of life. These treatments also reduce the risk of overdose death and injection-related infectious diseases.</p>
<p>Buprenorphine is safer than methadone and other opioids, so it can be prescribed from a doctor’s office. Methadone maintenance is administered under supervision in clinics that patients visit daily. </p>
<p>Unfortunately, many patients are <a href="http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/02/11/waiting-lists-grow-for-medicine-to-fight-opioid-addiction">unable to access these treatments</a>. Despite a sharp rise in opioid addiction over the past decade, there has been only a slight increase in referrals for medication-assisted treatment in state-licensed drug treatment programs. Patients who are able to obtain treatment with buprenorphine must often visit <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473522/">private practice physicians</a> who don’t accept commercial insurance or Medicaid. </p>
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<p>Until effective treatment for opioid addiction is easier to access than opioid painkillers, heroin or fentanyl, opioid overdose deaths are likely to remain at record high levels.</p><img src="https://counter.theconversation.com/content/81601/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Kolodny receives funding from the United States Food and Drug Administration for research on prescription drug monitoring programs. He is also the director of Physicians for Responsible Opioid Prescribing, a nonprofit group with a mission to reduce opioid-related morbidity and mortality caused by opioid overprescribing.
</span></em></p>Your guide to a public health crisis that’s likely to get worse.Andrew Kolodny, Co-Director of Opioid Policy Research, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/820562017-10-02T18:59:31Z2017-10-02T18:59:31ZHow to talk to your kids about opioids<figure><img src="https://images.theconversation.com/files/185891/original/file-20170913-20276-vsvhw9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Talk it out.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mature-mother-consoles-daughter-home-352494392">Iakov Filimonov/shutterstock.com</a></span></figcaption></figure><p>By now, most people are aware of the enormity of the opioid epidemic. In 2015, over 33,000 Americans died from an <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">opioid overdose</a> – more from opioid pain relievers <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">than heroin</a>. </p>
<p>Just because someone experiments with opioids doesn’t mean that he or she will become addicted. However, there’s risk with any opioid use, even when it’s medically warranted. The U.S. Drug Enforcement Agency classifies opioids as a <a href="https://www.deadiversion.usdoj.gov/21cfr/cfr/1308/1308_12.htm">Schedule II drug</a>, a substance with medically accepted use but a high potential for abuse. </p>
<p>Many parents and guardians don’t think their child is at risk for misusing opioids. While that may be true, consider this: In 2013, <a href="http://doi.org/10.1016/j.drugalcdep.2015.11.005">one in eight U.S. high school seniors</a> reported using opioids for nonmedical reasons. In 2015, 122,000 teens under 17 and 427,000 adolescents between 18 and 25 had a <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf">pain reliever use disorder</a>, meaning that they had a problem with the drug.</p>
<p>I’ve studied substance use prevention for 15 years, including time in rehabilitation centers with teenagers addicted to heroin, so I understand how critical it is to prevent opioid use at a young age. Fortunately, there’s a lot of research on this topic, as well as numerous resources to help parents figure out where to start. </p>
<h1>What parents need to know</h1>
<p>First, parents should educate themselves about opioids: what they are, how they work in the brain and body, risk factors for using them and how to spot signs of use. </p>
<p>Parents shouldn’t convey misinformation about opioids to their children. If their children find out that what they’ve been told isn’t accurate, they may turn instead to their peers for information.</p>
<p>There are excellent online resources available for parents and their children, such as the <a href="https://teens.drugabuse.gov/drug-facts/prescription-pain-medications-opioids">National Institute on Drug Abuse for Teens</a> website and the Partnership for Drug-Free Kids’ <a href="https://drugfree.org/drug-guide/?drug_type=13204">Parent Drug Guide</a>. </p>
<p>It’s particularly important to note the long-term effects that nonmedical use of opioids can have on adolescents. <a href="http://doi.org/10.3238/arztebl.2013.0425">Around puberty</a>, the brain starts a massive restructuring process. Neural connections get stronger and stronger, helping adolescents go from the emotional decision-making of youth to rational decision-making in early adulthood. This process continues until the mid- to late 20’s. </p>
<p>During this time, what adolescents do can get <a href="https://www.psychologytoday.com/blog/inspire-rewire/201402/pruning-myelination-and-the-remodeling-adolescent-brain">“hard-wired”</a> into the brain. So, for example, if a young person is engaged in academics, sports or learning a musical instrument, those connections get set in the brain. If they spend a lot of time using drugs, those could be the connections that stick. That means they’d have an increased chance of developing a substance use disorder later in life. </p>
<p>In adolescence, many people learn important life skills, including how to cope with adversity. However, long-term drug use that starts during adolescence can affect <a href="https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain">our memory and learning</a>. Because drugs, particularly opioids, help alleviate both physical and emotional pain, adolescents may then continually turn to this drug as a way to cope, rather than using more adaptive coping skills that are usually learned during this time.</p>
<h1>Starting the conversation</h1>
<p>One of the most important tools that parents have is the ability to talk to their child about substance use. While talking about drugs with young people isn’t always comfortable, research has shown that <a href="http://files.eric.ed.gov/fulltext/ED521530.pdf">it’s critical for prevention</a>. </p>
<p>Chances are good that even young teenagers will have heard about opioids and overdose deaths at some point. Pretending that opioid use is not a problem – or thinking that a child is a “good kid” and therefore doesn’t need to hear and talk about it – is a mistake. Being a “good kid” does not mean that an adolescent will not be curious or be tempted by peers. </p>
<p>Starting the conversation can be difficult. I advise parents to keep an eye out for a time when the topic can naturally come up. For example, if a celebrity is found to be using opioids or other drugs, or if the problem comes up in the child’s school or neighborhood, or even on the child’s social media account, this could provide the opening for a discussion. </p>
<p>Parents could ask their children if they have heard about opioids and, if so, what they know. That could be a good starting point and an opportunity to do the research together.</p>
<p>There are also helpful online resources that provide tips and advice on how to have these types of conversations, such as the <a href="http://medicineabuseproject.org/assets/documents/Parent_talk_kit_2014_.pdf">Parent Talk Kit</a>, which provides advice on what to say in specific scenarios with kids of different ages. For example, the beginning of high school is an incredibly important time for parents to bring up how some teens use opioids and to let their child know that, if she ever makes a mistake or gets stuck in a bad situation, she should come and talk to them. </p>
<p>These conversations aren’t a one-shot deal. They should happen often, ideally repeating parents’ expectations and adding new information when relevant.</p>
<h1>Other tips</h1>
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<a href="https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185509/original/file-20170911-1336-2gazf4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Parents should properly and safely secure their prescription medication.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/several-containers-over-counter-prescription-medications-181476449?src=zKSqe6sGqtrVwGapuyneVA-1-0">David Smart/shutterstock.com</a></span>
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<p>Parents should make an effort to get to know their children’s friends. Having friends who use drugs is <a href="http://www.purdue.edu/newsroom/releases/2014/Q3/study-peers,-but-not-peer-pressure,-key-to-prescription-drug-misuse-among-young-adults.html">very strongly associated</a> with adolescents’ own drug use. </p>
<p>Additionally, children are <a href="http://www.sciencedirect.com/science/article/pii/S0306460315000234">less likely to use prescription drugs</a> if their parents monitor where they are when they’re not at home. </p>
<p>About two-thirds of teenagers who use prescription drugs for nonmedical reasons report getting the drugs <a href="https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/teen-prescription-drug-misuse-abuse">from friends or family members</a>, including taking them from medicine cabinets without people knowing. So, parents should <a href="http://www.lockyourmeds.org">properly and safely secure their prescription medication</a>, especially opioids. </p>
<p>Finally, if parents suspect that their child is using or has a problem with opioids, it’s imperative to get help as soon as possible. The best outcomes often come from <a href="http://www.simonandschuster.com/books/How-to-Raise-a-Drug-Free-Kid/Joseph-A-Califano/9781476728438/browse_inside">intervening early</a>.</p>
<p>For more information, the Partnership for Drug Free Kids has a <a href="https://drugfree.org/landing-page/get-help-support/how-do-i-help-my-child/">resource hotline</a> with advice on how to confront children about suspected drug use, as well as <a href="https://drugfree.org/download/treatment-ebook/">additional resources</a> to help parents navigate getting children help with a substance use disorder.</p>
<p>The good news is that <a href="http://doi.org/10.1542/peds.2016-2387">nonmedical opioid use among adolescents is on the decline</a>. However, it’s still a significant problem that needs attention. Parents have the power to help – and talking to their children is an important first step. </p>
<p><em>This story was published in collaboration with PBS NewsHour.</em></p><img src="https://counter.theconversation.com/content/82056/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Margie Skeer received funding from the National Institute on Drug Abuse. </span></em></p>While talking about drugs with young people isn’t always comfortable, research has shown that it’s critical for prevention.Margie Skeer, Associate Professor of Public Health and Community Medicine; Interim Director of the Health Communication Program, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810042017-09-29T12:49:27Z2017-09-29T12:49:27ZThe real reason some people become addicted to drugs<figure><img src="https://images.theconversation.com/files/188065/original/file-20170928-24379-jt0svr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Oxycodone-acetaminophen pills.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Tablets/231aa002c1b8404d84f57d790f77fd5f/13/0">Patrick Sison/AP</a></span></figcaption></figure><p>Why do they do it? This is a question that friends and families often ask of those who are addicted.</p>
<p>It’s difficult to explain how drug addiction develops over time. To many, it looks like the constant search for pleasure. But the pleasure derived from opioids like heroin or stimulants like cocaine declines with repeated use. What’s more, some addictive drugs, like nicotine, fail to produce any noticeable euphoria in regular users. </p>
<p>So what does explain the persistence of addiction? As an addiction researcher for the past 15 years, I look to the brain to understand how recreational use becomes compulsive, prompting people like you and me to make bad choices. </p>
<h1>Myths about addiction</h1>
<p>There are two popular explanations for addiction, neither of which holds up to scrutiny.</p>
<p>The first is that compulsive drug taking is a bad habit – one that addicts just need to “kick.”</p>
<p>However, to the brain, a habit is nothing more than our ability to carry out repetitive tasks – like tying our shoelaces or brushing our teeth – more and more efficiently. People don’t typically get caught up in an endless and compulsive cycle of shoelace tying.</p>
<p>Another theory claims that overcoming <a href="https://www.drugabuse.gov/about-nida/frequently-asked-questions#withdrawal">withdrawal</a> is too tough for many addicts. Withdrawal, the highly unpleasant feeling that occurs when the drug leaves your body, can include sweats, chills, anxiety and heart palpitations. For certain drugs, such as alcohol, withdrawal comes with a risk of death if not properly managed.</p>
<p>The painful symptoms of withdrawal are frequently cited as the reason addiction seems inescapable. However, even for heroin, withdrawal symptoms mostly subside after about two weeks. Plus, many addictive drugs produce varying and sometimes only mild <a href="https://drugabuse.com/library/drug-withdrawal/">withdrawal symptoms</a>.</p>
<p>This is not to say that pleasure, habits or withdrawal are not involved in addiction. But we must ask whether they are necessary components of addiction – or whether addiction would persist even in their absence.</p>
<h2>Pleasure versus desire</h2>
<p>In the 1980s, researchers made a surprising discovery. <a href="https://doi.org/10.1016/S0306-4522(98)00583-1">Food</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/9169543">sex</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/2899326">drugs</a> all appeared to cause dopamine to be released in certain areas of the brain, such as the nucleus accumbens. </p>
<p>This suggested to many in the scientific community that these areas were the brain’s pleasure centers and that dopamine was our own internal pleasure neurotransmitter. However, this idea has since been <a href="https://www.ncbi.nlm.nih.gov/pubmed/9858756">debunked</a>. The brain does have <a href="https://www.ncbi.nlm.nih.gov/pubmed/25950633">pleasure centers</a>, but they are not modulated by dopamine. </p>
<p>So what’s going on? It turns out that, in the brain, “liking” something and “wanting” something are two separate psychological experiences. “Liking” refers to the spontaneous delight one might experience eating a chocolate chip cookie. “Wanting” is our grumbling desire when we eye the plate of cookies in the center of the table during a meeting. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/14561867">Dopamine</a> is responsible for “wanting” – not for “liking.” For example, <a href="https://www.ncbi.nlm.nih.gov/pubmed/2493791">in one study</a>, researchers observed rats that could not produce dopamine in their brains. These rats lost the urge to eat but still had pleasurable facial reactions when food was placed in their mouths.</p>
<p>All drugs of abuse trigger a surge of dopamine – a rush of “wanting” – in the brain. This makes us crave more drugs. With repeated drug use, the “wanting” grows, while our “liking” of the drug appears to stagnate or even decrease, a phenomenon known as tolerance.</p>
<p>In my own <a href="https://www.ncbi.nlm.nih.gov/pubmed/25505310">research</a>, we looked at a small subregion of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28751460">amygdala</a>, an almond-shaped brain structure best known for its role in fear and emotion. We found that activating this area makes rats more likely to show addictive-like behaviors: narrowing their focus, rapidly escalating their cocaine intake and even compulsively nibbling at a cocaine port. This subregion may be involved in excessive “wanting,” in humans, too, influencing us to make risky choices.</p>
<h1>Involuntary addicts</h1>
<p>The recent opioid epidemic has produced what we might call “involuntary” addicts. Opioids – such as oxycodone, percocet, vicodin or fentanyl – are very effective at managing otherwise intractable pain. Yet they also produce surges in dopamine release.</p>
<p>Most individuals begin taking prescription opioids not for pleasure but rather from a need to manage their pain, often on the recommendation of a doctor. Any pleasure they may experience is rooted in the relief from pain.</p>
<p>However, over time, users tend to develop a tolerance. The drug becomes less and less effective, and they need larger doses of the drug to control pain. This exposes people to large surges of dopamine in the brain. As the pain subsides, they find themselves inexplicably hooked on a drug and compelled to take more. </p>
<p>The result of this regular intake of large amounts of drug is a hyperreactive “wanting” system. A sensitized “wanting” system triggers intense bouts of craving whenever in the presence of the drug or exposed to <a href="https://www.ncbi.nlm.nih.gov/pubmed/17364833">drug cues</a>. These cues can include drug paraphernalia, negative emotions such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/17915078">stress</a> or even specific people and places.
<a href="https://www.ncbi.nlm.nih.gov/pubmed/17364833">Drug cues</a> are one of an addict’s biggest challenges.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/27977239">These changes in the brain</a> can be long-lasting, if not permanent. Some individuals seem to be more likely to undergo these changes. Research suggests that <a href="https://www.ncbi.nlm.nih.gov/pubmed/27114539">genetic factors</a> may predispose certain individuals, which explains why a family history of addiction leads to increased risk. Early life stressors, such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/28899646">childhood adversity</a> or physical abuse, also seem to put people at more risk. </p>
<h1>Addiction and choice</h1>
<p>Many of us regularly indulge in drugs of abuse, such as alcohol or nicotine. We may even occasionally overindulge. But, in most cases, this doesn’t qualify as addiction. This is, in part, because we manage to regain balance and choose alternative rewards like spending time with family or enjoyable drug-free hobbies.</p>
<p>However, for those susceptible to excessive “wanting,” it may be difficult to maintain that balance. Once researchers figure out what makes an individual susceptible to developing a hyperreactive “wanting” system, we can help doctors better manage the risk of exposing a patient to drugs with such potent addictive potential. </p>
<p>In the meantime, many of us should reframe how we think about addiction. Our lack of understanding of what predicts the risk of addiction means that it could just as easily have affected you or me. In many cases, the individual suffering from addiction doesn’t lack the willpower to quit drugs. They know and see the pain and suffering that it creates around them. Addiction simply creates a craving that’s often stronger than any one person could overcome alone. </p>
<p>That’s why people battling addiction deserve our support and compassion, rather than the distrust and exclusion that our society too often provides.</p><img src="https://counter.theconversation.com/content/81004/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mike Robinson has previously received funding from the National Center for Responsible Gaming. </span></em></p>Drug addiction isn’t about bad habits, fear of withdrawal or a selfish search for pleasure. It’s about the brain.Mike Robinson, Assistant Professor of Psychology, Wesleyan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/820402017-09-26T00:16:30Z2017-09-26T00:16:30ZOpioid epidemic causing rise in hepatitis C infections and other serious illnesses<figure><img src="https://images.theconversation.com/files/186443/original/file-20170918-8255-rrgb6n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Discarded used hypodermic needles along the Merrimack River in Lowell, Massachusetts.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Needles-Everywhere/5df2883eb9694ee8a611d0c914db4b1e/1/0">Charles Krupa/AP Photos</a></span></figcaption></figure><p>Many Americans now know that, over the past decade, opioid addiction and deaths from <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6409a1.htm">opioid overdose</a> in the U.S. have skyrocketed. </p>
<p>But we don’t hear as often about the other epidemics intertwined with this public health crisis. In <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6416a4.htm">rural Scott County, Indiana</a>, for example, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6416a4.htm">prescription opioid injections</a> have been linked to overlapping outbreaks of HIV and the hepatitis C virus. </p>
<p>This is a “syndemic”: multiple diseases feeding off of one another, compounding a community’s health burdens. </p>
<p>Syndemic theory – <a href="https://www.ncbi.nlm.nih.gov/pubmed/14716917">first introduced</a> by medical anthropologist Merrill Singer more than a decade ago – explains how epidemics interact with one another. The interplay of these diseases increases the risk for a number of <a href="http://dx.doi.org/10.1093/cid/ciu643">infections</a>, like sexually transmitted infections and <a href="http://dx.doi.org/10.1007/s10461-009-9631-1">HIV</a>.</p>
<p>There are many interrelated epidemics within the “opioid syndemic.” Together, they make up perhaps the biggest public health challenge in the U.S. since the advent of the AIDS epidemic. </p>
<h1>What we need to know</h1>
<p>Before we can tackle this challenge, we need to understand where the opioid syndemic is most intense.</p>
<p>In the U.S., we have many public health surveillance systems that assess changes across geography and time. For example, <a href="https://aidsvu.org/">AIDSVu</a>, an online interactive map, tracks HIV data across U.S. counties. In some regions, the data maps across ZIP codes and census tracts. </p>
<p>Systems such as these help us compare disease outcomes across different places and demographic groups. However, when it comes to the opioid syndemic, we need to do more to identify local hotspots. Hotspots are places where outbreaks cluster together in a statistically significant way, in adjacent neighborhoods or communities with elevated disease rates.</p>
<p>Scientists like myself have started using a range of geospatial and statistical approaches to improve our understanding of the opioid syndemic. These tools allow us to find patterns in data on related health issues. We can also determine which characteristics of an individual, community or social network – such as syringe sharing and unsafe sex – are associated with hotspots. </p>
<p>These analyses can help public health departments and clinicians target local responses where they are most needed, when they are most needed and with the local subpopulations that most need them.</p>
<h1>Finding hotspots</h1>
<p>In Massachusetts, where I am based, opioid overdose deaths quintupled over the past 15 years. The state Senate and Governor Charlie Baker have established a new <a href="http://www.mass.gov/eohhs/docs/dph/stop-addiction/dph-legislative-report-chapter-55-opioid-overdose-study-9-15-2016.pdf">legislative mandate</a> to systematically assess the key factors associated with the opioid syndemic. </p>
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<p>There are <a href="https://www.ncbi.nlm.nih.gov/books/NBK64167/">many health issues</a> associated with opioid use, including HIV, hepatitis C, STIs, soft tissue infections, mental illness and neonatal abstinence syndrome, which is related to exposure to drugs in the womb. For example, <a href="http://www.cnn.com/2017/05/11/health/hepatitis-c-rates-cdc-study/index.html">hepatitis C infections</a> nationwide have nearly tripled since 2010.</p>
<p>Working alongside local and state public health departments, academic institutions and community-based agencies, we study the distribution of these health issues across Massachusetts and beyond. Our “risk maps” help us better understand the geographic distribution of opioid syndemic illnesses over time. </p>
<p>We measure risks by the burden of disease (e.g., the number of fatal overdoses) and rates (e.g., the number of hepatitis C infections per 100,000 people) across local communities. We also measure and map risk behaviors – such as syringe sharing, unsafe sex and doctor shopping – through surveys with health care professionals and people in the throes of addiction.</p>
<p>We have identified a number of hotspots tied to the opioid syndemic. For example, some hotspots for prescription opioids appear to overlap with <a href="http://www.mass.gov/eohhs/docs/dph/stop-addiction/dph-legislative-report-chapter-55-opioid-overdose-study-9-15-2016.pdf">drug overdoses</a>. </p>
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<p>We’ve identified cities and towns with significant clusters of <a href="http://dx.doi.org/10.1186/s12879-017-2400-2">hepatitis C</a> and <a href="https://doi.org/10.1371/journal.pone.0114822">HIV</a>. Springfield, Boston, Fall River, New Bedford and parts of Cape Cod, for instance, have notable overlapping hotspots for opioid overdose deaths, hepatitis C and HIV. </p>
<p>Among youth and young adults, we’ve also noted an increase in <a href="https://doi.org/10.1093/ofid/ofw157">infectious endocarditis</a>, an infection of the heart valve often caused by reuse and sharing of contaminated syringes.</p>
<h1>How hotspot mapping can help</h1>
<p>Mapping the opioid syndemic and related hotspots, we can better inform public health policy decisions, as well as clinical decisions for health care workers. </p>
<p>Such analyses can help to pinpoint the locations, communities and specific behaviors that could most benefit from interventions. For example, peer navigators who have “been there and done that” could visit overlapping hotspots and make it easier for high-risk populations to access sterile syringes, condoms, hepatitis C treatment and <a href="https://theconversation.com/explainer-naloxone-the-antidote-to-opioid-overdose-32481">naloxone</a>, the overdose reversal drug. </p>
<p>Additional programs could focus on educating medical providers, pharmacists and patients in hotspots, to improve opioid prescribing practices and increase disease testing rates. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5242316/">Released inmates</a> have some of the highest risks for opioid overdose. Corrections facilities could try to improve their transitions back into local hotspot communities, by facilitating direct referrals to drug treatment programs and job training programs.</p>
<p>Of course, it will take continued collaboration and enhanced funding from governments and foundations to see these efforts forward. But there is no better time than the present to address one of our nation’s largest health crises.</p><img src="https://counter.theconversation.com/content/82040/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas J. Stopka has received funding from the Providence/Boston Center for AIDS Research, the GE Foundation, the MAC AIDS Foundation, the Tufts University Clinical and Translational Science Institute, Tufts Collaborates, the Tufts Institute for Innovation, the Massachusetts Department of Public Health, and the National Institutes of Health.</span></em></p>HIV, STIs and other dangerous infections are feeding off of the opioid epidemic, creating an even more complicated threat to public health.Thomas J. Stopka, Assistant Professor of Public Health and Community Medicine, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/841142017-09-25T01:21:42Z2017-09-25T01:21:42ZAn ethical dilemma for doctors: When is it OK to prescribe opioids?<figure><img src="https://images.theconversation.com/files/187069/original/file-20170921-20991-1jy5lqo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For patients with chronic pain, the answer isn't simple.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Overcoming-Opioids-Better-Drugs/272b18e4a54b4d36ba696623819f04b9/1/0">Chris Post/AP Photo</a></span></figcaption></figure><p>America’s <a href="https://www.cdc.gov/drugoverdose/index.html">opioid crisis</a> is getting worse. The role of prescription opioids has both the medical establishment and the government justifiably worried. </p>
<p>In response, the National Academies of Science, Engineering and Medicine released an <a href="http://nationalacademies.org/hmd/Reports/2017/pain-management-and-the-opioid-epidemic.aspx">official report</a> on the crisis earlier this year. And, on September 21, the National Academy of Medicine released a <a href="http://www.nam.edu/FirstDoNoHarm">special publication</a> calling clinicians to help combat the crisis.</p>
<p>As a bioethicist working on the ethical and policy issues regarding prescription opioids, I am grateful to the National Academy of Medicine for inviting me to serve on this publication’s authorship team, and for taking seriously the ethical component of the prescription opioid crisis. The opioid epidemic is shot through with ethical challenges. </p>
<p>There are many discussions we could have, but I will here focus on just one of them: the issue of morally responsible prescribing. Should prescription opioids be used at all? And if so, how? The question is obviously important for clinicians, but the rest of us – patients – should understand what our doctors and nurses owe us regarding our care.</p>
<h1>Two public health crises</h1>
<p>One of the central challenges of the opioid epidemic is figuring out how to respond without harming pain patients. </p>
<p>If opioids prevent significant suffering from pain, then the solution to the prescription opioid problem cannot simply be to stop using them. To do so would be to trade one crisis (an opioid crisis) for another (a pain crisis). </p>
<p>The data suggest, however, that pain patients’ interests will not always run counter to the goal of curbing the opioid crisis. The evidence favoring opioid therapy for chronic, noncancer pain is <a href="http://annals.org/aim/article/2089370/effectiveness-risks-long-term-opioid-therapy-chronic-pain-systematic-review">very weak</a>, and there’s some evidence that opioid therapy can actually <a href="https://www.ncbi.nlm.nih.gov/pubmed/21412369">increase one’s sensitivity</a> to pain. </p>
<p>Opioid therapy also comes with <a href="https://www.ncbi.nlm.nih.gov/pubmed/18443635">significant costs</a> – the risk of addiction and the potential for drowsiness, constipation, nausea and other side effects. </p>
<p>As a result, more of the medical community is realizing that opioids are simply not good medications for chronic, noncancer pain. Getting patients off long-term opioid therapy may well improve their lives. </p>
<h1>Should we use opioids at all?</h1>
<p>It would be nice if we could simply stop using opioids. But the situation is rather more complicated than that.</p>
<p>Even if opioid therapy shouldn’t be first-line (or even second-line) treatment for chronic pain, that <a href="https://www.vox.com/policy-and-politics/2017/5/2/15440000/sean-mackey-opioids-chronic-pain">doesn’t mean that it won’t work for anyone</a>. Patients are individuals, not data points, and risks of opioid therapy – as well as the risks of not providing pain relief – are not the same for everyone.</p>
<p>This is important because debilitating chronic pain can lead to a life that seems not worth living, and sometimes even to <a href="https://academic.oup.com/painmedicine/article/15/3/345/1844827/Pain-and-Suicide-The-Other-Side-of-the-Opioid">suicide</a>. In the face of life-destroying pain, if we run out of other options, it’s not clear that we should avoid using a third-line treatment in the hopes of saving a life. </p>
<p>Those who have been on high doses of opioids for years or decades pose another serious challenge. Many of these patients are <a href="https://www.painnewsnetwork.org/stories/2015/9/28/high-dose-patients-worried-by-cdc-opioid-guidelines">concerned</a> about the backlash against opioids. Some believe that the opioids are saving their lives. Others may be terrified of going into withdrawal if their medication is taken away. </p>
<p>If we move away from opioid therapy too abruptly, physicians may abandon these patients or force them to taper before they are ready. Tapering, under the best of circumstances, is a long, uncomfortable process. If it’s badly managed, <a href="http://content.healthaffairs.org/content/36/1/182.full">it can be hell</a>. The health care system created these patients, and we don’t get to turn our backs on them now.</p>
<p>Finally, opioids are important medications for acute, surgical and post-traumatic pain. Such pain can require long-term treatment when a series of surgeries stretches out for months, or when a traumatic injury requires a long, painful recovery. In these cases, opioids often make life manageable. </p>
<p>Although calls to limit opioid prescriptions generally don’t target these patients, we might reasonably worry about shifting attitudes. If medical culture becomes too opioid-phobic, who will prescribe for these patients? </p>
<h1>Responsible prescribing</h1>
<p>Fighting the epidemic with nuance will require constant vigilance. In the new <a href="http://www.nam.edu/FirstDoNoHarm">National Academy of Medicine publication</a>, we suggest a number of ways that clinicians can work toward responsible prescribing and management of opioids.</p>
<p>In short, clinicians must prescribe opioids only when appropriate, employing nonopioid pain management strategies when indicated. Evidence supports the use of acetaminophen and ibuprofen, as well as physical therapy, exercise, acupuncture, meditation and yoga.</p>
<p>Clinicians must also be willing to manage any prescriptions they do write over the long term. And, at every stage, prescribers should collaborate with others as needed to ensure that patients receive the necessary care.</p>
<p>Although clinicians shouldn’t be “anti-opioid,” they should be justifiably wary of prescribing for chronic, noncancer pain. And when a prescription is appropriate, the clinician should not write for more than is needed. </p>
<p>Patients should go into opioid therapy with a rich understanding of the risks and benefits. They should also have a plan of care, including an “exit strategy” for getting off the medication. </p>
<h1>A role for nonclinicians?</h1>
<p>The suggestions above may seem straightforward, and perhaps even obvious. So it’s important to point out that this work is time-consuming and sometimes – as in the case of high-risk patients – challenging. Counseling, advising and trying to avoid unnecessary opioid use is <a href="https://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html">much more difficult</a> than writing a quick prescription. </p>
<p>Although this difficult work is still the clinician’s responsibility, the rest of us can make it easier for them to do their job well. After all, no one likes to experience unnecessary pain. Our expectation of powerful pain relief is part of the cultural backdrop of the epidemic. </p>
<p>That expectation is going to have to change. Moderate acute pain from injury, dental procedures or whatever may have yielded a prescription for Percocet or Vicodin in the past. And when we are the ones in pain, we might still prefer that doctors hand out such medication like candy. But the opioid epidemic is teaching us that we don’t, in fact, want that to be clinicians’ standard practice. We shouldn’t demand exceptions for ourselves.</p><img src="https://counter.theconversation.com/content/84114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Travis N. Rieder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If opioids prevent significant suffering, then the solution to the prescription opioid problem cannot simply be to stop using them.Travis N. Rieder, Research Scholar at the Berman Institute of Bioethics, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/826232017-08-28T02:44:58Z2017-08-28T02:44:58ZThe opioid epidemic is finally a national emergency – eight years too late<figure><img src="https://images.theconversation.com/files/183347/original/file-20170824-18740-l5137a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People without ID, like Steven Kemp, are sometimes turned away from the country's already threadbare system of drug treatment centers.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Addicted-Without-ID/adcb4b23ab414c9dba8220d049ded453/25/0">Matt Rourke/AP Photo</a></span></figcaption></figure><p>“It has been many long, hard, agonizing battles for the last few years and you fought like a warrior every step of the way. Addiction, however, won the war. To the person who doesn’t understand addiction, she is just another statistic who chose to make a bad decision.”</p>
<p>Despite working nearly two decades as an addiction scientist, I cannot read <a href="https://www.facebook.com/notes/kathleen-errico/kelsey-grace-endicott-eulogy/10154023124488818/">Kelsey Grace Endicott’s mother’s eulogy</a> without crying. The opioid epidemic has turned those who lost their lives to addiction into statistics, while leaving their families in sorrow. </p>
<p>Overdose deaths in the U.S. have tripled since 2000, with 52,404 deaths in 2015 as the highest ever recorded. While the Centers for Disease Control and Prevention (CDC) has yet to release official statistics for 2016, <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">early estimates</a> put the number of deaths at as many as 65,000.</p>
<p>In a speech on October 26, President Trump declared the opioid epidemic a national emergency. Nearly a decade into this epidemic, this national emergency was declared at least eight years too late. Policymakers have missed opportunities to implement strategies scientifically demonstrated to reduce overdose deaths and help people recover.</p>
<p>His announcement was vague on details and did not specify how much money would be dedicated to reducing overdose deaths. The President restated many initiatives that have already been initiated and focused on supply-reduction efforts that, while important, do little for the millions of Americans who are struggled with opioid addiction. We have proven prevention and treatment services that we need to significantly expand, and states need the money to do this. </p>
<h1>The right treatments</h1>
<p>Declaring the opioid epidemic a <a href="http://www.npr.org/sections/health-shots/2017/08/11/542767898/president-trump-to-declare-national-opioid-emergency">national emergency</a> expands the availability of federal funding; frees up public health workers to address the issue; and makes it possible to remove regulatory barriers to lifesaving medications. </p>
<p><a href="http://wchstv.com/news/raw-news/raw-news-sessions-addresses-opioid-problems-at-west-virginia-summit">In a speech on May 11</a>, Attorney General Jeff Sessions suggested that tools like “Just Say No” and Drug Abuse Resistance Education (DARE) can help fight the opioid epidemic. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/10450631">addiction science</a> has repeatedly proven that such drug prevention programs are <a href="https://www.scientificamerican.com/article/why-just-say-no-doesnt-work/">ineffective</a>. Some would argue that we are biologically wired to try new things, so education alone is not sufficient to prevent repeated drug use. </p>
<p>Prevention efforts are part of the solution, but we need more immediate solutions for people already ensnared by addiction. <a href="http://www.huffingtonpost.com/entry/naloxone_b_1475812.html">Naloxone</a>, known by the brand name Narcan, is usually the only thing that can prevent death when someone has overdosed on opioids. Science has <a href="http://www.nejm.org/doi/full/10.1056/NEJMra1202561">unequivocally demonstrated</a> that naloxone can reverse an opioid overdose, if administered in time and in an adequate dose. </p>
<p>When patients with opioid use disorders are treated with FDA-approved medications like methadone and buprenorphine, they not only reduce their use of opioids but they are also less likely to overdose. When these drugs are used to treat addiction, they are referred to as medication-assisted treatment. Medication-assisted treatment helps many people, particularly early in recovery, when otherwise their brains seem to focus only on using more drugs. In fact, <a href="http://ctndisseminationlibrary.org/protocols/ctn0030.htm">a National Institute on Drug Abuse study</a> found that only about 7 percent of patients can stop using opioids without buprenorphine.</p>
<p>We need drugs like naloxone and buprenorphine to prevent deaths and help people recover from addiction. In the past few years, state governments have taken significant steps to remove regulatory barriers and expand community access to naloxone.</p>
<p>But policies are infrequently aligned with addiction science. In 2015, only 11 percent of <a href="https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.pdf">people who needed addiction treatment</a> received it. There are not enough medication-assisted treatment treatment slots available: A recent study estimated that the U.S. was short 1.3 million treatment slots for medication-assisted treatment in 2012. Demand has <a href="http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2015.302664">only increased since then</a>. </p>
<p>There is an entrenched belief that people choose to use drugs and that this choice reflects a moral failing. Even the director of the U.S. Department of Health and Human Resources – which cites medication-assisted treatment as part of its strategy – <a href="https://www.hhs.gov/about/news/2017/06/19/sec-price-meets-opioid-addiction-specialists-providers-and-treatment-facilities-stakeholders-readout.html">has been quoted saying</a>: “If we’re just substituting one opioid for another, we’re not moving the dial much.”</p>
<h1>Moving too slowly</h1>
<p>Early on, everyone believed that the epidemic was fueled by widely available <a href="http://www.latimes.com/opinion/op-ed/la-oe-hari-prescription-drug-crisis-cause-20170112-story.html">prescription pain relievers</a>. Books like <a href="http://johntemplebooks.com/books/american-pain/">“American Pain”</a> by John Temple described “drug tourists” routinely traveling from states like Kentucky and West Virginia to Florida, where millions of prescription pills were dispensed at “pill mills.” </p>
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<p>Such overprescribing and doctor-shopping <a href="https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf">did contribute</a> to the current epidemic. States <a href="https://www.cdc.gov/media/releases/2017/p0706-opioid.html">have been successful</a> at dispensing fewer prescription opioids, but this doesn’t help the nearly 2.6 million Americans <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf">already addicted</a>, or the 329,000 who report currently using heroin. </p>
<p>And, since 2014, it has become clear that the epidemic is no longer just about prescription opioids. In addition, heroin is frequently mixed or substituted with <a href="http://www.herald-dispatch.com/_recent_news/dealer-behind-huntington-s-overdoses-sentenced-to-years-in-prison/article_4e22304c-2398-11e7-bcd1-97ce0311d81c.html">powerful synthetic opioids</a> like fentanyl or carfentanil. They require far more of the overdose reversal drug naloxone than is routinely dispensed in communities.</p>
<p>Meanwhile, in <a href="http://www.npr.org/2017/06/29/534916080/ohio-town-struggles-to-afford-life-saving-drug-for-opioid-overdoses">poor and rural areas</a>, community resources for public services are being <a href="https://www.nbcnews.com/news/us-news/too-many-bodies-ohio-morgue-so-coroner-gets-death-trailer-n733446">exhausted</a> by the costs of the epidemic.</p>
<p>Areas that have been disproportionately impacted by the epidemic, like West Virginia, have woefully inadequate access to harm-reduction services like syringe exchange programs and specialty addiction treatment. A clinic at our university that dispenses buprenorphine has more than 600 people on its waiting list. We will soon open a second clinic that will help reduce but not eliminate the waiting list. </p>
<p>A bill passed by President Obama, <a href="https://www.samhsa.gov/newsroom/press-announcements/201612141015">the 21st Century Cures Act</a>, is making approximately US$1 billion in funding available to help states combat the opioid epidemic. But, as <a href="https://www.vox.com/science-and-health/2017/8/1/15746780/opioid-epidemic-end">Dr. Keith Humphreys at Stanford University</a> has said: This is not enough. We likely need <a href="https://www.nytimes.com/2017/06/30/health/drug-treatment-opioid-abuse-heroin-medicaid.html?mcubz=1">50 times that</a>, as Ohio spent $1 billion in 2016 on the opioid epidemic. </p>
<h1>Fighting back</h1>
<p>It can be hard to grasp the devastation of the opioid epidemic. As the President’s Commission on Combating Drug Addiction and the Opioid Crisis <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf">has described it</a>, in the scale of deaths, it’s like the September 11 terrorist attacks happening every three weeks. A national emergency would have been declared 10 years ago if such a disaster occurred every three weeks. And it can be even harder to imagine the emotional turmoil and the depth of sorrow felt by the families who’ve lost their daughters, sons, brothers, sisters, mothers and fathers. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183346/original/file-20170824-28045-3by7iw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Joe Fitzpatrick looks at a portrait of his daughter, Molly, at an exhibit honoring those who have died in New Hampshire’s opioid epidemic.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Angels-of-Addiction/90769b4151664523b3effc0158f9c704/23/0">Holly Ramer/AP Photo</a></span>
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</figure>
<p>I think it’s fair to say that we all want a simple solution – something that we can wrap our arms around. Something that can be done in one legislative session. But that has not worked and it will not work, just as declaring a national emergency is not enough. </p>
<p>Addiction scientists know what needs to be done to turn the tide. While we may not understand every aspect of the epidemic and certainly need more research to understand these <a href="https://www.brookings.edu/bpea-articles/mortality-and-morbidity-in-the-21st-century">deaths of despair</a>, we are eager to collaborate with communities to find empirically informed solutions, such as medication-assisted treatment. The President’s <a href="https://www.whitehouse.gov/ondcp/presidents-commission/members">Commission on Combating Drug Addiction and the Opioid Crisis</a> consists of four politicians and one addiction scientist. It might help to start by asking an expert, rather than politicians, what should be done.</p>
<p><em>This is an updated version of an article originally published on August 27, 2017.</em></p><img src="https://counter.theconversation.com/content/82623/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erin Winstanley receives funding from the Hilton Foundation, CDC, and NIH. </span></em></p>President Trump declared the opioid epidemic a national emergency. But we need to do a lot more to prevent this crisis from escalating even further.Erin Winstanley, Associate Professor of Pharmacy, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.