tag:theconversation.com,2011:/global/topics/opioid-deaths-41117/articlesOpioid deaths – The Conversation2023-09-13T12:26:32Ztag:theconversation.com,2011:article/2125272023-09-13T12:26:32Z2023-09-13T12:26:32ZOffering treatment to drug users instead of arresting them reduces crime and addiction – new research into police diversion program shows<figure><img src="https://images.theconversation.com/files/547289/original/file-20230908-28933-n5gp3f.jpg?ixlib=rb-1.1.0&rect=16%2C8%2C5447%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People mourn loved ones who have died from drug overdoses before replica tombstones in Binghamton, N.Y., on Aug. 19, 2023.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/friends-and-family-members-of-people-who-have-died-from-news-photo/1626209256?adppopup=true">Andrew Lichtenstein/Corbis via Getty Images</a></span></figcaption></figure><p>When police get suspected drug abusers treatment rather than arresting them, those people are less likely to abuse drugs or commit drug-related crimes in the future, <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">new, limited research finds</a>. This kind of police intervention can help reduce opioid abuse.</p>
<p>The U.S. has been in the throes of <a href="https://www.npr.org/2021/12/30/1069062738/more-than-a-million-americans-have-died-from-overdoses-during-the-opioid-epidemi">rampant opioid abuse since the late 1990s</a>. Communities around the country have experienced <a href="https://doi.org/10.1016/j.drugpo.2021.103555">increases in opioid-related deaths</a> and crimes as a result. </p>
<p>One study <a href="https://doi.org/10.1001/jamanetworkopen.2018.0217">shows opioid-related deaths more than quadrupled</a> from 9,489 in 2001 to 42,245 in 2016. Another study indicates that people addicted to opioids are more likely than people who don’t use opioids <a href="https://doi.org/10.1001/jamanetworkopen.2018.0558">to have run-ins with police</a>. The rate of opioid-related crimes in the U.S. has increased substantially, <a href="https://doi.org/10.1016/j.drugpo.2021.103555">from 32 per 100,000 people in 2005 to 78 per 100,000 people in 2018</a>. </p>
<p>Historically, for public safety, <a href="https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/432/817">police have arrested people suspected of using drugs</a>. Research <a href="https://doi.org/10.1186/s12954-022-00652-2">shows, though, that this approach has not been effective</a> at reducing drug abuse or related crimes. </p>
<p>But there is another way that appears to work better. In Arizona, the Tucson Police Department is trying an approach known as <a href="https://www.thenationalcouncil.org/program/deflection-and-pre-arrest-diversion-to-prevent-opioid-overdose/">pre-arrest diversion</a>. When officers respond to community calls about crime, they sometimes suspect the perpetrator may be abusing drugs. When they do, they don’t always arrest that person. Instead, officers connect that person with substance abuse treatment providers. I <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">recently led a study</a> that found this approach is as effective as arrest at reducing both drug abuse and crime.</p>
<p>As a professor of social and behavioral sciences, <a href="https://sirow.arizona.edu/person/josephine-korchmaros-0">I study treatment models and policy improvement</a> regarding substance use and the criminal justice system. Following a <a href="https://doi.org/10.1146/annurev.publhealth.19.1.173">community-based approach</a>, I share the findings with other researchers and policymakers, as well as with the groups I studied.</p>
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<img alt="A man with his back to the camera points a heroin needle in the direction of his neck." src="https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A man shoots heroin in a South Bronx park in New York on June 7, 2017.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/man-shoots-heroin-in-a-park-in-the-south-bronx-on-june-7-news-photo/693529400?adppopup=true">Spencer Platt/Getty Images</a></span>
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<h2>The shift in policing</h2>
<p>Before 2011, most police departments in the U.S. typically arrested people for drug abuse without giving them an option for substance abuse treatment.</p>
<p>Seattle’s Law Enforcement Assisted Diversion program, which was launched in 2011, <a href="https://www.fordfoundation.org/work/learning/research-reports/seattles-law-enforcement-assisted-diversion-program/">is the first known pre-arrest diversion program in the country</a>. Seattle police worked with <a href="https://kingcounty.gov/en/legacy/depts/community-human-services/mental-health-substance-abuse/diversion-reentry-services/lead">behavioral health providers, court officials and community groups</a> to set up the program, commonly referred to as LEAD.</p>
<p>LEAD focuses on <a href="https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/432/817">addressing crime and community safety issues related to drug abuse</a>. The program also focuses on reducing problems such as difficulty finding a job when a person has a criminal record. </p>
<p>In 2015, the <a href="https://paariusa.org/about-us/">Police Assisted Addiction and Recovery Initiative</a> grew out of Gloucester, Massachusetts’ policy to send people who use drugs to substance abuse treatment instead of arresting them. The initiative has helped <a href="https://paariusa.org/about-us/">nearly 600 police departments, including Tucson’s, across 34 states</a> to put in place similar drug- and opioid-abuse diversion programs.</p>
<p>In Tucson, instead of arresting people for illicit drug use or related crimes such as trespassing, <a href="https://ptaccollaborative.org/wp-content/uploads/2019/11/11-12_Hall.pdf">officers may encourage those people</a> to enroll in substance abuse treatment and give them rides to treatment providers. In addition to <a href="https://doi.org/10.1176/foc.1.2.115">evidence-based substance abuse treatment</a>, such as providing medication that treats withdrawal symptoms, the providers offer <a href="https://www.codac.org/services/">other health care services</a>, mental health treatment and other support.</p>
<p>The department <a href="https://tucson.com/news/local/tucson-police-pushing-treatment-rather-than-jail-for-hundreds-of-drug-users/article_0d3dd2fa-83af-5457-acce-8dfb0168b100.html">rolled out the program in July 2018</a>. That year, Pima County, where Tucson is located, <a href="https://www.azdhs.gov/opioid/#dashboards-overdose-deaths">had 175 fatal opioid overdoses</a> and <a href="https://ptaccollaborative.org/wp-content/uploads/2019/11/11-12_Hall.pdf">an increase in property crime due to substance and opioid abuse</a>, and there were 1,116 opioid overdose deaths statewide in Arizona. </p>
<p>My <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_FeasAccept_Report_2022_final.pdf">research shows</a> that 2,129 times in a three-year period, officers sent people to substance abuse treatment instead of arresting them. And officers gave <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_FeasAccept_Report_2022_final.pdf">people rides to treatment</a> 965 times. The data I analyzed also shows this approach takes 25 minutes less time, per incident, on average, than arresting people.</p>
<p>Programs like these represent a shift from arrest and criminalization of people who abuse drugs toward a police response that focuses on longer-term reduction of drug abuse.</p>
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<img alt="Two women drop flowers on the pavement as five people sit with their arms locked and their backs against a building entrance." src="https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.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">
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<span class="caption">Protesters calling for overdose prevention policies drop flowers at the New York governor’s New York City office on Aug. 28, 2019, to symbolize the lives lost to drug overdose.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protesters-dropped-flowers-by-the-people-risking-arrest-news-photo/1164771437?adppopup=true">Erik McGregor/LightRocket via Getty Images</a></span>
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<h2>The effectiveness of pre-arrest diversion programs</h2>
<p>Findings from research on the effectiveness of Seattle’s pre-arrest diversion program suggest that these criminal diversion programs result in <a href="https://doi.org/10.1016/j.evalprogplan.2017.05.008">fewer arrests for people with substance abuse disorders</a>. The findings also indicate that the program decreased homelessness, another program goal, with participants <a href="https://doi.org/10.1177/0011128716687550">twice as likely to have housing after participating</a>.</p>
<p>My team’s research shows that people who were offered substance abuse treatment, instead of being arrested, decreased their drug use more than people who were not offered substance abuse treatment and were arrested. On average, <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">six months after their interaction with Tucson police</a>, people who accepted diversion to a substance abuse treatment program used illegal drugs less frequently than people who had been arrested. </p>
<p>In addition, diversion to substance abuse treatment in Tucson was as effective as arrest in <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">decreasing criminal activity</a>. </p>
<p>That is why these programs may be an effective way to address the opioid epidemic.</p><img src="https://counter.theconversation.com/content/212527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Josephine Korchmaros received funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Grant Number H79TI081559 and Arnold Ventures to support a research study evaluating the Tucson Police Department's pre-arrest deflection program.</span></em></p>Police diversion programs for drug users shift officers’ focus from criminalization to treatment.Josephine Korchmaros, Professor of Social and Behavioral Sciences, University of ArizonaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984972023-03-29T19:21:16Z2023-03-29T19:21:16ZFDA approval of over-the-counter Narcan is an important step in the effort to combat the US opioid crisis<figure><img src="https://images.theconversation.com/files/515985/original/file-20230317-22-wo4sgg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The use of naloxone administered by nasal spray can be a lifesaving drug with minimal side effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/demonstration-of-a-drug-nebulizer-for-intranasal-royalty-free-image/1457667344?phrase=naloxone&adppopup=true">TG23/iStock via Getty Images Plus</a></span></figcaption></figure><p>On March 29, 2023, the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray">approved Narcan</a> for <a href="https://apnews.com/article/business-medication-opioids-health-38ae986009788501bc418fe108593632">over-the-counter sale</a>. Narcan is the 4-milligram nasal spray version of naloxone, a medication that can quickly counteract an opioid overdose.</p>
<p>The FDA’s greenlighting of over-the-counter naloxone means that it will be available for purchase without a prescription at more than 60,000 pharmacies nationwide. That means that, for 90% of Americans, naloxone nasal spray will be accessible at a pharmacy <a href="https://doi.org/10.1016/j.japh.2022.07.003">within 5 miles from home</a>. It will also likely be available at gas stations, supermarkets and convenience stores. The transition from prescription to over-the-counter status is expected to take a few months.</p>
<p><a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">We are</a> <a href="https://scholar.google.com/citations?user=84WOMGkAAAAJ&hl=en">pharmacists</a> and <a href="https://www.pharmacy.pitt.edu/directory/profile.php?profile=99">public health experts</a> who seek to increase public acceptance of and access to naloxone. </p>
<p>We think that making naloxone available over the counter is an essential step in reducing deaths due to overdose and destigmatizing <a href="https://www.cdc.gov/dotw/opioid-use-disorder/index.html#">opioid use disorder</a>. Over-the-counter access to naloxone will permit more people to carry and administer it to help others who are overdosing. Moreover, increasing naloxone’s over-the-counter availability will convey the message that risks associated with substance use disorder warrant a pervasive intervention much as with other illnesses.</p>
<p>Deaths from opioid overdoses across the U.S. have <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">increased nearly threefold since 2015</a>.
Between October 2021 and October 2022, approximately 77,000 people died <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">from opioid overdoses in the U.S</a>. Since 2016, the synthetic opioid fentanyl has been responsible for most of the <a href="https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates">drug-involved overdose deaths in America</a>. </p>
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<figcaption><span class="caption">Naloxone can be a lifesaving intervention from opioids and other drugs that are laced with the synthetic opioid fentanyl.</span></figcaption>
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<h2>What is naloxone?</h2>
<p>Naloxone reverses overdose from prescription opioids like fentanyl, oxycodone and hydrocodone and recreational opioids like heroin. Naloxone works by competitively binding to the same receptors in the central nervous system that opioids bind to for euphoric effects. When naloxone is administered and reaches these receptors, it can block the euphoric effects of opioids and reverse respiratory depression when opioid overdose occurs. </p>
<p>There are two common ways to administer naloxone. One is through the prepackaged nasal sprays, such as <a href="https://www.narcan.com/">Narcan</a> and <a href="https://kloxxado.com/">Kloxxado</a> or generic versions of the drug. The other method is via auto-injectors, like <a href="https://zimhi.com/">ZIMHI</a>, which deliver naloxone through injection, similar to the way epinephrine is delivered by an EpiPen as an emergency treatment for life-threatening allergic reactions. </p>
<p>The FDA will review a second over-the-counter application for <a href="https://www.fda.gov/news-events/press-announcements/fda-announces-preliminary-assessment-certain-naloxone-products-have-potential-be-safe-and-effective">naloxone auto-injectors at a later date</a>. Although no interaction with a health care provider will be needed to purchase over-the-counter naloxone, when naloxone is purchased at a pharmacy, a knowledgeable pharmacist will be able to help people choose a product and explain instructions for use.</p>
<p>Research shows that when people who are likely to witness or respond to opioid overdoses have naloxone, <a href="https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf">they can save patients’ lives</a>. This also includes bystanders as well as first responders like police officers and paramedics. </p>
<p>But until now, people in those situations could intervene only if they were carrying prescription naloxone or knew where to retrieve it quickly. Friends and family of people who use opioids are often given prescriptions for naloxone for emergency use. Over-the-counter naloxone will help make the drug more accessible to members of the general public. </p>
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<figcaption><span class="caption">Naloxone works on a variety of opioids, including fentanyl.</span></figcaption>
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<h2>Reducing stigma and saving lives</h2>
<p>Naloxone <a href="https://www.cdc.gov/drugoverdose/featured-topics/naloxone.html">is a safe medication</a> with minimal side effects. It works only for those with opioids in their system, and it’s unlikely to cause harm if given by mistake to someone who’s not actively overdosing on opioids.</p>
<p>Since approximately 40% of overdoses <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html#:">occur in the presence of someone else</a>, we believe public access to naloxone is extremely important. People may wish to have naloxone on hand if someone they know is at an <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">increased risk for opioid overdose</a>, including people who have opioid use disorder or people who take high amounts of prescribed opioid medications.</p>
<p>Community centers and recreational facilities may also keep naloxone on hand, similar to the placement of automated external defibrillators in public spaces for emergency use when someone has a heart attack. </p>
<p>There’s a long-held public stigma that suggests addiction is a moral failing rather than a <a href="https://www.cdc.gov/stopoverdose/stigma/index.html">chronic yet treatable health condition</a>. Those who request naloxone or who have an opioid use disorder <a href="https://doi.org/10.1186/s13722-018-0116-2">experience stigma and often aren’t comfortable</a> disclosing their drug use to others, or seeking medical treatment. Removing naloxone’s prescription requirements by making it over the counter could decrease the stigma experienced by individuals since they no longer must request it from a health care provider or behind the pharmacy counter. </p>
<p>In addition, we encourage health care providers and members of the general public to <a href="https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction">use less stigmatizing language</a> when discussing addiction.</p>
<h2>Questionable accessibility</h2>
<p>Often, medications switched from prescription to over the counter are <a href="https://doi.org/10.4103/2279-042X.185706">not covered by insurance</a>. It remains unclear if this will be the case with Narcan. If so, the costs will shift to the patient, highlighting the reason continued support of <a href="https://www.samhsa.gov/find-help/harm-reduction">programs that offer naloxone free of charge</a> remains important.</p>
<p>What’s more, over-the-counter access could paradoxically cause a decrease in the drug’s availability. A rise in purchases could make it harder to buy naloxone if manufacturer supply does not keep up with increased consumer demand. The U.S. experienced such <a href="https://www.cnn.com/2022/12/28/health/flu-covid-rsv-medications-tests/index.html">shortages of over-the-counter drugs</a> in late 2022 during the nationwide surges in flu, respiratory syncytial virus and COVID-19. </p>
<p>Federal and state governments could lessen these potential barriers by subsidizing the cost of over-the-counter naloxone and working with drug manufacturers to provide production incentives to meet public demand.</p>
<p>The effects of nationwide access to over-the-counter naloxone on opioid-related deaths remain to be seen, but making this medication more widely available is an important next step in our nation’s response to the opioid crisis.</p><img src="https://counter.theconversation.com/content/198497/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Berenbrok is part owner of the consulting company, Embarx, LLC. </span></em></p><p class="fine-print"><em><span>Janice L. Pringle is affiliated with C4 Recovery. </span></em></p><p class="fine-print"><em><span>Joni Carroll receives grant funding from the Centers for Disease Control and Prevention Overdose Data to Action. </span></em></p>The Food and Drug Administration’s approval of Narcan will make the lifesaving drug more widely available, especially to those who might be likely to witness or respond to opioid overdoses.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghJanice L. Pringle, Professor of Pharmacy and Therapeutics, University of PittsburghJoni Carroll, Assistant Professor of Pharmacy and Therapeutics, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1981312023-03-21T12:42:53Z2023-03-21T12:42:53ZIncreases in opioid overdoses in Pennsylvania varied by county during the COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/516095/original/file-20230317-26-u4bttz.jpg?ixlib=rb-1.1.0&rect=32%2C14%2C1964%2C1416&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pills are one of the more common ways of ingesting opioids.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/OpioidGuidelines/b14b1e15c96b42f782bebfdf60a359c9/photo">AP Photo/Keith Srakocic</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>The COVID-19 pandemic intensified the opioid epidemic, according to our new research, which finds that <a href="https://doi.org/10.1016/j.healthplace.2022.102938">opioid overdoses increased in Pennsylvania</a> in 2020 compared with 2018 and 2019. </p>
<p>Yet general trends obscure critical local variations. Specifically, 19 Pennsylvania counties saw statistically significant increases in opioid overdose rates. The people who live in those 19 counties are both socially and economically diverse, signaling that overdoses did not just worsen for one group of people.</p>
<p>In our study, we analyzed age-adjusted rates of opioid-related overdose incidents, reported by emergency services personnel, at the county level in Pennsylvania from 2018 to 2020. This measure is based on the number of overdose incidents to which EMS responded during the study period. We also interviewed public health providers to identify the key factors influencing opioid misuse.</p>
<p>Opioid overdoses are the leading cause of <a href="https://www.ddap.pa.gov/overdose/Pages/Overdose_Overview.aspx">accidental death in Pennsylvania</a>, according to the Centers for Disease Control and Prevention. From 2010 to 2019, rates of opioid-related deaths in Pennsylvania almost quintupled, rising from <a href="http://wonder.cdc.gov/mcd-icd10.html">5 per 100,000 people</a> to 23.7 per 100,000 people. In 2020, it rose to <a href="https://www.cdc.gov/drugoverdose/deaths/2020.html">42.4 per 100,000 people</a>.</p>
<p>In earlier work, we showed that the <a href="https://theconversation.com/opioid-overdoses-spiked-during-the-covid-19-pandemic-data-from-pennsylvania-show-161635">initial four months of the COVID-19 pandemic</a> saw an increase in opioid overdoses in Pennsylvania. Our latest study extended this analysis through 2020.</p>
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<h2>Why it matters</h2>
<p>Since the early 1990s, the opioid epidemic has gone through several waves. First, high death rates were <a href="https://doi.org/10.1111/ajt.13776">caused by prescription opioids</a>, particularly among white rural populations. The epidemic then shifted to heroin use, and expanded to include <a href="https://doi.org/10.1177/0033354920968806">urban and non-Hispanic Black populations</a>. More recently, synthetic opioids like fentanyl have been the <a href="https://doi.org/10.15585%2Fmmwr.mm675152e1">main cause of overdoses</a>.</p>
<p>Overdose rates increased in Pennsylvania at the start of the COVID-19 pandemic. This initial increase occurred at the same time as a mandatory stay-at-home order that was designed to reduce the spread of the virus. While this order was a necessary response, it resulted in a range of social effects, including job losses, mental illness, isolation and reduced access to inpatient addiction treatment services.</p>
<p>In our newest study, we examined the longer-term trends and spatial patterns for the opioid epidemic. Our research shows statistically significant county-level changes in the age-adjusted rates of opioid-related overdose incidents before and after the onset of the COVID-19 pandemic. Some Pennsylvania counties saw a significant increase in opioid overdose rates, including some with small populations, while others saw a significant decrease. </p>
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<figcaption><span class="caption">Heroin injections can lead to heart infections that can kill.</span></figcaption>
</figure>
<p>Health care providers agree that while opioid misuse has increased across the state, local conditions matter and directly affect the epidemic. As one health provider told us in an interview, “There’s a lot of variation between counties. You can drive 20 minutes across the line, and it almost seems like a different state. I think the rates of use are similar, but you see different sorts of associated factors with substance use in these counties.”</p>
<p>In order to understand social factors, we examined differences in opioid overdose rates between men and women and between Black and white people. Our research shows overdose rates among men and women were declining from 2018 to 2019 but jumped in 2020. These trends were also declining among Black and white individuals from 2018 to 2019, but those groups also experienced a large increase from 2019 to 2020. A benefit of our research is that it shows that broader segments of the population are now being affected by the opioid epidemic.</p>
<h2>What’s next</h2>
<p>Our work is finding that the stress associated with the COVID-19 pandemic was overwhelming for many people, resulting in an increase in substance misuse or relapses. We believe research and policy attention to these factors is urgently needed, especially in states like Pennsylvania that were experiencing high rates of substance use prior to the pandemic. </p>
<p>Future work could evaluate whether funds are effectively distributed to address the effects of social isolation and the social inequities surrounding opioid misuse.</p><img src="https://counter.theconversation.com/content/198131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brian King receives funding from the Department of Geography and College of Earth and Mineral Science at the Pennsylvania State University.</span></em></p><p class="fine-print"><em><span>Andrea Rishworth, Louisa M. Holmes, and Ruchi Patel do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pennsylvania has long had one of the highest death rates from drug overdose in the US. But new studies suggest counties throughout the state have different rates of opioid deaths.Brian King, Professor of Geography, Penn StateAndrea Rishworth, Postdoctoral Fellow in Geography, University of TorontoLouisa M. Holmes, Researcher of Geography, Penn StateRuchi Patel, Doctoral Student in Geography, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1869062022-11-02T12:29:49Z2022-11-02T12:29:49ZCannabis holds promise for pain management, reducing the need for opioid painkillers – a neuropharmacology expert explains how<figure><img src="https://images.theconversation.com/files/477967/original/file-20220808-82349-qkr00w.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3325&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The cannabis plant produces both THC – the psychoactive component in marijuana – and the compound commonly known as CBD, which does not lead to a 'high.'</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/marijuana-leaves-background-royalty-free-image/1329249971?adppopup=true">Jena Ardell/Moment via Getty Images</a></span></figcaption></figure><p>Drug overdose deaths from opioids <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm">continue to rise in the U.S.</a> as a result of both the misuse of <a href="https://www.hhs.gov/opioids/about-the-epidemic/index.html">prescription opioids and the illicit drug market</a>. </p>
<p>But an interesting trend has developed: <a href="https://www.upmc.com/media/news/071221-drake-cannabisrcl">Opioid emergency room visits</a> drop by nearly 8% and <a href="https://doi.org/10.1007%2Fs11606-018-4782-2">opioid prescriptions</a> are modestly lower in <a href="https://www.usatoday.com/story/news/nation/2022/10/06/how-many-states-have-legalized-marijuana-cannabis-laws-unpacked/8200166001/">states where marijuana is legalized</a>. </p>
<p>Marijuana is produced by the cannabis plant, which is native to Asia but is now grown throughout the world. Individuals use marijuana for both its psychoactive, euphoria-inducing properties and its ability to <a href="https://doi.org/10.1002/j.1552-4604.1975.tb02348.x">relieve pain</a>. </p>
<p>Chemicals produced by the cannabis plant are commonly known as cannabinoids. The <a href="https://www.nccih.nih.gov/health/cannabis-marijuana-and-cannabinoids-what-you-need-to-know">two primary cannabinoids</a> that occur naturally in the cannabis plant are THC – the psychoactive compound in marijuana – and CBD, which does not cause the sensation of being high.</p>
<p>Many <a href="https://doi.org/10.1377/hlthaff.2018.05266">marijuana users say</a> they take it to treat pain, suggesting that readily available cannabinoids could potentially be used to offset the use of opioids such as morphine and oxycodone that are commonly used in pain treatment. A safer, natural alternative to opioid painkillers would be an important step toward <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">addressing the ongoing opioid epidemic</a>. </p>
<p>Intriguingly however, research suggests that cannabis use could also lessen the need for opioids directly by interacting with the body’s own natural <a href="https://doi.org/10.1097/j.pain.0000000000002527">opioid system</a> to produce similar pain-relief effects.</p>
<p>I am <a href="https://pharmacology.uw.edu/team-member/benjamin-land/">a neuropharmacology scientist</a> who <a href="https://scholar.google.com/citations?user=dux-xtoAAAAJ&hl=en">studies both opioids and cannabinoids</a> as they relate to pain treatment and substance abuse. My research focuses on the development of drug compounds that can provide chronic pain relief without the potential for overuse and without the tapering off of effectiveness that often accompanies traditional pain medications.</p>
<h2>How opioids work</h2>
<p>Our bodies have their own built-in opioid system that can aid in managing pain. These opioids, <a href="https://www.health.harvard.edu/mind-and-mood/endorphins-the-brains-natural-pain-reliever">such as endorphins</a>, are chemicals that are released when the body experiences stress such as strenuous exercise, as well as in response to pleasurable activities like eating a good meal. But it turns out that humans are not the only organisms that can make opioids. </p>
<p>In the 1800s, scientists discovered that <a href="https://www.history.com/topics/crime/history-of-heroin-morphine-and-opiates#">the opioid morphine</a> – isolated from opium poppy – was highly effective at relieving pain. In the last 150 years, scientists have developed additional synthetic opioids like hydrocodone and dihydrocodeine that also provide pain relief.</p>
<p>Other opioids like heroin and oxycodone are very similar to morphine, but with small differences that influence how quickly they act on the brain. Fentanyl has an even more unique chemical makeup. It is <a href="https://www.dea.gov/factsheets/fentanyl">the most powerful opioid</a> and is the culprit behind the <a href="https://theconversation.com/what-is-fentanyl-and-why-is-it-behind-the-deadly-surge-in-us-drug-overdoses-a-medical-toxicologist-explains-182629">current surge in drug overdoses and deaths</a>, <a href="https://www.uclahealth.org/news/adolescent-drug-overdose-deaths-rose-exponentially-first">including among young people</a>.</p>
<p>Opioids, whether naturally produced or synthetic, produce pain relief by binding to specific receptors in the body, which are proteins that act like a lock that can only be opened by an opioid key.</p>
<p>One such receptor, <a href="https://doi.org/10.1124%2Fpr.112.007138">known as the mu-opioid receptor</a>, is found on pain-transmitting nerve cells along the spinal cord. When activated, mu-receptors tamp down the cell’s ability to relay pain information. Thus, when these opioids are circulating in the body and they reach their receptor, stimuli that would normally cause pain are not transmitted to the brain.</p>
<p>These same receptors are also found in the brain. When opioids find their receptor, the brain releases <a href="https://www.health.harvard.edu/mind-and-mood/feel-good-hormones-how-they-affect-your-mind-mood-and-body">dopamine – the so-called “feel-good” chemical</a> – which has its own receptors. This is in part why opioids can be highly addicting. Research suggests that these receptors drive the <a href="https://doi.org/10.1016/j.biopsych.2019.05.023">brain’s reward system</a> and promote further drug-seeking. For people who are prescribed opiates, this creates the potential for abuse. </p>
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<figcaption><span class="caption">Opioid drugs, which include heroin, oxycodone and fentanyl, are highly addictive.</span></figcaption>
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<p>Opioid receptors are dynamically regulated, meaning that as they get exposed to more and more opioids, the body adapts quickly by deactivating the receptor. In other words, the body needs more and more of that opioid to get pain relief and to produce the feel-good response. This process is known as tolerance. The drive to seek more and more reward paired with an ever-increasing tolerance is what leads to the potential for overdose, which is why opioids are generally not long-term solutions for pain. </p>
<h2>The potential of THC and CBD for pain treatment</h2>
<p>Both THC and CBD have been shown in <a href="https://doi.org/10.2174/157015906778019527">numerous</a> <a href="https://pubmed.ncbi.nlm.nih.gov/20073408/">studies</a> to lessen pain, though – importantly – they differ in which receptors they bind to in order to produce these effects.</p>
<p>THC binds to cannabinoid receptors that are located throughout the central nervous system, producing a variety of responses. One of those responses is the high associated with cannabis use, and another is pain relief. Additionally, THC is believed to reduce inflammation in a manner <a href="https://theconversation.com/how-do-painkillers-actually-kill-pain-from-ibuprofen-to-fentanyl-its-about-meeting-the-pain-where-its-at-173804">similar to anti-inflammatory drugs like ibuprofen</a>. </p>
<p>In contrast, CBD appears to bind to <a href="https://doi.org/10.1111/bcpt.13710">several distinct receptors</a>, and many of these receptors can play a role in pain reduction. Importantly, this occurs without the high that occurs with THC. </p>
<p>Because they target different receptors, THC and CBD may be more effective working in concert <a href="https://doi.org/10.3390/ijms23158649">rather than alone</a>, but more studies in <a href="https://doi.org/10.2217/pmt-2020-0110">animal models and humans are needed</a>.</p>
<p>Cannabinoids may also be helpful for other conditions as well. Many studies have demonstrated that cannabinoid drugs approved for medical use are effective for pain and other symptoms like <a href="https://www.ninds.nih.gov/health-information/disorders/spasticity#">spasticity</a>, nausea and <a href="https://doi.org/10.1186/s12916-022-02459-1">appetite loss</a>.</p>
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<figcaption><span class="caption">The opioid crisis: Painkillers are killing us.</span></figcaption>
</figure>
<h2>Moving pain research forward</h2>
<p>Along with the pairing of THC and CBD, researchers are beginning to explore the use of those two cannabinoids together with existing opioids for pain management. This research is being done in <a href="https://doi.org/10.1038/s41386-022-01322-4">both animal models and humans</a>. </p>
<p>These studies are designed to understand both the benefits – pain relief – and risks – primarily addiction potential – of co-treatment with cannabinoids and opioids. The hope would be that THC or CBD may lower the amount of opioid necessary for powerful pain relief without increasing addiction risk.</p>
<p>For example, one study tested the <a href="https://doi.org/10.1038/s41386-018-0011-2">combination of smoked cannabis and oxycontin</a> for pain relief and reward. It found that co-treatment enhanced pain relief but also increased the pleasure of the drugs. This, as well as a limited number of other <a href="https://doi.org/10.1038/s41386-022-01322-4">studies</a>, suggests there may not be a net benefit.</p>
<p>However, many more studies of this type will be necessary to understand if cannabinoids and opioids can be safely used together for pain. Still, using cannabinoids as a substitution for opioids remains a promising pain treatment strategy. </p>
<p>The next decade of research will likely bring important new insights to the therapeutic potential of cannabinoids for chronic pain management. And as <a href="https://www.politico.com/news/2022/08/03/cannabis-legalization-efforts-across-the-states-00049224">marijuana legalization continues to spread</a> across the U.S., its use in medicine will undoubtedly grow exponentially.</p><img src="https://counter.theconversation.com/content/186906/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Land receives funding from the NCCIH for cannabinoid work distinct from opioids, and has received cannabinoid related funding from the University of Washington Addiction and Drug Abuse Institute and SCAN Design Foundation.</span></em></p>Studies suggest that marijuana and CBD use might help relieve chronic pain while also reducing a patient’s need for opioids.Benjamin Land, Research Associate Professor of Pharmacology, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1437312020-09-03T12:23:57Z2020-09-03T12:23:57ZAddiction treatment shrinks during the pandemic, leaving people with nowhere to turn<figure><img src="https://images.theconversation.com/files/355364/original/file-20200828-23-t3tf4v.jpg?ixlib=rb-1.1.0&rect=21%2C0%2C4820%2C3199&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Josh Ledesma displays safe injection supplies with outreach specialist Rachel Bolton outside the Access Drug User Health Program drop-in center in Cambridge, Massachusetts on March 31, 2020. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/site-coordinator-josh-ledesma-displays-safe-injection-news-photo/1209081159?adppopup=true">Craig F. Walker/The Boston Globe via Getty Images</a></span></figcaption></figure><p>COVID-19 has overshadowed the U.S. opioid crisis, but that doesn’t mean opioid addiction has gone away. During the COVID-19 pandemic, the opioid crisis has gotten worse. Drug overdose death rates rose <a href="https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html">13% in the first half of 2020</a>. COVID-19 threatens to dismantle an already frayed addiction treatment system, creating a <a href="https://doi.org/10.1038/s41591-020-0898-0">crisis on top of a crisis.</a> </p>
<p>The opioid crisis, or, more aptly, the <a href="https://www.changingthenarrative.news/polysubstances">overdose crisis</a>, has plagued the U.S. for two decades. Drug overdose is the leading cause of accidental death, <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">claiming 70,000 American lives each year</a>. Opioids contribute to 130 deaths daily, enough people to fill a commercial airliner. </p>
<p>As a <a href="https://www.researchgate.net/scientific-contributions/80833856-Elizabeth-Chiarello">medical sociologist</a> who has researched the opioid crisis for the last decade, I have seen the havoc it has wrought. Here is how I see COVID-19 making it worse. </p>
<h2>A glimmer of hope, dashed</h2>
<figure class="align-center ">
<img alt="A road sign advertises help for addiction in West Virginia, one of the states hit hardest by the opioid crisis." src="https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=489&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=489&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=489&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In the city of Logan, West Virginia, a road sign advertises help for addiction.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/road-sign-advertises-help-for-addiction-on-march-26-2019-in-news-photo/1139164952?adppopup=true">Andrew Lichtenstein/Corbis via Getty Images</a></span>
</figcaption>
</figure>
<p>Overdose deaths increased steadily each year since 1999 until they <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">declined 4.1% in 2018</a>, largely due to fewer deaths involving prescription opioids. <a href="https://www.nytimes.com/interactive/2019/07/17/upshot/drug-overdose-deaths-fall.html">Experts suggest</a> that lower opioid prescribing rates, <a href="https://pubmed.ncbi.nlm.nih.gov/30138057/">expanded treatment access</a> and increased naloxone access help explain the decline.</p>
<p>That brief downturn gave way to <a href="https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html">steeply rising overdose death rates in 2019 and 2020</a> as deaths involving other drugs like cocaine and methamphetamine rose. </p>
<p>Not only are numbers going up, but the drugs that contribute to overdose have changed. </p>
<p>Many overdose deaths <a href="https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf">involve multiple drugs</a>. Prescription drugs now play a less prominent role than heroin, cocaine and methamphetamine. Synthetic fentanyl – <a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">a potent illegal opioid manufactured in labs</a> – poses the biggest threat. It contributes to <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">twice as many overdose deaths</a> as prescription opioids.</p>
<h2>Inadequate addiction treatment</h2>
<p>The overdose death rate – <a href="https://www.kff.org/other/state-indicator/opioid-overdose-death-rates/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">20.7 deaths per 100,000 people</a> – comes as no surprise to people familiar with U.S. addiction treatment.</p>
<p>Only <a href="https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf">17% of people with addiction get treatment</a>. </p>
<p>And addiction treatment is notoriously fragmented and underfunded. <a href="https://www.ncbi.nlm.nih.gov/books/NBK19830/">Cordoned off from mainstream health care</a>, the addiction treatment industry receives <a href="https://thehill.com/opinion/healthcare/407755-effective-regulation-of-the-addiction-treatment-industry-will-take">scant regulation</a>. Quality varies. <a href="https://www.samhsa.gov/data/sites/default/files/2016_NSSATS.pdf">Only one-third of facilities</a> provide medications for addiction treatment, evidence-based care <a href="https://doi.org/10.1001/jamanetworkopen.2019.20622">that reduces overdose risk</a>. </p>
<p>In the face of inadequate addiction treatment, harm reduction strategies are effective. <a href="https://www.drugpolicy.org/issues/harm-reduction">Harm reductionists</a> encourage people who use drugs to use strategies that protect them from overdose, infectious disease and abscesses from sharing or reusing syringes.</p>
<p>Programs that reduce harm include <a href="https://newrepublic.com/article/158645/coronavirus-blowing-best-response-opioid-crisis">naloxone programs</a> that distribute naloxone throughout communities and <a href="https://www.cdc.gov/ssp/syringe-services-programs-summary.html">syringe services programs</a> that distribute clean syringes to people who inject drugs. These programs, while effective, receive tepid support, largely due to stigma. Naloxone distribution programs and syringe services programs operate on <a href="https://doi.org/10.1016/j.drugpo.2019.04.006">shoestring budgets with limited hours</a> that have only become more restricted during the pandemic. </p>
<figure class="align-center ">
<img alt="COVID-19's emergence has further complicated the opioid crisis." src="https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=512&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=512&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=512&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=643&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=643&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=643&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A medical assistant in Charlestown, Massachusetts takes a swab sample from from a patient.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/medical-assistant-suleika-nunez-takes-a-swab-sample-from-news-photo/1265742379?adppopup=true">Matt Stone/MediaNews Group/Boston Herald via Getty Images</a></span>
</figcaption>
</figure>
<h2>Clash of the crises</h2>
<p>When the COVID-19 pandemic began, the federal government <a href="https://doi.org/:%2010.1377/hblog20200331.557887">took measures</a> to lessen the pandemic’s impact on the opioid crisis. </p>
<p>The government lowered barriers to medications for addiction treatment by allowing methadone clinics to give patients medication to take home and by allowing physicians to provide buprenorphine, another drug used in recovery, through telemedicine. These measures reduced in-person contact. </p>
<p>But people dealing with the disorder still face challenges. For one, they cannot attend in-person support groups. <a href="https://www.health.harvard.edu/blog/a-tale-of-two-epidemics-when-covid-19-and-opioid-addiction-collide-2020042019569">Social isolation</a> increases the likelihood of drug use and overdose. While figures are not yet available, much anecdotal evidence suggests that coping with the pandemic increases stress and anxiety while <a href="https://qz.com/1889798/covid-19-is-making-the-opioid-crisis-much-worse/">disrupting routines</a> that are important for recovery.</p>
<p>And, COVID-19 has made the illegal drug supply <a href="https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/">more dangerous</a>. In the illicit market, drugs contain various substances. A person who purchases heroin might end up with a mix of heroin, fentanyl and oxycodone, drugs of varying strengths. People who use drugs typically get them from a known supplier, so they know what they are getting and how much to take. </p>
<p><a href="http://www.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf">COVID-19 interrupted the illicit drug trade</a>, so there were fewer drugs coming into the country. When supply runs low, people do not stop using drugs; <a href="https://www.aamc.org/news-insights/covid-19-and-opioid-crisis-when-pandemic-and-epidemic-collide">they get drugs of unknown composition from new suppliers</a>. If someone buys heroin but unknowingly receives much stronger fentanyl, the overdose risk skyrockets. People die because they do not know what drug they are taking.</p>
<h2>Crisis compounded</h2>
<p>In addition, COVID-19 exacerbates the trauma that leads to overdose. Addiction is a <a href="https://press.princeton.edu/books/hardcover/9780691190785/deaths-of-despair-and-the-future-of-capitalism">“disease of despair,”</a> meaning it is more common among people with poor social and economic prospects. Mental health conditions, job loss and housing instability all contribute to drug use. </p>
<p>COVID-19 makes treatment less available. Treatment centers struggling to stay open are <a href="https://www.npr.org/sections/health-shots/2020/06/15/865006675/a-new-addiction-crisis-treatment-centers-face-financial-collapse">reducing hours and furloughing staff</a>. <a href="https://doi.org/10.1007/s10461-020-02886-2">Syringe service program site closures</a> and <a href="https://www.businessinsider.com/indiana-and-texas-police-officers-no-longer-equipped-with-naloxone-2020-4">stalled naloxone programs</a> undermine harm reduction efforts.</p>
<p>Strategies to expand treatment have been of some help. However, only physicians who already have an <a href="https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner">X Waiver</a> – a special dispensation to prescribe opioids for addiction – can provide telemedicine for buprenorphine. The federal government’s actions have moved care online, but only minimally increased treatment capacity. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1298989660060790786"}"></div></p>
<h2>A systemic solution</h2>
<p>Things are dire, but leaders can deploy effective strategies now. In the short term, leaders can double down on harm reduction. They can blanket communities with naloxone, putting it in every library, gas station, pharmacy and vending machine, making it as commonplace as a fire extinguisher. They can invest in syringe services programs and encourage people to use <a href="https://doi.org/10.1186/s12954-018-0276-0">drug test strips to test for fentanyl</a>. </p>
<p>They can expand medications for addiction treatment by <a href="https://doi.org/10.1001/jamapsychiatry.2018.3685">eliminating the X waiver</a>, letting all licensed physicians provide them, and by allowing pharmacists to provide buprenorphine, an approach <a href="https://www.bostonglobe.com/metro/2019/03/12/getting-addiction-care-pharmacy/m1mcceVlLRXX1W9X3WdeOP/story.html">showing favorable results in Rhode Island</a>. They can expand Medicaid, which requires insurers to cover treatment for addiction. These measures could save lives.</p>
<p>Leaders also need a long-term strategy that tackles the root causes of addiction. As COVID-19 makes clear, disrupting the drug supply does not make addiction disappear – it puts people with addiction at greater risk. The rise in cocaine overdose deaths is especially worrying, because while medications for addiction treatment work for opioid use disorders, <a href="https://doi.org/%2010.1097/YCO.0000000000000518">they do not work for cocaine use disorders</a>. </p>
<p>In the last 20 years, the U.S. has cycled through <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">overdose spikes</a> due to prescription opioids, then heroin, then fentanyl. Now cocaine and methamphetamine pose looming threats. </p>
<p>Investing in healthy communities is the best line of defense against overdose. A stronger social safety net would improve problems that lie at the root of addiction such as unemployment, homelessness and mental health conditions. Building infrastructure to prevent and treat addiction will equip our communities to weather storms like COVID-19. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/143731/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Chiarello receives funding from the National Science Foundation.</span></em></p>COVID-19 plagues an overtaxed opioid addiction treatment system.Elizabeth Chiarello, Associate Professor of Sociology, Saint Louis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1327322020-03-09T19:01:05Z2020-03-09T19:01:05ZOpioid marketing to Canadian doctors hyped benefits, downplayed harms<figure><img src="https://images.theconversation.com/files/317913/original/file-20200301-166503-ukpk31.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5447%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The way opioid drugs were marketed to doctors may have contributed to the opioid crisis. </span> <span class="attribution"><span class="source">AP Photo/Mark Lennihan</span></span></figcaption></figure><p>Between January 2016 and June 2019 there were over <a href="https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html">13,900 deaths from opioid overdoses</a> in Canada, 4,500 of which occurred in 2018. Based on information to date, 2019 is likely to have a similar mortality rate. Most deaths these days are from street drugs laced with fentanyl, carfentanil and other similar products. </p>
<p>But most <a href="https://www.nature.com/articles/d41586-019-02686-2">experts agree that aggressive marketing of prescription opioids has been one of the major triggers for what we are seeing today</a>. In 2000, OxyContin (long-acting oxycodone), made by Purdue Pharma, was added to Ontario’s drug formulary, a list of all medications covered under the Ontario Drug Benefit program. By 2004, all opioid-related <a href="https://doi.org/10.1503/cmaj.090784">deaths had gone up by 50 per cent and deaths specifically from long-acting oxycodone had increased more than five-fold</a>.</p>
<p>At one point, Purdue was paying <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">100 doctors per year up to $2,000 per talk</a> to go across Canada and talk about pain management to other physicians. One of those doctors was CBC radio’s Brian Goldman, host of <em>White Coat, Black Art</em>. In his 2010 book, <em>Night Shift</em>, <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">Goldman recounts how he was treated by the companies who paid him</a>: </p>
<blockquote>
<p>“… I was put up in five-star hotels and taken to nice restaurants. When I travelled across the continent, I was invariably given a ticket in business class.”</p>
</blockquote>
<p>The most effective method companies have to promote their products, the one that they put the most money into, is visits to doctors by sales representatives. These men and women are paid to go from office to office touting the products made by their companies. In the United States, <a href="https://doi.org/10.1001/jama.2018.19320">over $5.5 billion </a>is spent on drug marketing by sales representatives.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.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">
<figcaption>
<span class="caption">OxyContin, a long-acting oxycodone, was added to the Ontario drug formulary in January 2000.</span>
<span class="attribution"><span class="source">AP Photo/Toby Talbot, File</span></span>
</figcaption>
</figure>
<p>Here in Canada, sales representatives are regulated through the <a href="http://innovativemedicines.ca/wp-content/uploads/2018/06/Code-Formatted_Regular_EN-2.pdf">Code of Ethical Practices</a> of Innovative Medicines Canada (IMC), the lobby group representing the major pharmaceutical companies operating in Canada. The code states: </p>
<blockquote>
<p>“Members must provide full and factual information on products, without misrepresentation or exaggeration. Statements must be accurate and complete. They should not be misleading, either directly or by implication.”</p>
</blockquote>
<h2>Claims about benefits</h2>
<p>As researchers of pharmaceutical policy, we were interested in the extent to which these standards are upheld in practice. In 2009-10, we carried out a <a href="https://doi.org/10.1007/s11606-019-05584-5">research project with an international team</a>. In the Canadian side of this study, we asked general practitioners in Vancouver and Montréal who saw sales representatives, to fill out questionnaires after each visit to record what they had been told. In total this study included nearly 1,700 reports by doctors, around half in Canada and the rest in the U.S. and France. Claims about benefits of drugs were made twice as often as statements about harms. Contraindications — information on who should not use a medicine — were mentioned about 15 per cent of the time, and serious harmful effects only five to six per cent of the time.</p>
<p>This study was carried out at the height of opioid prescribing. We therefore went back to see what doctors reported about what sales representatives had said when they were promoting the opioids. There were 69 sales visits with opioid promotions, reported on by 54 doctors. We called this the “nuts and bolts” of opioid promotion as doctors reported on the specific messages sales representatives used to promote prescription opioids.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In more than half of opioid promotions, pharmaceutical representatives did not mention any harmful effects.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graeme Roy</span></span>
</figcaption>
</figure>
<p>In over half of these opioid promotions, no harmful effects were mentioned, although health benefits were discussed nearly 80 per cent of the time. These benefits were often vague, broad claims, such as a promise of “better quality of life” with oxycodone use. Serious harms, such as respiratory depression or arrest, were mentioned in just 12 per cent of promotions.</p>
<p>Even when information on harm was provided, often the aim was to reassure. For example, when one doctor raised the risk of a potentially fatal interaction between an opioid and an antidepressant, the representative answered that “the drug label does not refer to this situation as dangerous and therefore the drug is not contraindicated.”</p>
<p>In nine per cent of promotions, doctors said that the sales representatives had mentioned addiction or abuse. However, the only information doctors reported hearing was claims of a low addiction or abuse potential. For example, statements included: “good drug if [you are] concerned about abuse, cannot get abused” and “safer than codeine and other opiates and non-addictive,” or for “elderly patients not wanting any strong narcotics.”</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.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">
<figcaption>
<span class="caption">Oxycodone 5 milligram tablets.</span>
<span class="attribution"><span class="source">AP Photo/Keith Srakocic, File</span></span>
</figcaption>
</figure>
<p>Despite the inadequate safety information and the lack of warnings about the need for caution reported by the doctors, most said that they were somewhat or very likely to increase prescribing of the drug compared with before the sales visit. In nearly 60 per cent of promotions, doctors judged the quality of scientific information to be good or excellent.</p>
<p>Given the serious harm from overprescribing of opioids, this study highlights the need for doctors to seek out information on medicines from sources that are independent of the pharmaceutical industry, and to avoid relying on sales representatives.</p>
<h2>The fox guarding the henhouse</h2>
<p>Health Canada has largely turned over regulation of sales representatives’ activities to IMC, which waits for complaints before it acts. Complaints are adjudicated by representatives of member companies. Even if companies are found guilty of violating the Code, the <a href="http://innovativemedicines.ca/wp-content/uploads/2018/06/Code-Formatted_Regular_EN-2.pdf">maximum penalty is $100,000</a>, small change for a multinational company.</p>
<p>Relying on the pharmaceutical industry to regulate its own marketing of medicines is a classic case of the fox guarding the henhouse. We know from the experience with opioids that there are serious consequences for public health when doctors rely on misleading information about the benefits and harms of medicines.</p>
<p>If we want to stop the next round of deaths from misleading promotion, Health Canada needs to start actively regulating drug promotion, including imposing meaningful sanctions.</p><img src="https://counter.theconversation.com/content/132732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2016-2019, Joel Lexchin was a paid consultant on two projects: one looking at developing principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a second deciding what drugs should be provided free of charge by general practitioners (Government of Canada, Ontario Supporting Patient Oriented Research Support Unit and the St Michael’s Hospital Foundation). He also received payment for being on a panel at the American Diabetes Association, for a talks at the Toronto Reference Library, for writing a brief in an action for side effects of a drug for Michael F. Smith, Lawyer and a second brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p><p class="fine-print"><em><span>Barbara Mintzes is a member of Health Action International (HAI-Europe Association), a non-profit organization that supports public interests in pharmaceutical policy. She was a member of Health Canada’s Expert Advisory Group on the Marketing of Opioids in 2018 and 2019. She has no other interests to declare and receives no funding from pharmaceutical companies. </span></em></p>Aggressive marketing of prescription opioids by pharmaceutical companies provided doctors with scant information about potential harmful effects.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, Emergency Physician at University Health Network, Associate Professor of Family and Community Medicine, University of TorontoBarbara Mintzes, Senior Lecturer, Faculty of Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1191482019-09-04T11:52:54Z2019-09-04T11:52:54ZAn opioid success story: Efforts to minimize painkillers after surgery appear to be working<figure><img src="https://images.theconversation.com/files/290207/original/file-20190829-106512-1ydlodk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many hospitals are implementing new procedures to replace prescribing opioids after surgery. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/urgent-surgery-professional-smart-intelligent-surgeons-1062215336?src=-1-28">Dmytro Zinkevych/Shutterstock.com</a></span></figcaption></figure><p>The opioid epidemic has been wreaking misery and death across the nation for years. In 2017 alone, opioid overdoses killed more than <a href="https://www.cdc.gov/drugoverdose/data/index.html">47,000 people</a> – <a href="https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812603">10,000 more deaths</a> than were caused by traffic accidents that year. </p>
<p>For many people who abuse opioids, the problem begins with opioid prescriptions from their doctors for pain relief. Government data show that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25785523">21%-29% of patients</a> who are prescribed opioids go on to misuse them, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25785523">8% to 12% develop an opioid</a> abuse disorder. From 2016-2017, <a href="https://www.hhs.gov/opioids/sites/default/files/2018-09/opioids-infographic.pdf">800,000 people used heroin</a> for the first time, according to the U.S. Department of Health and Human Services, with <a href="https://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm">80% starting</a> with prescription drugs. </p>
<p>Many hospitals have begun to take steps to minimize the amount of opioids prescribed after surgery by managing pain through alternative methods. Research suggests that these programs can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943369/">reduce the need for opioids after surgery</a> and can reduce both post-surgical complications and the average length of hospital stay. </p>
<p>At Keck Medicine at the University of Southern California, I’m the director of our program to reduce opioid prescriptions and manage pain in other ways. I have spent the past year leading our enhanced recovery team to design and implement various pathways that have significantly reduced the opioid burden in our surgical patients. Here’s how these programs look in practice.</p>
<h2>New practices, less pain</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290210/original/file-20190829-106475-16fwuw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Making sure that patients are hydrated after surgery is an important part of pain management.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/selective-focus-orange-juice-bottle-blurry-1441467887?src=-1-3">Komsan Loonprom/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>We have modeled our program to manage pain after others that were developed originally to improve outcomes and shorten hospital stays after colorectal surgery. These programs, called Enhanced Recovery After Surgery, or ERAS, involve a range of measures, such as employing many different ways to reduce pain, and early mobility.</p>
<p>We have found that these protocols are easy to enact and can be as simple as giving the patients non-narcotic pain relievers in the days leading up to surgery to prep the body prior to surgery.</p>
<p>Some of the other methods include:</p>
<ul>
<li>Ensuring the patients and their families have clear understanding and expectations about post-surgical pain management</li>
<li>Making sure a patient has plenty of fluids and carbohydrates</li>
<li>Using a nerve block during surgery </li>
<li>Encouraging the patient to get up and walking within a day after surgery</li>
<li>Sending the patients home with no opioid prescriptions, or with a prescription for a very small number of pills. </li>
</ul>
<p>We have partnered with clinicians across the health care continuum. The process involves physicians, nurses, physical therapists, occupational therapists, case management, nutrition, pre-op management and social work. </p>
<p>While we have not yet published the results of our programs in an academic journal, I can say that these practices produced very tangible results; the post-operative opioid usage decreased by 50% in our division of thoracic surgery and by 60% in our department of urology.</p>
<p>The hospital’s division of cardiac surgery also reduced the use of post-operative opioid use by 45% for patients undergoing minimally invasive valve-replacement procedures. We anticipate publishing data on this finding as well. Some of our patients have gone through pre-op, surgery and post-operative care without the use of opioids at all and without any undue pain.</p>
<p>Other hospitals have reported success, too. </p>
<p>The <a href="https://www.modernhealthcare.com/care-delivery/hospitals-look-cut-opioids-surgery-and-beyond">University of Pittsburgh Medical Center</a> cut the number of post-surgical opioid prescriptions in half. </p>
<p>A <a href="https://www.wsj.com/articles/the-push-for-fewer-opioids-for-new-mothers-11559554201">Cleveland Clinic</a> pilot program to reduce opioid prescriptions in new mothers following Cesarean sections immediately reduced opioid use by two-thirds, and opioid-free hospital stays more than tripled. </p>
<p>A year after the <a href="https://www.ncbi.nlm.nih.gov/pubmed/29510097">University of Virginia</a> implemented its ERAS protocol for patients undergoing thoracic surgery, it reduced the use of post-surgical morphine equivalents by more than half, reduced length of stay by two days, and even cut hospital operating costs.</p>
<p>These practices go beyond minimizing opioid prescriptions and can contribute to better overall patient care. For example, at Keck Medicine, our preliminary results show that we have been able to decrease the length of patient stay by up to 21% and have reduced complications from <a href="https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af">atrial fibrillation</a>, or irregular heart beats that can lead to stroke, blood clots and heart failure, in thoracic surgery to less than 10%. We have also decreased intensive care stay for head and neck surgery by as much as one day. Also, we have cut by two days the length of time that catheters need to remain inserted into the bladders of post-operative urological patients. This is important because the <a href="https://www.emedicinehealth.com/foley_catheter/article_em.htm#foley_catheter_risks">risk of infection increases</a> the longer a catheter remains inserted.</p>
<h2>Advocating for patients</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290209/original/file-20190829-106508-cp6x7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Consulting with patients before surgery can help them understand how to deal with post-surgical pain in different ways.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-patient-having-consultation-doctor-office-317573702?src=-1-10">Monkey Business Images/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>An integral piece of the success is patient education. Most patients are so overwhelmed when they are about to undergo surgery and may be unaware that there are procedures to help limit opioid usage. And those who hear about opioid-minimizing practices may fear potential post-operative pain and may not consider that option. </p>
<p>It is important to educate patients well before their surgeries so they know their expected level of pain after their surgery and the different medication and procedures in place to minimize that post-operative pain. This kind of education is key in empowering patients to make informed decisions regarding opioids and their health.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/119148/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Kim works for Keck USC School of Medicine. </span></em></p>About 1 in 4 people prescribed an opioid for pain end up abusing it. New methods to reduce the need for opioids after surgery have been shown to work – and thus minimize the need for such drugs.Michael Kim, Clinical Assistant Professor of Anesthesiology, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1131012019-08-29T12:20:40Z2019-08-29T12:20:40ZWhy companies file for bankruptcy – and how it protects both debtors and creditors<figure><img src="https://images.theconversation.com/files/289919/original/file-20190828-184217-85d8hm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Critics have worried Purdue might use bankruptcy to avoid accountability. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Purdue-Bankruptcy/59244806d067425bba37138857b93bc9/62/0">AP Photo/Jessica Hill</a></span></figcaption></figure><p><a href="https://www.nytimes.com/2019/08/27/health/sacklers-purdue-pharma-opioid-settlement.html?action=click&module=Top%20Stories&pgtype=Homepage">Reports have emerged</a> that Purdue Pharma is in settlement talks to resolve thousands of federal and state lawsuits over its role in fueling the <a href="https://theconversation.com/us/topics/opioid-epidemic-26182">opioid epidemic</a>. As part of the reported settlement, the company would file for bankruptcy. </p>
<p>Earlier this year, Insys Therapeutics <a href="https://www.npr.org/2019/06/10/731363225/insys-files-for-chapter-11-days-after-landmark-opioid-settlement-of-225-million">became the first opioid drugmaker</a> to enter bankruptcy following its US$225 million settlement with the Department of Justice. In recent months, <a href="https://www.commondreams.org/news/2019/03/04/when-we-say-pharma-greed-kills-what-we-mean-critics-respond-possible-purdue">there’s been speculation</a> that drugmakers might use bankruptcy as a way to escape accountability and avoid billions of dollars in litigation costs. </p>
<p>Fortunately, that’s not how bankruptcy works. Rather, as <a href="http://www.law.uga.edu/profile/lindsey-simon">I’ve learned in my experience</a> studying and practicing bankruptcy law, the process is designed to not only protect debtors like Insys or Purdue but also creditors such as states and other opioid litigants. </p>
<p>Bankruptcy is not perfect, and sometimes outcomes seem unfair. But it’s definitely not the “get out of jail free” card that many fear. </p>
<h2>Making the best of a grim situation</h2>
<p>To most people, bankruptcy <a href="https://hbswk.hbs.edu/item/how-chapter-11-saved-the-us-economy">has a negative image</a>. And for good reason: A filing almost always means there’s not enough money to go around. </p>
<p>But the system makes the best of a grim situation by imposing an orderly and open process that preserves value and encourages negotiation. Bankruptcy reorganizations by well-known brands such as <a href="https://www.reuters.com/article/us-delta-bankruptcy/delta-exits-bankruptcy-after-19-month-restructuring-idUSWNAS850820070430">Delta</a> and <a href="https://ssrn.com/abstract=3252104">General Motors</a> show that it can bring parties together and resurrect struggling companies. </p>
<p>At the most fundamental level, the Bankruptcy Code creates an estate to collect all of the debtor’s assets into one place, identify and categorize claims against the debtor in terms of priority and then distribute the assets accordingly. </p>
<p>Exactly how those three core tasks play out in a given case will vary depending on what type of bankruptcy case the debtor files and specific facts about the debtor.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/264725/original/file-20190319-60964-f92spd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Delta went public after emerging from bankruptcy in 2007.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Delta-Stock/18e8c3a4e01748f190d454f514311bf3/8/0">AP Photo/Mark Lennihan</a></span>
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<h2>Chapter 7 vs. Chapter 11</h2>
<p>Large business debtors have two bankruptcy options: liquidation or reorganization. </p>
<p><a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-7-bankruptcy-basics">Chapter 7 cases are designed</a> to liquidate the company, meaning it will no longer exist, and any remaining value will be divided up and distributed to creditors. </p>
<p>In contrast, a <a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-11-bankruptcy-basics">Chapter 11 reorganization</a> allows a debtor to sell some or all of its assets or propose a reorganization plan that aims to resolve and satisfy enough creditors to re-emerge as a going concern. </p>
<p>For example, airlines United, Delta and American <a href="https://www.vox.com/the-goods/2019/3/11/18259894/bankruptcy-business-chapter-11-close-stores">all filed for Chapter 11</a> protection in the mid-2000s and managed to unload enough debt to stay aloft. More recent filings seeking reorganization include those by <a href="https://www.investopedia.com/news/downfall-of-sears/">Sears</a>, <a href="https://www.reuters.com/article/us-pg-e-us-bankruptcy/pge-bondholders-propose-competing-bankruptcy-plan-worth-up-to-30-billion-idUSKCN1TQ21D">Pacific Gas and Electric Company</a> and <a href="https://www.dailyrepublic.com/all-dr-news/wires/business/toys-r-us-is-back-from-the-dead-but-its-new-stores-are-unrecognizable/">Toys R Us</a>. </p>
<p>Companies sometimes initially file under Chapter 11 to reorganize but later decide to shut down after they fail to confirm a plan or find a suitor. Recent examples of this include <a href="https://money.cnn.com/2018/04/19/news/companies/bon-ton-liquidation/index.html">Bon-Ton Stores</a>, <a href="http://www.nbcnews.com/id/28691963/ns/business-us_business/t/circuit-city-liquidate-remaining-us-stores/#.XPWBgS2ZNTY">Circuit City</a> and <a href="https://dealbook.nytimes.com/2011/02/16/borders-files-for-bankruptcy/">Borders</a>.</p>
<p>For companies looking to survive, the <a href="https://uscode.house.gov/view.xhtml?path=/prelim@title11&edition=prelim">Bankruptcy Code</a> requires either creditor support or payment in full. If even one class of impaired creditors votes against a plan, the company must go through a demanding “cramdown” process for court approval to proceed.</p>
<p>Once a Chapter 11 plan of reorganization is finalized and approved, a debtor emerges from bankruptcy and continues operating, usually in a stronger position than before. </p>
<h2>Benefits of bankruptcy for debtors</h2>
<p>Bankruptcy provides at least two valuable benefits to all debtors: time and space. </p>
<p>The moment a debtor files its petition, an automatic stay is imposed on creditors, which operates like a pause button on any collection efforts, litigation or similar actions. Creditors can ask the court to lift the stay under certain circumstances, but the standard for doing so is often difficult to meet.</p>
<p>The bankruptcy court has broad authority to control all matters involving the debtor’s estate, including claims that are distantly related to the main bankruptcy case. The debtor may ask the court to pause other lawsuits outside of the bankruptcy case if they affect the estate. By bringing together all those with a stake in the company’s assets in one place, a debtor can more efficiently deal with all claims against it.</p>
<p>While the stay is in place, debtors use the bankruptcy process to evaluate their problems and make the necessary changes to succeed after reorganizing. This includes deciding which contracts they want to carry forward and which to abandon. </p>
<p>To avoid a contested process, savvy debtors seek a global settlement with as many stakeholders as possible – which is what <a href="https://www.cnbc.com/2019/08/27/purdue-pharma-offers-10-12-billion-to-settle-opioid-claims.html">Purdue is likely trying to do</a> – and include “sweeteners” to sway undecided creditors in favor of the plan.</p>
<h2>Benefits for creditors</h2>
<p>Clearly, bankruptcy provides debtors with significant power to rearrange their business affairs.</p>
<p>What many people misunderstand, however, is that this power is balanced by <a href="https://www.uscourts.gov/services-forms/bankruptcy/bankruptcy-basics/chapter-11-bankruptcy-basics">strong creditor protections</a>. The Bankruptcy Code requires debtors to disclose significant information about their operations and imposes strict checks on debtor actions. </p>
<p>For example, the debtor must publicly file information about all of its assets and liabilities, sit for a bankruptcy deposition with creditors and seek the court’s permission before taking many actions outside of the ordinary course of business. </p>
<p>Under Chapter 11, the debtor is allowed to remain in possession of its estate and continue operating. Creditors that are concerned about the debtor’s ability to preserve the estate’s value may ask the court to appoint an examiner or <a href="https://www.justice.gov/ust">trustee</a> to take control. Creditors may even move to dismiss the case if they believe the debtor is abusing the bankruptcy process. </p>
<p>The Bankruptcy Code creates a committee of unsecured creditors – those without assets backing their claims – to advocate on behalf of claimants who are likely not involved in the case. The court may also form a special committee representing tort claimants in cases where debtors face litigation or future claimants whose injuries are not yet known. The court overseeing the bankruptcy of Imerys, for example, <a href="https://www.law.com/delbizcourt/2019/03/07/11-lawyers-named-to-tort-claims-committee-in-talc-suppliers-bankruptcy/">appointed plaintiffs</a> to represent cancer victims with <a href="https://www.bloomberg.com/news/articles/2019-02-13/imerys-sa-unit-seeks-bankruptcy-protection-over-talc-lawsuits">claims against the talc supplier</a>. </p>
<p>These and other features add a degree of fairness to an inherently unjust situation. The debtor may be sitting in the driver’s seat, but numerous other stakeholders have the power to make sure that the company follows the rules of the road.</p>
<p>With such protections in place, creditors and the general public need not fear the worst if bankruptcy plays a bigger role in the unfolding opioid saga.</p><img src="https://counter.theconversation.com/content/113101/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lindsey Simon 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>While critics accuse companies facing lots of lawsuits of using bankruptcy as a sort of ‘get of jail free card,’ the reality of the legal procedure is more complicated.Lindsey Simon, Assistant Professor of Law, University of GeorgiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/981372018-06-14T10:45:23Z2018-06-14T10:45:23ZSuicide nation: What’s behind the need to numb and to seek a final escape?<figure><img src="https://images.theconversation.com/files/222881/original/file-20180612-112599-5lllwr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paramedics and firefighters in Cincinnati respond to a possible opioid overdose at a hotel on Nov. 2, 2017.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Overdose-Deaths-Drug-Mixes/b86d757fda5b45cd8c8016df0a6bec29/195/0">John Minchillo/AP Photo</a></span></figcaption></figure><p><a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm">Suicide rates in the U.S.</a> have increased nearly 30 percent in less than 20 years, the Centers for Disease Control and Prevention reported June 7. These mind-numbing statistics were released the same week two very famous, successful and beloved people committed suicide – <a href="https://www.cnn.com/2018/06/05/us/kate-spade-dead/index.html">Kate Spade</a>, a tremendous entrepreneur, trendsetter and fashion icon, and <a href="https://www.cnn.com/2018/06/08/us/anthony-bourdain-obit/index.html">Anthony Bourdain</a>, a distinguished chef and world traveler who took us on gastronomic journeys to all corners of the world through his TV shows. </p>
<p>Their tragic deaths, and others like them, have brought new awareness to the rapidly growing public health problem of suicide in the U.S. These deaths have renewed the country’s conversation about the scope of the problem. The sad truth is that suicide is the <a href="https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2016-508.pdf">10th leading cause of death</a> among all Americans, and among youth and young adults, <a href="https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2016-508.pdf">suicide is the third leading cause of death</a>. </p>
<p>I believe it’s time for us to pause and to ask the question why? Why are the suicide rates increasing so fast? And, are the increasing suicide rates linked to the seeming increase in demand for drugs such as marijuana, opioids and psychiatric medicine? As a public health researcher and epidemiologist who has studied these issues for a long time, I think there may be deeper issues to explore.</p>
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<h2>Suicide: More than a mental health issue</h2>
<p>Suicide prevention is usually focused on the individual and within the context of mental health illness, which is a very limited approach. Typically, <a href="https://www.nimh.nih.gov/health/statistics/suicide.shtml">suicide is described as an outcome of depression, anxiety and other mental health concerns including substance use.</a> And, these should not be trivialized; these conditions can be debilitating and life-threatening and should receive treatment. (If you or someone you know need help, call the <a href="https://suicidepreventionlifeline.org/">National Suicide Prevention Lifeline</a> at 1-800-273-8255). </p>
<p>The fact that so many Americans have mental illnesses is critically important as <a href="https://www.scientificamerican.com/article/1-in-6-americans-takes-a-psychiatric-drug/">1 in 6 Americans takes a psychiatric drug</a>, most commonly antidepressants, anxiety relievers and antipsychotics. In addition, more than <a href="https://www.samhsa.gov/data/sites/default/files/report_3210/ShortReport-3210.pdf">1 in 3 U.S. adults</a> are also prescribed pain reliever for physical pain. And, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26522868">physical pain</a> substantially increases risk for suicide. </p>
<p>In our national discussion of this issue, we raise important questions about the <a href="https://www.nytimes.com/2018/06/08/health/suicide-spade-bordain-cdc.html">potential failure of our mental health system</a>, its infrastructure and the stigma around mental health diagnoses, substance use and treatment. We also talk about the treatment gap, meaning the difference between those who need treatment versus those who can access and get treatment.</p>
<p>These are all valid concerns and critically important to address, but they are only part of the problem. As the CDC pointed out in its report, <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm">more than half of the suicide deaths</a> in the U.S. did not have a known diagnosed mental health condition. So, while there are many reasons for raising concerns about our fragmented mental health system, the treatment gap and associated factors, I don’t think it is sufficient to understand our increasing suicide rates. One needs to look more broadly at underlying factors to understand why the suicide rate is increasing so significantly. </p>
<h2>Suicide and substance use</h2>
<p>The <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm">CDC report</a> noted that among those suicide deaths which had a toxicology test, nearly <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm">80 percent had one or more substance in their system</a>, with alcohol being the most common, followed by opioids, benzodiazepines, cocaine, amphetamines, marijuana and antidepressants. More troubling, “the mortality rate from drug poisoning, alcohol poisoning, and suicide increased by 52 percent between 2000 and 2014,” according to a separate <a href="https://scholars.unh.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1291&context=carsey">report</a> by Carsey Research. Perhaps that provides some insight into what may be driving the increase in suicide rates. Research shows that many <a href="https://stacks.cdc.gov/view/cdc/11981">suicide deaths are caused by a substance overdose</a>, but <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872355/">alcohol</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25644860">substance abuse and addiction</a> are also key risk factors for suicide. </p>
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<p>Overall in the U.S., <a href="https://www.drugabuse.gov/publications/drugfacts/nationwide-trends">illicit drug use has been increasing</a>. Marijuana use in particular has increased rapidly and doubled in the last decade. Currently <a href="https://www.nih.gov/news-events/news-releases/prevalence-marijuana-use-among-us-adults-doubles-over-past-decade">nearly 10 percent of adults use marijuana</a> and a third of these users meet criteria for a substance use disorder. This increase in marijuana use may not be surprising given that 30 states and the District of Columbia now have some form of <a href="http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html">legalized marijuana</a>, allowing millions of people to legally access and use the drug.</p>
<p>Opioid use is also increasing dramatically. Just last year, the U.S. declared the opioid epidemic a public health emergency. In 2016, 42,249 people in the U.S. <a href="https://www.hhs.gov/opioids/about-the-epidemic/index.html">died from an opioid overdose</a>. That’s nearly as many as <a href="https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2016-508.pdf">those who died from suicide that year</a>. The current opioid epidemic, which comprises both <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis">prescription pain relievers as well as illicit drugs like heroin and synthetic opioids such as fentanyl</a>, has raised alarms across the country. Isn’t it time that we ask why there is such high demand for these drugs? </p>
<p>Taken together, it seems that the majority of our U.S. population is currently under the influence of some form of psychoactive substance or drug, whether prescribed or not, or whether legally used or not, that changes brain function, mood, consciousness and behavior. And, let’s not forget alcohol in this context since <a href="https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics">70 percent of U.S. adults drink alcohol</a>, and more than 1 in 4 binge drink. </p>
<p>What drives the demand for these psychoactive substances? And can the increasing demand and prevalence of both illicit and licit substance help explain the rising rates of suicides? </p>
<p>Research that seeks to understand the reasons for <a href="https://www.samhsa.gov/data/sites/default/files/report_3210/ShortReport-3210.pdf">prescription misuse</a> finds that people who report misusing prescription drugs such as tranquilizers do it because they want to relax or relieve tension; those who misuse stimulants state they need to stay alert; and those who misuse sedatives state it helps with sleep. </p>
<p>I believe it’s also worth considering whether higher levels of stress are driving more Americans to take psychoactive substances and, in extreme cases, take their own lives. Last year, <a href="http://news.gallup.com/poll/224336/eight-americans-afflicted-stress.aspx">8 in 10 U.S. adults reported feeling stressed</a> during their day, and <a href="http://www.apa.org/monitor/2011/01/stressed-america.aspx">44 percent reported that their stress levels had increased over the past five years</a>. Most people state their stress is <a href="https://www.apa.org/news/press/releases/stress/2017/state-nation.pdf">due to concerns about the future, money, work, the political climate, and violence and crime</a>.</p>
<p>In addition to our high stress levels, it turns out that only about <a href="http://time.com/4389726/harris-poll-happiness-index-2016/">1 in 3 Americans are happy.</a> </p>
<p>This is happening as U.S. performance on a range of health and social measures has been deteriorating, which has led some to compare America to a <a href="https://www.huffingtonpost.com/sean-mcelwee/america-third-world-country_b_4945892.html">developing country</a>. Most other developed countries score better than we do on a range of <a href="https://www.usnews.com/news/best-countries/quality-of-life-full-list">quality of life indices</a> and markers of health and longevity, including <a href="https://www.washingtonpost.com/news/wonk/wp/2013/11/21/the-u-s-ranks-26th-for-life-expectancy-right-behind-slovenia/?noredirect=on&utm_term=.f2b3bf4cb48a">life expectancy</a>, <a href="http://fortune.com/2015/11/11/chart-work-week-oecd/">working conditions</a>, <a href="https://www.savethechildren.net/state-worlds-mothers-2015">mothers’ well-being</a>, <a href="https://www.theguardian.com/news/datablog/2010/dec/07/world-education-rankings-maths-science-reading">school performance</a>, <a href="http://www.nationmaster.com/country-info/stats/Crime/Total-crimes">crime rates</a> and <a href="http://amjmed.org/violent-death-rates-us-vs-22-other-countries/">violent death rates</a> to mention a few. Could these factors explain our high stress levels and low levels of happiness?</p>
<p>It is not clear what exactly drives the demand for the psychoactive substances and what has driven the increase in suicides. But I think it’s worth speculating whether a perceived low quality of life for many Americans, marked by high stress and low levels of happiness, is contributing. </p>
<p><a href="http://www.pewresearch.org/fact-tank/2015/03/12/how-do-americans-stand-out-from-the-rest-of-the-world/">Americans</a> stand out from people in other countries with respect to their focus on individualism. Americans believe that success is determined by our own control and that it is very important to work hard to get ahead in life. Perhaps it is this focus on our own achievements, successes and work culture that have created an environment that is no longer sustainable – it has become too stressful.</p>
<p>What other options do we have in a culture where we are also expected to solve our own problems? I believe that for many, the use of substances and suicides may tragically be the only available coping mechanism.</p><img src="https://counter.theconversation.com/content/98137/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monica H. Swahn previously received funding from the Centers for Disease Control and Prevention, the National Institutes of Health and the American Foundation for Suicide Prevention. </span></em></p>Deaths from opioid overdose and suicide are at an all-time high. One in 10 adult Americans uses marijuana. And only 1 in 3 Americans self-describes as ‘happy.’ A public health expert asks, what’s going on?Monica Swahn, Professor, epidemiology and public health, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/938982018-03-27T10:45:09Z2018-03-27T10:45:09ZTrump plan to execute ‘big drug pushers’ will do nothing to stop opioid overdoses<p>On March 19, President Donald Trump unveiled his administration’s <a href="https://www.whitehouse.gov/briefings-statements/president-donald-j-trumps-initiative-stop-opioid-abuse-reduce-drug-supply-demand/">plan</a> to stem the opioid overdose crisis in the United States, which has <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">claimed some 350,000</a> lives since 2000. Among other measures, it proposes severe punishment for people involved in the illegal drug trade, including longer minimum jail sentences and potentially the death penalty.</p>
<p>This is an extreme version of what’s actually an old approach to combating substance use: Attacking the supply side of the drug trade. </p>
<p>From <a href="https://books.google.com/books?hl=en&lr=&id=quFLDwAAQBAJ&oi=fnd&pg=PT43&ots=Hmit6PKvxr&sig=rf0M6vjNoYbZ7qHm6DgbAeM3DvU#v=onepage&q&f=false">banning Chinese immigration in 1882</a> – supposedly on the grounds that Chinese people promoted vices like smoking opium – to the <a href="https://www.aclu.org/other/cracks-system-twenty-years-unjust-federal-crack-cocaine-law?redirect=criminal-law-reform/cracks-system-twenty-years-unjust-federal-crack-cocaine-law">mass incarceration that followed the 1980s-era crack panic</a>, the United States has long sought to reduce drug consumption by clamping down on drug sources. It has never <a href="https://www.politico.com/story/2018/03/20/death-penalty-drug-dealers-trump-clinton-476374">killed citizens for trafficking drugs</a>, though.</p>
<p>Worldwide, 33 countries have laws prescribing the death penalty for drug offenses, <a href="https://www.hri.global/files/2018/03/06/HRI-Death-Penalty-Report-2018.pdf">according to Harm Reduction International</a>, a nonprofit group that advocates to end this practice.</p>
<p>Ample evidence shows that <a href="https://www.rand.org/pubs/reprints/RP942.html">harshly punishing drug trafficking does not end drug consumption</a>. Instead, <a href="https://scholar.google.com/citations?user=xAzqC34AAAAJ&hl=en">my research suggests</a>, it creates the spillover effect of criminalizing everyone associated with drugs – including drug users and, in particular, people from the most marginalized sectors of society. </p>
<h2>Where is the death penalty used?</h2>
<p>International human rights law mandates that the death penalty only be imposed for the “<a href="http://www.ohchr.org/EN/ProfessionalInterest/Pages/CCPR.aspx">most serious crimes</a>.” And many of the countries that allow capital punishment for drug crimes rarely apply this punishment in practice. A few – including Myanmar and Laos – never do.</p>
<p>Currently, seven countries regularly execute their citizens for drug offenses, <a href="https://www.hri.global/files/2018/03/06/HRI-Death-Penalty-Report-2018.pdf">according to Harm Reduction International</a>: China, Indonesia, Iran, Saudi Arabia, Malaysia, Vietnam and Singapore. </p>
<p>Between January 2015 and December 2017, at least 1,320 people worldwide were <a href="https://www.hri.global/files/2018/03/06/HRI-Death-Penalty-Report-2018.pdf">executed after being convicted of drug-related offenses</a>, many of them for nonviolent crimes like street dealing.</p>
<p>It’s noteworthy, I think, that all of these countries are either authoritarian regimes or democracies where civil liberties are seriously threatened. Among the 33 countries that punish drug offenses with death, only three – India, South Korea and Taiwan – are <a href="https://freedomhouse.org/report/freedom-world/freedom-world-2018">considered democratic by the watchdog group Freedom House</a>.</p>
<h2>China and Iran: High drug use despite death penalty</h2>
<p>Typically, governments that kill their citizens for drug offenses don’t publish good statistics on drug use. That makes it difficult to document the effects of these policies. </p>
<p>Most of the information I use in this analysis comes from <a href="http://www.unodc.org/unodc/en/drug-trafficking/index.html">the United Nations Office on Drugs and Crime (UNODC)</a> and from reports by international human rights organizations. Taken together, this data shows little correlation between harsh criminal sanctions and rates of drug use. </p>
<p>Iran has <a href="http://www.unodc.org/wdr2017/">persistently high opioid consumption</a> despite the government’s relentless persecution of drugs. In 2017, Iran accounted for <a href="https://www.hri.global/files/2018/03/06/HRI-Death-Penalty-Report-2018.pdf">242 of 280</a> people executed worldwide based on death penalty laws for drug crimes. </p>
<p><a href="http://www.unodc.org/wdr2017/">Over 2 percent</a> of Iranians report having used heroin or other opioids in the past year. That’s higher than the global average, which is just 0.73 percent.</p>
<p>In China, <a href="https://www.amnesty.org/download/Documents/ASA1758492017ENGLISH.PDF">researchers from Amnesty International</a> estimate that least 13 percent of all executions between 2011 and 2016 were related to drug offenses. Nonetheless, <a href="http://www.unodc.org/wdr2017/field/Booklet_2_HEALTH.pdf">global statistics</a> suggest that the country has one of the world’s largest population of injection drug users. </p>
<h2>Singapore and Philippines: No evidence of progress</h2>
<p>Singapore, which executed three people for drug offenses in 2017, claims that the death penalty has worked to reduce drug use. But this <a href="https://theconversation.com/trump-take-note-why-singapores-claim-that-the-death-penalty-works-for-drug-offences-is-fake-news-92305">position is difficult to verify</a>. </p>
<p>Government data there indicates that just 0.3 percent of Singaporeans have taken drugs in the past year – which is a low consumption rate. But the <a href="https://data.unodc.org/#state:5">most recent available estimates</a> also show that opioid use in Singapore is now rising. If the death penalty actually deterred drug use, consumption rates should have either decreased or remained steady.</p>
<p>Then there’s Philippines, home to the world’s deadliest war on drugs. Since Rodrigo Duterte became president in 2016, government forces have killed an estimated <a href="https://www.hrw.org/news/2018/01/18/philippines-dutertes-drug-war-claims-12000-lives">12,000 Filipinos accused of using and selling drugs</a>. Most of them were poor. None were given due process or allowed to <a href="https://www.hrw.org/news/2018/01/18/philippines-dutertes-drug-war-claims-12000-lives">defend themselves in court</a>. </p>
<p>President Trump has praised Duterte, saying “<a href="https://www.nytimes.com/2017/05/23/us/politics/trump-duterte-phone-transcript-philippine-drug-crackdown.html">he has done an unbelievable job on the drug trade</a>.” </p>
<p>Little suggests that this bloody campaign is stemming drug consumption in the Philippines. In 2012, years before Duterte came to power, the country already had generally low rates of drug use, <a href="https://data.unodc.org/#state:1">according to government data</a>. And between 2008 and 2012, consumption of marijuana – the most widely used drug in the Philippines – decreased 17 percent. </p>
<p>These numbers call into question Duterte’s <a href="https://www.reuters.com/article/us-philippines-duterte-drugs/more-blood-but-no-victory-as-philippine-drug-war-marks-its-first-year-idUSKBN19G05D">claim</a> that “drug abuse” in the Philippines is a symptom of “virulent social disease.” </p>
<h2>Minimum sentences and mass incarceration</h2>
<p>Globally, more countries are <a href="https://news.un.org/en/story/2016/04/527112-world-drug-problem-un-adopts-new-framework-policies-put-people-first">introducing reforms to treat drug use as a public health problem rather than a criminal matter</a>. At the 2016 United Nations General Assembly Special Session on Drugs, <a href="http://fileserver.idpc.net/library/Drug-Policy-Reform-NEO-1.pdf">many nations voiced strong opposition</a> to punishing drug crimes with execution. </p>
<p>The Trump administration has stipulated that the death penalty would only be used against “<a href="https://www.c-span.org/video/?442817-1/president-trump-pushes-death-penalty-drug-dealers">big drug pushers</a>.” But, historically, United States drug laws have primarily punished the <a href="https://www.ussc.gov/sites/default/files/pdf/research-and-publications/research-publications/2017/20171025_Drug-Mand-Min.pdf">lowest-level people in the drug trade</a>.</p>
<p>In 1986, the Reagan administration <a href="https://www.ussc.gov/sites/default/files/pdf/news/congressional-testimony-and-reports/mandatory-minimum-penalties/20111031-rtc-pdf/Chapter_02.pdf">enacted mandatory minimum sentences for drug crimes</a>. Under these laws, judges were required to give at least <a href="https://www.aclu.org/other/cracks-system-twenty-years-unjust-federal-crack-cocaine-law?redirect=criminal-law-reform/cracks-system-twenty-years-unjust-federal-crack-cocaine-law">five years of jail time</a> to people convicted of possessing just 5 grams of crack, for example – about 10 or 20 doses. By law, the judges could not account for mitigating factors such as addiction, mental health or poverty.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212024/original/file-20180326-188616-3gv8kv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">President George H.W. Bush continued the Reagan administration’s punitive take on crack use, calling drugs ‘the gravest domestic threat facing our nation.’</span>
<span class="attribution"><span class="source">AP Photo/Dennis Cook</span></span>
</figcaption>
</figure>
<p>As a result, minimum sentencing guidelines have primarily swept up not violent kingpins but street dealers, mules, couriers and users who have occasionally sell drugs to maintain their own habit. </p>
<p>In 2016, 50 percent of federal <a href="https://www.ussc.gov/sites/default/files/pdf/research-and-publications/research-publications/2017/20171025_Drug-Mand-Min.pdf">inmates were drug offenders</a>. Three-quarters of them were serving mandatory minimum sentences. Roughly half of those people had <a href="https://www.ussc.gov/sites/default/files/pdf/research-and-publications/research-publications/2017/20171025_Drug-Mand-Min.pdf">no or little criminal history</a> prior to their drug convictions. </p>
<p>Mandatory minimums helped the U.S. <a href="https://www.bjs.gov/index.cfm?ty=pbse&tid=0&dcid=0&sid=40&iid=0&sortby=&page=paging&curpg=1">prisoner population explode</a>. Between 1986 and 2000, the number of people in jail <a href="https://academicworks.cuny.edu/cgi/viewcontent.cgi?article=1026&context=jj_pubs">almost quadrupled</a>, though incarceration rates have somewhat slowed since the <a href="https://www.ussc.gov/research/congressional-reports/2015-report-congress-impact-fair-sentencing-act-2010">2010 Fair Sentencing Act</a>. </p>
<p>None of these policies led drug use in the United States to drop. Cocaine consumption, for example, decreased in <a href="http://www.cedro-uva.org/lib/harrison.cannabis.03.html">the late 1980s</a>, peaked in the 1990s and declined again starting in 2006. Meanwhile, heroin use has <a href="https://theconversation.com/the-opioid-epidemic-in-6-charts-81601">risen dramatically</a>. </p>
<p><a href="http://eds.a.ebscohost.com.umasslowell.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=1&sid=5e69265f-6bf6-44dc-8f16-0288527c2f4c%40sessionmgr4009">The real reasons for these trends</a> remain under-researched but likely include demographic, social and economic factors, as well as changing perceptions of drugs. </p>
<p>Punitive drug policies have not helped countries deal with drugs. They’ve just created lasting social harms, both in the U.S. and worldwide.</p><img src="https://counter.theconversation.com/content/93898/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angélica Durán-Martínez has received funding from the United States Institute of Peace and the Social Science Research Council (SSRC). In 2011, she was an SSRC Drugs, Security and Democracy fellow, a program funded by Open Society Foundations.
</span></em></p>Just seven countries worldwide regularly execute people for drug crimes, most of them authoritarian regimes. Nothing suggests that this brutal policy actually curbs drug use.Angélica Durán-Martínez, Assistant Professor of Political Science, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/875812017-11-20T02:25:51Z2017-11-20T02:25:51ZThe dangers and potential of ‘natural’ opioid kratom<figure><img src="https://images.theconversation.com/files/195255/original/file-20171117-19250-16k090r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The leaves of the plant kratom.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mitragyna-speciosa-korth-kratom-worker-hand-480333337?src=A9uj9ESb-Br4U0X7phK94w-1-6">MIA Studios/Shutterstock.com</a></span></figcaption></figure><p>Given the <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">opioid addiction crisis</a>, it would seem preposterous that an opioid is legal for use in the United States and can be purchased at tea stores, convenience stores, over the internet and, yes, even <a href="https://www.statnews.com/2017/06/01/kratom-vending-machine/">from vending machines</a>. </p>
<p>However, kratom is not your average opioid. The Drug Enforcement Agency found this out when it tried to ban the herb in 2016. </p>
<p>Public outcry from users and 51 <a href="http://nationalpainreport.com/congressional-members-ask-dea-to-delay-kratom-ban-8831565.html">congressmen around the country</a> from both political parties was loud. The DEA has since dropped its <a href="https://www.usnews.com/news/us/articles/2016-05-20/states-ban-kratom-supplement-over-abuse-worries">attempt to ban kratom</a>, although its use is banned in Alabama, Arkansas, Indiana, Tennessee, Vermont, Wisconsin and Louisiana. </p>
<p>More recently, on Nov. 14, 2017, the FDA issued a <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm584970.htm">public warning about kratom, citing 36 deaths</a> that the agency has attributed to kratom use.</p>
<p>Kratom lies at the intersection between natural product and drug of abuse, areas I have been been exploring as a clinical pharmacology researcher and a pharmacist <a href="https://pharmacy.uconn.edu/person/c-michael-white/">for two decades</a>. From ephedra for weight loss to MDMA (molly) for PTSD, experience has taught me that natural products are not always safe and that banned drugs may actually benefit some patients.</p>
<h2>A popular plant</h2>
<p>Thousands of people take kratom, which grows naturally in Thailand, Malaysia, Indonesia and Papua New Guinea, to <a href="https://www.painnewsnetwork.org/stories/2016/9/21/survey-kratom-very-effective-for-many-chronic-pain-conditions">relieve pain</a>, believing a natural herb to be safe. However, we just do not know enough about the herb to deem it safe, or effective.</p>
<p>We do know that kratom has very mild pain-relieving effects and a slight stimulant effect. It brings a low risk of stopping breathing, the main risk of stronger opioids. </p>
<p>The opioid effects from kratom come from two potent chemicals, mitragynine and 7-hydroxymitragynine in kratom’s leaf. Mitragynine is the more prominent and has very mild opioid effects, while 7-hydroxymitragynine is <a href="https://www.ncbi.nlm.nih.gov/pubmed/23206666">13 times more potent than morphine</a> milligram for milligram.</p>
<p>But just because kratom is not as dangerous as heroin and fentanyl does not mean it is free of adverse effects. In fact, they are all <a href="https://www.ncbi.nlm.nih.gov/pubmed/25262913">highly addictive</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/195273/original/file-20171117-11450-rs8s12.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Capsules of kratom in Albany, N.Y. in a Sept. 27, 2017 file photo, after the death of a young police officer in upstate New York was classified as a kartom overdose.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Alternative-FDA-Warning/87d788428941445bb09bbcb5b22074ca/2/0">AP Photo/Mary Esch</a></span>
</figcaption>
</figure>
<p>In an assessment of the 660 calls about kratom to United States poison control centers from 2010-2015, the major adverse effects included racing heartbeat, agitation or irritability, drowsiness, nausea and high blood pressure. The <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6529a4.htm">adverse effects</a> were moderate or severe in 42 percent and 7 percent of people, respectively. </p>
<p>In addition, unlike prescription drugs, the quantities of the active ingredients in unregulated kratom products can change over time or can be adulterated with other products. In an assessment of several kratom products commercially sold in the Western world, the concentrations of 7-hydroxymitragynine were <a href="http://addictionresearch.health.ufl.edu/faculty/bonnie-a-avery-ph-d/">substantially higher</a> than could be achieved naturally, which negates the safety benefits of using kratom versus other opioids.</p>
<h2>Help for hard workers?</h2>
<p>Kratom has been used widely in Southeast Asia for millennia, but it was banned in Thailand in 1943. Fans of the herb said the <a href="http://entheology.com/news-articles/why-kratom-was-banned-in-thailand/">ban was due to politics</a>, not health. </p>
<p>The ban hardly stopped its usage there. According to the 2008 national survey in Thailand, more than a million people reported using kratom. In several southern districts in Thailand, up to <a href="https://www.pri.org/stories/2016-09-07/thailand-moving-closer-decriminalizing-meth">70 percent of the male population reportedly uses kratom</a> daily. </p>
<p>In Malaysia, the majority of people reported use of kratom to enhance their ability to work long hours with less pain and fatigue, but 31 percent began out of curiosity or peer pressure. <a href="https://www.ncbi.nlm.nih.gov/pubmed/24698080">Fifteen percent</a> reported using kratom to wean off illicit drugs and alcohol. Eighty-nine percent of subjects tried to abstain from kratom in the past but all had relapsed due to withdrawal symptoms, such as insomnia, nausea, vomiting, diarrhea, muscle pains and shakiness, runny eyes and nose, anxiousness, depression and tension.</p>
<p>In the U.S., kratom’s safety profile – at least compared to other opioids – led people as far back as 1836 to recommend kratom as a substitute for people who became addicted to opioids. This belief was the main reason for the outcry <a href="https://www.ncbi.nlm.nih.gov/pubmed/23206666">against the proposed DEA ban</a> in 2016. Despite the internet hype and extensive anecdotal experience, I do not think there any high-quality studies assessing how well it actually works and the best ways to use it.</p>
<h2>Keeping quiet</h2>
<p>A small study in Malaysia of <a href="https://www.ncbi.nlm.nih.gov/pubmed/20092998">136 kratom users</a> in 2010 suggested that kratom was effective at reducing the use of opioids. But, of the 78 percent of the respondents who subsequently tried to quit using kratom, none was successful. </p>
<p>We already have drugs that can be used for opioid addiction, including suboxone and methadone, which have been rigorously studied but also are addictive. It is reasonable to ask: Why would someone use kratom to help treat addiction? </p>
<p>Kratom offers something that other drugs to treat addiction do not – the ability to treat oneself in anonymity and to receive treatment without involving the health care system or law enforcement. </p>
<p>We need more information. Having the DEA ban a product makes the scientific inquiry into that product extremely difficult. This has impaired researchers’ ability to sensibly investigate the medicinal properties of marijuana, to the detriment of patients, I believe. </p>
<h2>What is the bottom line?</h2>
<p>Kratom is a promising option as an effective and safe substitute for people addicted to prescription opioids, which needs to be explored.</p>
<p>At the same time, kratom has high addiction potential and is risky when combined with other psychiatric drugs or drugs of abuse. Having kratom available to purchase in nearly unlimited quantities in venues that do not restrict purchase by age is a very bad idea.</p>
<p>A middle ground between this Wild West policy and a ban on kratom is to establish it as a third class of drugs. In 2006, Congress passed a law <a href="https://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm072423.htm">moving decongestants</a> (pseudoephedrine, ephedrine and phenylpropanolamine) from over-the-counter to behind-the-pharmacy-counter status. </p>
<p>That law limits the monthly amount of the decongestants any individual could purchase. It also limits the sale to adults with photo identification and requires retailers to keep personal information about these customers for at least two years after purchase. Congress could pass a similar law for kratom and even place further restrictions, such as requiring kratom products to contain a standardized amount of the active constituents and that patients provide a medication history to the pharmacist, who can check for harmful drug-drug interactions and counsel patients on safer ways to use the drug. </p>
<p>As with decongestants, this can be done efficiently and discreetly, because there are over <a href="https://pdfs.semanticscholar.org/6215/52c5422c82367330037a5360ee0b1b6b9cf6.pdf">275 million patient visits</a> to places that have pharmacies in them in the United States each week.</p><img src="https://counter.theconversation.com/content/87581/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C. Michael White 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>The herb kratom has a large following and is so popular that it is sold in vending machines. The FDA recently issued a public warning about the herb, which contains low levels of opioids.C. Michael White, Professor and Head of the Department of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/865982017-11-09T17:02:24Z2017-11-09T17:02:24ZThe opioid crisis is at its worst in rural areas. Can telemedicine help?<figure><img src="https://images.theconversation.com/files/193794/original/file-20171108-14182-kf9rmw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People wait in line for a methadone clinic to open in Hoquiam, Washington, a small town within a predominantly rural area.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Despair-and-Donald-Trump/6e96f36a969b47bca1b4ff7e9edb77cc/2/0">David Goldman/AP Photo</a></span></figcaption></figure><p>Some of the communities hit hardest by the opioid epidemic are in rural America. However, many of those same communities lack access to comprehensive treatment. </p>
<p>To address the epidemic’s increasing reach, the White House declared a <a href="http://www.bbc.com/news/world-us-canada-41756705">public health emergency</a> on Oct. 26. The administration outlined a need to expand treatment in rural communities, most notably by making telemedicine more readily available. Telemedicine, also referred to as telehealth, aims to improve treatment access by allowing people to consult their provider remotely – for example, by using videoconferencing. </p>
<p>As a researcher of opioid treatment in Michigan, I’m excited to see the call for greater availability of telemedicine as a way to help rural communities. However, telemedicine has important limitations that need to be considered. </p>
<h2>Rural struggles</h2>
<p>Drug overdose deaths are rising in rural areas across the U.S. In 2015, the overdose death rate for rural areas surpassed the death rate for urban or suburban areas. People living in rural areas were <a href="https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm">four times more likely to die from overdoses</a> in 2015 than they were in 1999. The opioid epidemic hit states east of the Mississippi River hardest, with the highest death rates in relatively rural states: <a href="https://www.cdc.gov/drugoverdose/data/statedeaths.html#tabs-1092063-3">West Virginia, New Hampshire and Kentucky</a>.</p>
<p>The most scientifically supported <a href="http://dx.doi.org/10.1097/HRP.0000000000000075">opioid treatments</a> combine medications – like buprenorphine, methadone or Suboxone – with behavioral therapy. These opioid treatment programs help patients stop abusing opioids and promote long-term recovery.</p>
<p>However, people living in rural areas face a number of barriers in accessing opioid treatment. Many rural populations have a limited number of <a href="http://dx.doi.org/10.1111/jrh.12178">clinics that provide opioid treatment and behavioral therapy</a>, as well as a shortage of <a href="http://dx.doi.org/10.1370/afm.1735">providers who prescribe opioid treatment medications</a>. People living in rural areas frequently <a href="https://dx.doi.org/10.1155/2011/948789">travel long distances to their opioid treatment provider</a>. Moreover, many may feel <a href="https://dx.doi.org/10.1001/jama.2014.2147">ashamed or stigmatized</a> if they seek out opioid treatment in their local community. </p>
<p>In northern Michigan, for example, roughly 400,000 residents live north of the closest clinic in Otsego County that provides both methadone and behavioral therapy. People in need of comprehensive opioid treatment in these remote areas require their own transportation and finances to support multiple hours of travel. </p>
<p>The shortage of providers is also an obstacle for rural communities in less remote areas of Michigan. In Lenawee County, which is situated roughly an hour from Ann Arbor and Toledo, there are approximately 100,000 citizens with access to a handful of buprenorphine treatment providers. The few rural providers in areas like this typically offer opioid treatment within small family medicine practices and have limited staff to provide behavioral therapy. </p>
<h2>Telemedicine pros and cons</h2>
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<a href="https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/193843/original/file-20171108-14167-wpykgl.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">Telemedicine lets patients confer with doctors many miles away.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-her-surgery-office-headset-570590131?src=UcZT61BS2Rq3A7w6fv4r5Q-1-0">Agenturfotografin/shutterstock.com</a></span>
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<p>With these issues in mind, telemedicine seems like a promising way to <a href="https://dx.doi.org/10.1007/s11414-012-9299-6">help rural communities</a>, and specifically, <a href="http://dx.doi.org/10.1016/j.drugalcdep.2017.01.048">to aid in rural opioid treatment</a>. </p>
<p>One study from Ontario demonstrated that the more sessions patients attended via telemedicine, the more likely they were to stay in an opioid treatment program. Patients in the study attended telemedicine sessions under a nurse’s supervision at an affiliated opioid treatment clinic. The prescribing physicians, who likely oversee other clinics from afar, were videoconferenced in from a different location. Videoconferencing helped patients better access providers to discuss medication issues, but still required patients to travel to an affiliated clinic.</p>
<p>The White House has yet to provide explicit details on how expanded telemedicine services will be funded. The US$57,000 released through the public health emergency isn’t enough by itself to lead to meaningful changes and needs renewal after 90 days. </p>
<p>The use of telemedicine for opioid treatment also presents particular challenges. Providers are <a href="https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/ryan-haight-act">required by law to see patients for initial in-person assessment</a> before prescribing controlled medications like Suboxone. </p>
<p>There are <a href="https://www.healthcarelawtoday.com/2017/04/17/prescribing-controlled-substances-without-an-in-person-exam-the-practice-of-telemedicine-under-the-ryan-haight-act/">exceptions to this law</a>, including letting the patient see other clinical staff in person while videoconferencing with the prescribing physician. The emergency declaration could offer even more flexibility.</p>
<p>What’s more, most people need services for other problems besides opioid addiction, such as <a href="https://dx.doi.org/10.1001/archpediatrics.2010.217">mental health problems like depression</a> or <a href="http://dx.doi.org/10.3109/00952990.2011.643971">difficulties with other drugs like cocaine</a>. Many also <a href="https://www.cdc.gov/vitalsigns/heroin/infographic.html">lack private health insurance or financial means</a> to pay out of pocket for telemedicine. </p>
<p>Despite these issues, the administration’s call to improve treatment access is a positive step for rural health.</p>
<h2>Not just rural areas</h2>
<p>Urban areas, too, may benefit from this technology-assisted treatment, as people living in rural and urban areas face similar obstacles. </p>
<p>Within my home state of Michigan, drug overdose deaths are overrepresented in urban areas. The two most densely populated counties, Wayne and Macomb, both ranked among the top counties for <a href="http://www.mlive.com/news/index.ssf/2016/07/michigans_largest_counties_ran_1.html">overdose deaths in 2014</a> and <a href="http://www.freep.com/story/opinion/contributors/raw-data/2017/04/21/drug-overdose-deaths-quadruple-michigan-since-1999/100686662/">2015</a>. This risk among urban communities may be in part due to the <a href="http://dx.doi.org/10.1016/j.jsat.2017.01.004">increased availability and use of highly potent, synthetic opioids such as fentanyl</a>.</p>
<p>My research on opioid treatment highlights strikingly similar treatment barriers for rural and urban patients. In a study at an urban opioid treatment clinic, we found <a href="https://dx.doi.org/10.1016/j.jsat.2017.04.007">those who live farther from the clinic were more likely to drop out sooner</a>, potentially due to transportation-related hardships in accessing the clinic. </p>
<p>Urban patients have similar needs for comprehensive services to treat other <a href="https://doi.org/10.1016/j.drugalcdep.2004.12.001">mental health</a> and <a href="https://dx.doi.org/10.1016/j.jsat.2017.04.007">drug</a> problems and they, too, experience <a href="https://dx.doi.org/10.1016/j.jsat.2017.04.007">financial problems and a lack of private health insurance</a>. </p>
<h2>Steps toward a solution</h2>
<p>A few steps, including the advancing of telemedicine, could help save countless lives currently being lost to the opioid epidemic. </p>
<p>First, the administration is still considering <a href="https://www.washingtonpost.com/news/post-politics/wp/2017/10/26/trump-plans-to-declare-the-opioid-crisis-a-public-health-emergency/">declaring a national emergency</a>. That would provide access to more funds, or eliminate proposed budget cuts to <a href="https://www.npr.org/2017/10/26/560083795/president-trump-may-declare-opioid-epidemic-national-emergency">existing addiction treatment programs</a>. These monies could be used to train providers interested in delivering telemedicine or used to increase the number of staff able to provide comprehensive services. </p>
<p>Second, we need to investigate the effectiveness of existing telemedicine approaches within rural communities, and continue developing new technology-assisted opioid treatments for rural and urban communities. </p>
<p>Universities, especially those located within surrounding rural communities, should develop dedicated rural health initiatives. My colleagues and I are currently conducting <a href="https://socialwork.wayne.edu/news/school-of-social-work-study-examines-unique-barriers-to-opioid-use-disorder-treatment-in-rural-areas-27901">a study to better understand rural patients’ views on treatment access</a>. We will also ask providers about their likelihood to use new treatments – like telemedicine or treatments delivered through mobile or internet devices – in their practice. </p>
<p>Last, it’s important to provide publicly funded treatment and comprehensive services to both rural and urban communities. Practically speaking, many people in need of opioid treatment are able to access treatment only using public health insurance programs like the Affordable Care Act, Medicaid and block grant programs.</p>
<p>Until all communities, rural or otherwise, have better access to comprehensive opioid treatment, we will continue to lose loved ones at alarming and unacceptable rates.</p><img src="https://counter.theconversation.com/content/86598/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamey Lister receives funding from the Michigan Department of Health and Human Services through the State Targeted Response to the Opioid Crisis Grant, which is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA).</span></em></p>Many who need help with opioid addiction live far from dedicated treatment centers.Jamey J. Lister, Assistant Professor of Social Work, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/798962017-08-09T05:31:15Z2017-08-09T05:31:15ZHow we can reduce dependency on opioid painkillers in rural and regional Australia<p>Between 2008 and 2011, the rate of people treated for dependency on morphine in rural and regional Australia was <a href="https://www.ncbi.nlm.nih.gov/pubmed/26781123">roughly double that of their major city counterparts</a>.</p>
<p>Dependency on morphine, codeine, oxycodone and other opioid painkillers reflects what we already know about life in the small towns of Australia. Outside major cities, <a href="https://theconversation.com/investing-in-rural-health-brings-dollar-returns-to-local-economies-and-improves-health-73454">people tend to have poorer health</a> and reduced life expectancy. </p>
<p>Long <a href="https://www.ncbi.nlm.nih.gov/pubmed/26131919">travel times to health services</a>, <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/national-strategic-framework-rural-remote-health">small health facilities</a> and greater demand for doctors makes accessing support for improved health difficult.</p>
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Read more:
<a href="https://theconversation.com/how-to-reduce-opioid-overdose-deaths-in-australia-10197">How to reduce opioid overdose deaths in Australia</a>
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<p>But living in country Australia doesn’t have to be a prescription for poor health.</p>
<h2>Why opioid risk is greater outside the cities</h2>
<p>There are <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/national-strategic-framework-rural-remote-health">less jobs, infrastructure, family support services and recreational opportunities</a> outside the major cities of Australia. Many people leave rural and regional areas for work elsewhere. Health services tend to be basic when they cater for a smaller population.</p>
<p>People who stay may not be inclined to seek help for managing pain. Some <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1584.2006.00780.x/full">choose to endure pain without complaint</a>, preferring to remain pragmatic and get on with their jobs and family life.</p>
<p>A stoic way of life, combined with low access to health services, makes it harder to manage pain effectively - particularly chronic pain. </p>
<p>Chronic pain is a common condition. Migraines, arthritis, nerve damage and other forms of chronic pain are often treated with opioid painkillers, an approach that contributes to increased consumption of the drugs.</p>
<p>The problem is, opioid painkillers are <a href="https://www.nps.org.au/medical-info/consumer-info/chronic-pain-explained?c=opioid-medicines-for-chronic-pain-804d9703">often not effective for chronic pain</a>. And there are many side effects and risks including dependency, depression, poisoning and even death. In Victoria, <a href="https://www.ncbi.nlm.nih.gov/pubmed/21164159">deaths associated with oxycodone in rural and regional areas were greater</a> than with the general population.</p>
<p>Less engagement with health professionals, and little discussion in communities about managing pain, means patients may not be aware of potential problems in using opioid painkillers. Or of other <a href="http://adf.org.au/insights/script-for-your-doctor/">more effective options for treating chronic pain</a>.</p>
<h2>Managing chronic pain</h2>
<p>The good news is people are willing to try <a href="https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/297842/Chronic_Pain_Telehealth_Pilot_Project_Evaluation_report_2016_v2.pdf">innovative, effective approaches that use technology</a> for managing chronic pain.</p>
<p>Health agencies and patients are already using the internet and other technology to help improve access to health care. Patients can stay in their own home and use <a href="https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/297842/Chronic_Pain_Telehealth_Pilot_Project_Evaluation_report_2016_v2.pdf">online video consultations</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496327/">phone support</a> and other kinds of “telehealth” for advice, assessment, treatment and support.</p>
<p>Last year, the Children’s Hospital and the Orange Hospital in NSW provided patients who lived in rural and remote areas with access to help for managing chronic pain.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180492/original/file-20170801-12621-jaj4zd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&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">Telehealth can help those often out of reach manage chronic pain.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>Using internet-based video calls in the home and at work, patients spoke with health professionals for a combination of assessments (physiotherapy, psychological and medical), education, follow up consultations and medication reviews. Most of the <a href="https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/297842/Chronic_Pain_Telehealth_Pilot_Project_Evaluation_report_2016_v2.pdf">32 sessions led to positive health outcomes</a>. </p>
<p>Other similar initiatives such as <a href="https://painhealth.csse.uwa.edu.au/pain-stories/">painHealth in Western Australia</a> and the <a href="http://www.abc.net.au/news/2016-02-25/south-west-qld-pain-patients-finding-relief-through-telehealth/7198888">Manage Your Pain TeleHealth group</a> in Queensland exist too.</p>
<p>Telehealth chronic pain initiatives offer an opportunity to review opioid painkiller use, and to try to manage pain differently.</p>
<p>Reviewing the use of medications with a health professional can <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/treatment-approvals/safer-use-of-opioids">help patients to develop a plan for their use</a>, and discuss ways of dealing with drowsiness, dizziness, headaches and other side effects. Patients can avoid taking too much of the drug as well.</p>
<p>Taking too much of an opioid painkiller is <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/treatment-approvals/safer-use-of-opioids">unlikely to relieve pain</a>, and increases the risk of overdose and death.</p>
<p>Psychological therapies are important, too. Treatments like cognitive behavioural therapy, relaxation exercises, mindfulness-based techniques and biofeedback <a href="https://www.ncbi.nlm.nih.gov/pubmed/23459093">can reduce pain intensity</a>.</p>
<p>A <a href="https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040">better understanding of pain</a> combined with non-drug based treatment may help to remove the need for opioid painkillers entirely.</p>
<h2>What else can we do?</h2>
<p>Not everyone can easily <a href="https://www.ncbi.nlm.nih.gov/pubmed/24801522">access telehealth</a>. Many people are not aware it exists, and <a href="http://adf.org.au/wp-content/uploads/2017/02/ADF-PreventionResearch-Nov16.pdf">more initiatives are needed</a>. A lack of equipment and skill in using video communication and other technology are issues.</p>
<p>But other steps can be taken now to help rural and regional Australians better manage pain and the use of opioid painkillers.</p>
<p>Health professionals can access <a href="http://www.painaustralia.org.au/health-professionals/education-training">education and training</a> on topics like pain management, yoga for pain practice and chronic pain management in general practice. </p>
<p>Specialised <a href="http://www.painaustralia.org.au/getting-help/pain-services-programs/pain-services">pain management clinics</a> may be an option for people able to travel to urban areas - but waiting lists are long. Greater investment in <a href="http://example.com/">statewide pain management programs</a> could help.</p>
<p>The Alcohol and Drug Foundation’s <a href="http://adf.org.au/insights/script-for-your-doctor/">Things To Ask Your GP</a> is an easy-to-use resource for patients to help them talk with their doctors about opioid drug side effects and non-drug based alternatives. <a href="https://www.aci.health.nsw.gov.au/chronic-pain/painbytes">Painbytes</a> provides information about chronic pain and how to manage it.</p>
<p>More use of existing tools and telehealth will only further strengthen the resilience and creativity of people living outside major cities seeking to manage pain better - and hopefully remove a need for <a href="http://adf.org.au/insights/no-silver-bullet/">the quick and risky fix of an opioid painkiller</a>.</p>
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<p><em>Dr Shauna Sherker from the Alcohol and Drug Foundation co-authored this article.</em></p><img src="https://counter.theconversation.com/content/79896/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben O'Mara is affiliated with the Alcohol and Drug Foundation where he works as a science writer.</span></em></p>Dependency on opioid painkillers reflects what we already know about life in the small towns of Australia - people tend to have poorer health.Ben O'Mara, Adjunct Research Fellow, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817342017-08-08T00:56:18Z2017-08-08T00:56:18ZHow Big Pharma is hindering treatment of the opioid addiction epidemic<figure><img src="https://images.theconversation.com/files/181290/original/file-20170807-25539-iz6tj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paul Wright, in treatment for opioid addiction in June 2017 at the Neil Kennedy Recovery Clinic in Youngstown Ohio, shows a photo of himself from 2015, when he almost died from an overdose. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Medicaid-Cuts-Opioid-Epidemic/2e3bf787f50d4b0aa7161ad9618e4239/24/0">AP Photo/David Dermer</a></span></figcaption></figure><p>“A crippling problem.” “A total epidemic.” “A problem like nobody understands.” These are the words President Trump used to describe the opioid epidemic ravaging the country during a <a href="https://www.whitehouse.gov/the-press-office/2017/03/29/remarks-president-trump-listening-session-opioids-and-drug-abuse">White House listening session</a> in March. </p>
<p>The percentage of people in the U.S. dying of drug overdoses has effectively <a href="https://www.cdc.gov/drugoverdose/data/index.html">quadrupled</a> since 1999, and drug overdoses now rank as the <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">leading cause of death</a> for Americans under 50. </p>
<p>Drugs do exist to reverse opioid overdoses or treat long-term opioid addiction. But while opioids have become easier and easier to obtain through illicit markets and <a href="https://www.nytimes.com/2017/06/10/business/dealbook/opioid-dark-web-drug-overdose.html">sellers on the dark web</a>, a drug that could save countless lives has become increasingly out of reach. </p>
<p>Consider the addiction treatment drug, <a href="https://www.drugs.com/suboxone.html">Suboxone</a>. Patents and other <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2815667">exclusivities</a> on the basic version of Suboxone expired some time ago, yet the price remains sky-high, and <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/Ketcham-Testimony-.pdf">access problems</a> persist. Oral film strips now <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/Ketcham-Testimony-.pdf">cost</a> over US$500 for a 30-day supply; even simple tablets <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/Ketcham-Testimony-.pdf">cost</a> a whopping $600 for a 30-day supply. The cost alone puts the medication out of reach for many.</p>
<p>I study the pharmaceutical industry, and I see how drug companies are able to play games that keep competition out and prices high. Lack of access to addiction treatment drugs like <a href="https://www.drugs.com/suboxone.html">Suboxone</a> can be traced, in part, to the soaring prices, access problems and anti-competitive conduct that has become business as usual in the pharmaceutical industry across the board. </p>
<h2>Patent incentives</h2>
<p>Pharmaceutical companies have brought tremendous advances in medicine. I believe they should be adequately compensated for the enormous amount of time and resources needed to develop a new drug. Our intellectual property system is designed to do just that, rewarding companies that bring new drugs to market with a competition-free period – 20 years from the patent application date – during which they can recoup their profits. </p>
<p>After this defined period, generic versions of the drug are supposed to appear on pharmacy shelves, bringing down prices to levels that can be borne more easily by consumers and the health care market generally.</p>
<p>Brand-name companies, however, engage in myriad games to make sure theirs is the only version of the drug on pharmacy shelves, long after generics should have joined the ranks. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=479&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=479&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=479&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=602&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=602&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=602&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Martin Shkreli en route to a federal court house Aug. 3, 2017 in the fourth day of jury deliberations in the trial of the former drug company CEO. He was found guilty on three counts of fraud.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Martin-Shkreli-Trial/e537fe493fba424292a1b9bd08e94493/7/0">AP Photo/Seth Wenig</a></span>
</figcaption>
</figure>
<p>Martin Shkreli, the infamous pharmaceutical industry CEO responsible for hiking the cost of his company’s lifesaving drug from <a href="https://www.theatlantic.com/news/archive/2017/08/shkreli-fraud-history-balleisen/536115/">$13.50 to $750 overnight</a>, once <a href="http://www.telegraph.co.uk/news/worldnews/northamerica/usa/11882281/American-hedge-funder-Martin-Shkreli-increases-price-of-Aids-related-drug-by-5000pc.html">tweeted</a> that “Every time a drug goes generic, I grieve.” </p>
<p>And it is not just a case of a few bad apples. Complex schemes to hold off generic competition are widespread throughout the pharmaceutical industry, as I have <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2833151">found in my research</a>.</p>
<h2>The games pharma plays, sort of like Monopoly®</h2>
<p><a href="https://www.washingtonpost.com/news/wonk/wp/2017/01/11/trump-on-drug-prices-pharma-companies-are-getting-away-with-murder/">Legislators</a> on <a href="http://jamanetwork.com/journals/jama/fullarticle/2533698">both</a> sides of the aisle have decried sky-high drug prices, but it can be hard to pin down the specific behavior to address. Pharmaceutical game-playing has grown over the decades into a multi-headed monster, with a new tactic popping up as soon as the old one is cut off. My colleague and I set out to clearly identify and expose these various games in our book, “<a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">Drug Wars: How Big Pharma Raises Prices and Keeps Generics Off the Market.</a>” </p>
<p>One game we analyzed involved the <a href="https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=10.30">filing of petitions</a> at the Food and Drug Administration (FDA) that raise unfounded or frivolous concerns in an effort to delay generic competitors.</p>
<p>Some of the petitions were just stunning to us. For example, some petitions soberly ask the FDA to require, well, what it already <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2833151">requires</a>, such as ensuring that the generic drug product is stable and has an appropriate shelf life. Other petitions tie the application up in knots for reasons that are hard, even for the FDA, to discuss with a straight face. </p>
<p>For example, the company that manufactures the blood pressure medicine <a href="http://www.webmd.com/drugs/2/drug-7243/plendil-oral/details">Plendil</a> filed a <a href="https://www.regulations.gov/document?D=FDA-2007-P-0123-0002">petition</a> asking the FDA to delay approval of generics by citing concerns over how different types of oranges in orange juice might affect absorption of the medication and demanding additional information on the juice used in the clinical trials. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A drug company argued that the types of oranges used in orange juice played a role in whether generic versions of the drug should be permitted.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/glass-squeezed-orange-juice-fresh-juicy-596489408?src=4DnbgYOEqQxHp5Iawf7FNA-1-4">Facanv/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Although <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2832319">80 percent</a> of these petitions are eventually denied, it takes time and resources for the FDA to review each petition. </p>
<p>Citing concerns over citizen petition games, Congress recently required the FDA to respond to such petitions within five months, but a five-month delay for a blockbuster drug can be worth hundreds of millions of dollars. (The Federal Trade Commission recently filed an <a href="https://www.ftc.gov/news-events/press-releases/2017/02/ftc-charges-shire-viropharma-inc-abused-government-processes">antitrust suit</a> against Shire ViroPharma for attempts to hold off competition related to its gastrointestinal drug Vancocin, a campaign that included 24 filings related to a single petition.) Congress also gave the FDA the ability to summarily deny petitions when appropriate, a power that the FDA has failed to use even once. </p>
<p>By parsing through 12 years of FDA data, we found that out of all citizen petitions filed, the percentage of petitions with the possibility of delaying generic entry <a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">doubled</a> since 2003, rising from 10 percent to 20 percent. Thus, in some years, one in five petitions filed at the FDA on any topic, including tobacco, food and dietary supplements, had the potential to delay generic competition. </p>
<p>Moreover, we found that <a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">40 percent</a> of such petitions were filed a year or less before the FDA approved the generic, indicating that companies are using these petitions as a last-ditch effort to hold off competition.</p>
<p>There are plenty of other games to play, as well. For example, generic applicants need samples of the brand-name drug to show the FDA that their version is equivalent; some brand-name companies flatly <a href="http://www.hpm.com/pdf/blog/THALOMID%20-%20Celgene%20MTD%20re%20BE%20Sample.pdf">refused</a> to sell samples to generic companies. </p>
<p>Another common tactic involves making tiny modifications to the dosage or formulation of a drug just as the original patents are about to expire. This strategy, known as “<a href="https://poseidon01.ssrn.com/delivery.php?ID=207103102008005127081027011085084077015002001000090086121025069112086094029103094091030096049125038001052023094108031096120003046002046043009065001117079098101061037082102103070094110088115110108098099114122115103124069097093018086122115118112110&EXT=pdf">product hopping</a>,” allows the drug company to obtain a brand-new set of patents on their “new and improved” version of the drug. </p>
<p>Even if the patents are overturned – and studies show that generics convince courts to overturn the <a href="https://www.ftc.gov/sites/default/files/documents/reports/generic-drug-entry-prior-patent-expiration-ftc-study/genericdrugstudy_0.pdf">majority</a> of patents they challenge – the process again takes time. </p>
<p>Much of the attention is focused on patents, but the <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2815667">13 regulatory exclusivities</a> that the FDA doles out also help create competition-free zones. These offer months or even years of additional protection, by taking steps such as carrying out pediatric studies or developing drugs for rare diseases termed “orphan drugs.” Drug companies have stretched these systems to the point at which the costs to society far outweigh the benefits.</p>
<h2>The crippling cost of medicine</h2>
<p>One can understand the motivation – delaying entry of a generic competitor for even a few months can translate into <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2815667">billions</a> of dollars in extra revenue for the brand-name company. Thus, drug companies string out games that obstruct and delay competition, one after another. As I noted when <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/114-97_22123.pdf">testifying</a> before Congress about such strategies, “A billion here, a billion there; that adds up to real money.”</p>
<p>In 2015, <a href="https://www.wsj.com/articles/for-prescription-drug-makers-price-increases-drive-revenue-1444096750">80 percent</a> of the profit growth of the 20 largest drug companies resulted from price hikes. And drugs are vastly more expensive in the U.S. than abroad. (The liver failure drug Syprine, for example, sells for less than $400 a year in many countries; in the U.S., the average list price is <a href="http://www.vanityfair.com/news/2016/06/the-valeant-meltdown-and-wall-streets-major-drug-problem">US$300,000</a>. Gilead’s hepatitis C drug, Sovaldi, <a href="http://www.fiercepharma.com/sales-and-marketing/hep-c-drug-tourism-has-begun-as-patients-seek-harvoni-sovaldi-overseas">reportedly</a> sells for the equivalent of $1,000 abroad – in the U.S., it sells for $84,000.) </p>
<p>The industry can do this, in part, because unlike the demand for other goods, the demand for pharmaceuticals is highly inelastic. Consumers will continue to pay for the drugs that can save their lives, even if it breaks the bank. </p>
<h2>The impact on addiction treatment</h2>
<p>Nowhere is the pain of these games more troubling than in the market for opioid addiction medicine. </p>
<p>In September, <a href="https://judiciary.house.gov/hearing/treating-opioid-epidemic-state-competition-markets-addiction-medicine/">I testified</a> before a House Judiciary Subcommittee at a hearing about the state of competition in the markets for addiction medicine, noting that, while “Open and vigorous competition is the backbone of U.S. markets…we are not seeing that in the market for addiction medicine.” </p>
<p>Pharmaceutical companies often argue that high profits are needed to fund development of new drugs, some of which don’t make it to market.</p>
<p><a href="https://judiciary.house.gov/hearing/treating-opioid-epidemic-state-competition-markets-addiction-medicine/">“The competitive market is structured to take maximum advantage of savings from brand competition,”</a> testified Anne McDonald Pritchett, vice president, policy and research for the Pharmaceutical Research and Manufacturers of America. </p>
<p>However, open and vigorous competition is certainly not what the manufacturer behind the addiction treatment drug Suboxone <a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">had in mind</a> when it combined several games to fight off generics appearing on the horizon. These games included <a href="https://www.ftc.gov/news-events/press-releases/2012/11/ftc-files-amicus-brief-explaining-pharmaceutical-product-hopping">product hopping</a> (shifting the market to a new form of the drug just as the exclusivity expires so pharmacists cannot fill the prescription with a generic), refusing to cooperate with generic companies on safety plans, and petitioning the FDA to impose safety measures on generic versions that were never required for the brand-name version.</p>
<p>The opioid addiction epidemic is a complex problem, and there are no simple answers. One thing, however, is certain. The U.S. system should not reward companies for blocking generic competition. When we do that, the American public pays the price.</p><img src="https://counter.theconversation.com/content/81734/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Feldman receives funding through the Institute for Innovation Law, which she directs at UC Hastings College of the Law. Full funding information for the Institute can be found at <a href="http://innovation.uchastings.edu/about/funding/">http://innovation.uchastings.edu/about/funding/</a></span></em></p>The number of people dying from opioid overdose continues to rise, in part because of cheap street drugs. Yet the price of a drug used to treat addiction is out of reach for many.Robin Feldman, Professor of Intellectual Property, University of California College of the Law, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/799912017-07-25T01:12:50Z2017-07-25T01:12:50ZHow killing the ACA could lead to more opioid deaths in West Virginia and other Trump states<figure><img src="https://images.theconversation.com/files/179502/original/file-20170724-11666-1wuw0pn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A neighborhood in Huntington, West Virginia, where more than two dozen opioid overdoses occurred within four hours in August, 2016. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Overdoses-Four-Hours-in-Huntington/5b517c23a3e3498f9262ba9610a9ff30/33/0">AP Photo/Claire Galofino</a></span></figcaption></figure><p>President Trump spoke at the National Scout Jamboree in West Virginia on July 24, joining a long list of presidents who have spoken to the huge meeting of Boy Scouts, troop leaders and volunteers. The visit was not surprising, as West Virginia, in the center of Appalachia, is overwhelmingly Trump Country. </p>
<p>It is also at the center of the nation’s opioid epidemic, with a rate of <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">42 overdose deaths per 100,000</a>, more than double the national average. Indeed, on Aug. 15, 2016, Huntington, home of Marshall University, experienced more than two dozen overdoses in a <a href="http://www.cnn.com/2016/08/17/health/west-virginia-city-has-27-heroin-overdoses-in-4-hours/index.html">span of just four hours</a>. </p>
<p>West Virginia is also a state that has been aggressive in taking advantage of <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">opportunities offered by the federal government under the Affordable Care Act</a>, including the ACA insurance marketplaces and the Medicaid expansion. </p>
<p>While about <a href="https://www.nytimes.com/elections/results/west-virginia">two-thirds of voters supported</a> Trump in the election, support for expanding Medicaid has largely been bipartisan. At least until now.</p>
<p>With GOP repeal-and-replace efforts still very much up in the air, one thing has become clear: All proposals made public by congressional Republicans have significant, detrimental effects on West Virginia’s and America’s ability to combat the opioid epidemic.</p>
<h2>An escalating problem</h2>
<p>The opioid addiction crisis in America is growing worse. An analysis in June 2017 by The New York Times showed a <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">19 percent increase in drug overdose deaths </a>from 2015 to 2016, and experts cited opioids as the likely reason for the increase.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179507/original/file-20170724-16930-1p3t7e1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioid overdose is blamed for a sharp increase in deaths due to drug overdose. Prescription opioids used to treat pain have contributed to the epidemic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hydrocodone-prescription-bottle-generic-medication-name-523921741?src=_Co2MOkNI9QylEAVo8GWUA-1-4">Sherry Yates Young/Shutterstock.com</a></span>
</figcaption>
</figure>
<p><a href="https://www.addictioncenter.com/addiction/addiction-statistics/">More than 20 million Americans</a> suffer from an addiction. Close to <a href="https://www.addictioncenter.com/addiction/addiction-statistics/">seven million of these addicts</a> also have a mental illness. The Surgeon General’s office has estimated that the yearly losses in productivity, health care costs and criminal justice expenses for alcohol misuse and illicit drug abuse amount to <a href="https://addiction.surgeongeneral.gov/executive-summary">US$442 billion</a>. </p>
<p>In 2015, the most recent year for which figures are available from the Centers for Disease Control and Prevention (CDC), more than <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">52,000 Americans died from drug overdoses</a>. More than <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">33,000 of these</a> were due to opioids. This means that, compared to 1999, the number of opioid <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">deaths nearly tripled</a>. </p>
<p>This epidemic is not only killing people and ripping apart families. It also has created an enormous drain on America’s health and social systems.</p>
<p>Drug overdoses lead to more than <a href="https://www.addictioncenter.com/addiction/addiction-statistics/">five million emergency department visits</a> per year.</p>
<p>In towns in West Virginia and many other states, school systems, fire and police departments, and city governments spend ever-growing funds on providing emergency <a href="http://www.emsworld.com/news/12317582/w-v-departments-footing-the-bill-for-naloxone">overdose treatments such as Naloxone</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179509/original/file-20170724-24759-10768vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Emergency responders and departments have been taxed in dealing with opioid overdoses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-emergency-team-transfer-ambulance-blur-536327245?src=wFt5BIh2PTn5FAZfgUnBKQ-1-1">Chaikom/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Indeed, Medicaid spending on the drug has increased by <a href="http://www.urban.org/sites/default/files/publication/91521/2001386-rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf">90,000 percent</a> in just five years.</p>
<p>A West Virginia program to <a href="https://www.washingtonpost.com/news/wonk/wp/2017/03/07/drugs-are-killing-so-many-people-in-west-virginia-the-state-cant-keep-up-with-the-funerals/?utm_term=.f143feb25dce">support needy families with burial expenses</a> has run out of funds for five years straight.</p>
<p>The epidemic has also created tremendous problems for <a href="http://www.governing.com/topics/health-human-services/gov-opioid-epidemic-child-welfare.html">child welfare system and schools</a>, which have to deal with the drug-addicted parents and abandoned children.</p>
<p>Perhaps the saddest part of the story is the <a href="http://wvpublic.org/post/born-addicted-race-treat-ohio-valley-s-drug-affected-babies">growing number of newborns delivered by addicted mothers</a>, who have to undergo addiction treatment from the minute they are born.</p>
<h2>How Obamacare helped</h2>
<p>The ACA called for states to expand Medicaid coverage to more lower-income people. Not all states did this; the 19 who bucked expansion were Republican states.</p>
<p>But not all Republican states resisted expansion. West Virginia, desperate for help for its laid-off miners and for its thousands of people addicted to opioids, was one of <a href="http://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Current%20Status%20of%20Medicaid%20Expansion%20Decision%22,%22sort%22:%22asc%22%7D">the more than a dozen states that voted for the president and expanded Medicaid</a>.</p>
<p>The expansion of Medicaid has been crucial in two ways. For one, providing insurance coverage for an <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">additional 180,000 West Virginians</a> has proven critical to getting many of them into treatment.</p>
<p>Moreover, the expansion population was subject to the ACA’s <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">Essential Health Benefit provisions</a>. This required states to make available substance abuse and mental health treatment to them.</p>
<p>Finally, the <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">ACA’s Essential Health Benefit</a> provisions required policies sold in the individual market to cover addiction and mental health services. It also eliminated annual and lifetime limits on <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">these benefits</a>.</p>
<p>Overall, <a href="https://www.hcp.med.harvard.edu/sites/default/files/Key%20state%20SMI-OUD%20v3.pdf">more than 210,000 West Virginians</a> with substance abuse or mental health problems gained coverage under the ACA.</p>
<h2>Epidemic would escalate</h2>
<p>While the exact nature of Republican repeal-and-replace efforts remains unclear at this moment, all proposals made public so far would pose enormous challenges for states like West Virginia to turn the tide on the devastating opioid epidemic.</p>
<p>One of the most essential tools in fighting the epidemic, the expansion of Medicaid, would be rolled back either immediately or over several years. Furthermore, the entire Medicaid program, the <a href="https://www.theatlantic.com/politics/archive/2017/07/opioid-medicaid-health-care/533451/?utm_source=twb">backbone of states’ efforts to provide treatment and services</a> for opioid addiction treatment, would be further curtailed by per capita caps.</p>
<p>Moreover, all proposals would either outright eliminate or allow states to waive the crucial <a href="https://theconversation.com/essential-health-benefits-suddenly-at-center-of-health-care-debate-but-what-are-they-75125">Essential Health Benefit provisions</a>. These provisions require insurers to provide coverage for certain specified conditions, such as pregnancy, addiction treatment and emergency room care, that they might otherwise refuse to cover because of their costs. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179514/original/file-20170724-16930-1meu7y8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Maternity health benefits have been considered essential care under the ACA, as has addiction treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-shot-doctor-stethoscope-listening-belly-651615208?src=ST2YcfBzCleyODRQYICsjw-1-0">LIghtField Studios/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Under certain proposals, lifetime and annual limits could also affect those covered by employer-provided insurance to lose access to crucial treatment options.</p>
<p>In its most recent iteration, Senate Republicans have added $45 billion over 10 years <a href="http://www.nbcnews.com/storyline/americas-heroin-epidemic/senate-health-care-bill-no-fix-opioid-epidemic-experts-say-n782721">specifically to deal with the opioid crisis</a> to bring on-board crucial moderates like Senators Shelley Moore Capito (Republican-West Virginia) and Robert Portman (Republican-Ohio).</p>
<p>However, as Ohio Gov. John Kasich stated, given the enormous size of the opioid problem, this amounts to “<a href="http://abcnews.go.com/Politics/senate-health-bill-force-choosing-children-seniors-disabled/story?id=48392178">spitting in the ocean</a>.” Medicaid alone spends more than <a href="http://www.urban.org/sites/default/files/publication/91521/2001386-rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf">$1 billion annually</a> solely on medications for addiction treatments. This does not include costs to providers or treatment facilities.</p>
<h2>Moving forward</h2>
<p>Treating addiction is challenging and involves more than access to insurance coverage. However, <a href="https://www.usatoday.com/story/opinion/2017/06/22/gop-health-bill-disaster-substance-abuse-patients-vivek-murthy-column/103023032/">evidence-based treatment</a>, which includes replacement medications and counseling, has shown success in America’s fight against the epidemic ravaging many of its communities.</p>
<p>In my opinion, stemming the opioid epidemic requires a prolonged, multi-pronged approach.</p>
<p>It requires a hard look at how we prescribe painkillers. Health care providers like <a href="https://share.kaiserpermanente.org/article/kaiser-permanente-targets-reduction-of-opioid-prescribing/">Kaiser Permanente</a> have shown that success is possible.</p>
<p>It also requires taking a hard look at the <a href="https://www.bloomberg.com/view/articles/2017-07-11/states-have-good-reason-to-investigate-opioid-makers">role that pharmaceutical companies play</a>.</p>
<p>It requires providing jobs and hope to rural America, which overwhelmingly voted for President Trump and his promises, and which disproportionately suffers from this epidemic.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179515/original/file-20170724-28519-jmsptg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Coal miners in Maidsville, West Virginia, ready to descend into the mines in this 1938 photo. The coal industry has been declining for a number of years, however, leading to fewer jobs in mining.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/coal-miners-ready-descend-into-mine-242289910?src=s46GMhDiHarI3hpC85iMuQ-1-1">Everett Historical/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Most definitely, it requires also providing medical treatment to individuals trying to overcome their additions. Unfortunately, so far, none of the GOP proposals have done that. GOP proposals do not include the means to do that.</p>
<p>Trump has long championed the people of West Virginia, but a visit to the Boy Scouts does little to alleviate the suffering in the heart of Appalachia.</p><img src="https://counter.theconversation.com/content/79991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder 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>West Virginia favored Trump by more than 2:1 in the 2016 election, but Trump’s policies would particularly hurt the state. Its residents depend heavily on Medicaid to treat opioid addiction.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.