tag:theconversation.com,2011:/nz/topics/opioid-addiction-29323/articlesOpioid addiction – The Conversation2023-11-30T17:23:43Ztag:theconversation.com,2011:article/2148952023-11-30T17:23:43Z2023-11-30T17:23:43ZBuvidal: is it really a ‘game changer’ in the treatment of problematic opioid use?<p>To overcome problematic opioid use, traditional forms of opioid substitution therapy, such as <a href="https://www.nhs.uk/medicines/methadone/">methadone</a> and <a href="https://www.nhs.uk/medicines/buprenorphine-for-pain/">oral buprenorphine</a>, have become valuable tools. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/full?highlightAbstract=opioid">Research</a> shows that patients receiving substitution therapy are more likely to stay in treatment and stop using heroin than patients receiving treatments that do not involve substitutes – such as counselling or group therapy.</p>
<p>But not all those on substitute medication are able to stop using illicit opioids. Some continue to use them in addition to the substitute. One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871621001460">barrier</a> to success is the need to attend a clinic or pharmacy every day, or every few days, to obtain the substitute. </p>
<p>In early 2019, a new form of substitute treatment, long-acting injectable buprenorphine, was approved for use in the UK. Unlike methadone and oral buprenorphine, <a href="https://www.nice.org.uk/advice/es19/evidence/evidence-review-pdf-6666819661#:%7E:text=Buprenorphine%20prolonged%2Drelease%20injection%20is,buprenorphine%20prolonged%2Drelease%20injection%20subcutaneously.">long-acting injectable buprenorphine</a> is administered via an injection either weekly or monthly. The treatment – also known by its brand names Buvidal or Sublocade – has been heralded as a “<a href="https://nation.cymru/news/welsh-university-carries-out-game-changer-drug-treatment-research/">game changer</a>” by both doctors and patients. </p>
<h2>Opioids</h2>
<p>In 2021, nearly 5,000 drug-related deaths were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations">registered</a> in England and Wales. About half of those involved an opioid. </p>
<p>Opioids are a class of drugs that include substances derived from the opium poppy. They include <a href="https://www.nhs.uk/medicines/morphine/">morphine</a> and <a href="https://www.emcdda.europa.eu/publications/drug-profiles/heroin_en">heroin</a>, as well as synthetic alternatives that mimic the effects of naturally occurring opioids such as <a href="https://www.nhs.uk/medicines/tramadol/">tramadol</a> and <a href="https://bnf.nice.org.uk/drugs/fentanyl/">fentanyl</a>.</p>
<p>Opioids work in the brain to produce a variety of effects, including pain relief. They also produce feelings of euphoria, joy and pleasure. Opioids have a depressant effect on the body, so if someone overdoses, they can stop breathing and may die. Overdose is a particular risk for those who use illegally obtained opioids of unknown strength, such as heroin.</p>
<p>Often people are unable to stop using opioids despite the risk of death and the serious negative health and social consequences. Such drugs are hard to give up, partly because stopping causes painful physical and psychological withdrawal symptoms.</p>
<h2>Opioid substitution therapy</h2>
<p>An effective form of treatment for problematic opioid use is opioid substitution therapy, where illegally obtained opioids are substituted for prescribed alternatives. </p>
<p>Providing a legal substitute of known purity is useful in many ways. Most notably, it removes the need to buy and use illicit opioids. This reduces the risk of <a href="https://www.bmj.com/content/357/bmj.j1550">overdose</a> and the need to commit crimes like <a href="https://academic.oup.com/bjc/article-abstract/49/4/513/2747197">theft and shoplifting</a> to get money to pay for drugs.</p>
<p>But while daily attendance and supervised consumption may help to minimise the risk of misuse, it also has its drawbacks. For example, it can bring patients into regular contact with their former drug-using networks and can require time-consuming journeys that interfere with employment, education and other responsibilities.</p>
<p>Long-acting injectable buprenorphine does not have these drawbacks. It is not unlike <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369037/">long-acting</a> forms of contraception, in that the medicine releases slowly over time, thereby avoiding the peaks and troughs associated with oral formulations.</p>
<p>When the pandemic broke and the UK went into lockdown, <a href="https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en">concerns</a> were raised by experts that daily attendance at clinics or pharmacies for opioid substitution medication might increase the risk of COVID transmission. </p>
<p>Keen to stop the spread of the virus while also providing safe and continuous treatment to patients, the Welsh government <a href="https://committees.parliament.uk/writtenevidence/107535/pdf/">agreed</a> to fund the roll-out of long-acting injectable buprenorphine to drug services across Wales. </p>
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<figcaption><span class="caption">Two doctors discuss Buvidal from the perspective of lived experience.</span></figcaption>
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<p>That decision was supported by <a href="https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-023-01348-5">emerging evidence</a> of the effectiveness of the medication from a drug service in south Wales that had been piloting the medicine before the pandemic. </p>
<h2>Results</h2>
<p>While the primary aim at that time was to stop the spread of COVID, it quickly became clear that the medication was benefiting patients in many other ways. </p>
<p>Patients taking part in a <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">survey</a> about the new medication reported reductions in cravings, lower levels of anxiety, reductions in offending and abstinence from illicit opioids. They described rebuilding their lives, getting jobs, reconnecting with family members and heralded long-acting injectable buprenorphine as a “game changer”, “life changing” and even a “miracle”. </p>
<p>Positive results have also been reported in <a href="https://www.jsatjournal.com/article/S0740-5472(22)00058-7/fulltext">systematic reviews</a> that summarise the findings of the currently small, and not very robust, body of evidence on the effectiveness of the medication.</p>
<p>However, alongside the reports of success, less positive <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">stories</a> have emerged suggesting that the treatment may not be a silver bullet. Some patients have found the transition onto the medication challenging because it required them to be in full withdrawal before their first dose. </p>
<p>Others have been overwhelmed with emotions because the medication made them feel so clear-headed that their past traumas – suppressed by years of illicit opioid use – had begun to resurface. There have also been <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">reports</a> of an increase in crack cocaine use among some patients and concerns about the reduced amount of contact (from daily to monthly) with drug services.</p>
<p>Even though there is a “<a href="https://pubmed.ncbi.nlm.nih.gov/16764215/">ceiling effect</a>” that reduces the risk of overdose, this medication still carries a risk of respiratory depression. This risk is <a href="https://pubmed.ncbi.nlm.nih.gov/15957155/">greater</a> among those using alcohol, benzodiazepines or other opioids such as heroin.</p>
<p>Long-acting injectable buprenophine is still in its infancy worldwide, so the evidence for its effectiveness is slim. To determine if it really is a “game changer”, experts will need to look at its impact across a wider range of outcomes, over longer periods and with larger samples than have been considered to date.</p><img src="https://counter.theconversation.com/content/214895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katy Holloway receives funding from Welsh Government and is a member of Welsh Government's National Implementation Board for Drug Poisoning Prevention. </span></em></p><p class="fine-print"><em><span>Fabrizio Schifano receives funding from Welsh Government. Currently a World Health Organization (WHO) member of the Expert Committee on Drug Dependence (ECDD; 2023). Previously, Schifano was a member of the ACMD UK and an expert advisor of the European Medicines Agency (EMA) for Psychiatry. </span></em></p>Long-acting injectable buprenorphine is also known by the brand names Buvidal or Sublocade.Katy Holloway, Professor of Criminology, University of South WalesFabrizio Schifano, Chair in Clinical Pharmacology and Therapeutics, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045222023-05-30T12:24:11Z2023-05-30T12:24:11ZYour body naturally produces opioids without causing addiction or overdose – studying how this process works could help reduce the side effects of opioid drugs<figure><img src="https://images.theconversation.com/files/528436/original/file-20230525-27-cw53qp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2309%2C1299&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioid neurotransmitters are located in many areas of the body, including the brain, spine and gut.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/neurotransmitter-release-mechanisms-royalty-free-image/1396888608">ALIOUI Mohammed Elamine/iStock via Getty Images Plus</a></span></figcaption></figure><p>Opioid drugs such as morphine and fentanyl are like the two-faced Roman god Janus: The kindly face delivers pain relief to millions of sufferers, while the grim face drives an opioid abuse and overdose crisis that <a href="https://www.cdc.gov/drugoverdose/deaths/index.html">claimed nearly 70,000 lives</a> in the U.S. in 2020 alone. </p>
<p><a href="https://scholar.google.com/citations?user=LXVL7f0AAAAJ&hl=en">Scientists like me who study pain and opioids</a> have been seeking a way to separate these two seemingly inseparable faces of opioids. Researchers are trying to design drugs that deliver effective pain relief without the risk of side effects, including addiction and overdose.</p>
<p>One possible path to achieving that goal lies in understanding the molecular pathways opioids use to carry out their effects in your body.</p>
<h2>How do opioids work?</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/16082232/">opioid system in your body</a> is a set of neurotransmitters your brain naturally produces that enable communication between neurons and activate protein receptors. These neurotransmitters include small proteinlike molecules like <a href="https://doi.org/10.1124/mol.120.119388">enkephalins and endorphins</a>. These molecules regulate a tremendous number of functions in your body, including pain, pleasure, memory, the movements of your digestive system and more.</p>
<p>Opioid neurotransmitters activate receptors that are <a href="https://www.ncbi.nlm.nih.gov/books/NBK546642/">located in a lot of places</a> in your body, including pain centers in your spinal cord and brain, reward and pleasure centers in your brain, and throughout the neurons in your gut. Normally, opioid neurotransmitters are released in only small quantities in these exact locations, so your body can use this system in a balanced way to regulate itself.</p>
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<figcaption><span class="caption">The opioids your body produces and opioid drugs bind to the same receptors.</span></figcaption>
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<p>The problem comes when you take an opioid drug like morphine or fentanyl, especially at high doses for a long time. These drugs <a href="https://theconversation.com/how-do-drugs-know-where-to-go-in-the-body-a-pharmaceutical-scientist-explains-why-some-medications-are-swallowed-while-others-are-injected-182488">travel through the bloodstream</a> and can activate every opioid receptor in your body. You’ll get pain relief through the pain centers in your spinal cord and brain. But you’ll also get a euphoric high when those drugs hit your brain’s reward and pleasure centers, and that could <a href="https://doi.org/10.1016%2FS2215-0366(16)00104-8">lead to addiction</a> with repeated use. When the drug hits your gut, you may develop constipation, along with other common <a href="https://www.asahq.org/madeforthismoment/pain-management/opioid-treatment/what-are-opioids/">opioid side effects</a>.</p>
<h2>Targeting opioid signal transduction</h2>
<p>How can scientists design opioid drugs that won’t cause side effects?</p>
<p>One approach my research team and I take is to understand how cells respond when they receive the message from an opioid neurotransmitter. Neuroscientists call this process <a href="https://doi.org/10.1097%2FALN.0b013e318238bba6">opioid receptor signal transduction</a>. Just as neurotransmitters are a communication network within your brain, each neuron also has a communication network that connects receptors to proteins within the neuron. When these connections are made, they trigger specific effects like pain relief. So, after a natural opioid neurotransmitter or a synthetic opioid drug activates an opioid receptor, it activates proteins within the cell that carry out the effects of the neurotransmitter or the drug.</p>
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<figcaption><span class="caption">Cells communicate with one another in multiple ways.</span></figcaption>
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<p>Opioid signal transduction is complex, and scientists are just starting to figure out how it works. However, one thing is clear: Not every protein involved in this process does the same thing. Some are more important for pain relief, while some are more important for side effects like <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">respiratory depression</a>, or the decrease in breathing rate that makes overdoses fatal.</p>
<p>So what if we target the “good” signals like pain relief, and avoid the “bad” signals that lead to addiction and death? Researchers are tackling this idea in different ways. In fact, in 2020 the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-opioid-intravenous-use-hospitals-other-controlled-clinical-settings">approved the first opioid drug based on this idea</a>, oliceridine, as a painkiller with fewer respiratory side effects.</p>
<p>However, relying on just one drug has downsides. That drug might not work well for all people or for all types of pain. It could also have other side effects that show up only later on. Plenty of options are needed to treat all patients in need.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="drawing depicting a tangle of red, blue and yellow curly and straight lines" src="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&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">This figure shows the structure of Hsp90.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/heat-shock-protein-90-chaperone-complex-royalty-free-illustration/185759601">Laguna Design/Science Photo Library via Getty Images</a></span>
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<p>My research team is targeting a protein called <a href="https://doi.org/10.1007/128_2012_356">Heat shock protein 90, or Hsp90</a>, which has many functions inside each cell. Hsp90 has been a hot target in the <a href="https://doi.org/10.3390/ijms221910317">cancer field</a> for years, with researchers developing Hsp90 inhibitors as a treatment for many cancer types. </p>
<p>We’ve found that Hsp90 is also really important in regulating opioid signal transduction. <a href="https://doi.org/10.1074/jbc.m116.769489">Blocking Hsp90 in the brain</a> blocked opioid pain relief. However, <a href="https://doi.org/10.1126/scisignal.aaz1854">blocking Hsp90 in the spinal cord</a> increased opioid pain relief. Our recently published work uncovered more details on exactly how <a href="https://doi.org/10.1126/scisignal.ade2438">inhibiting Hsp90 leads to increased pain relief</a> in the spinal cord.</p>
<p>Our work shows that manipulating opioid signaling through Hsp90 offers a path forward to improve opioid drugs. Taking an Hsp90 inhibitor that targets the spinal cord along with an opioid drug could improve the pain relief the opioid provides while decreasing its side effects. With improved pain relief, you can take less opioid and reduce your risk of addiction. We are <a href="https://reporter.nih.gov/search/zF-FuD_ZC0CFwl6deU7tQw/project-details/10294366">currently developing</a> a new generation of Hsp90 inhibitors that could help realize this goal. </p>
<p>There may be many paths to developing an improved opioid drug without the burdensome side effects of current drugs like morphine and fentanyl. Separating the kindly and grim faces of the opioid Janus could help provide pain relief we need without addiction and overdose.</p><img src="https://counter.theconversation.com/content/204522/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Streicher receives funding from the National Institutes of Health, the Arizona Biomedical Research Commission, the Flinn Foundation, and the University of Arizona. He is an equity holder in Teleport Pharmaceuticals, LLC, and Botanical Results, LLC, however, no company products or interests were discussed in this article. </span></em></p>Unlike opioid drugs like morphine and fentanyl that travel throughout the body, the opioids your body produces are released in small quantities to specific locations.John Michael Streicher, Associate Professor of Pharmacology, University of Arizona Health SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1915242022-10-03T15:00:41Z2022-10-03T15:00:41ZDrug addiction in South Africa: what was learned from six young men recovering from opioids<figure><img src="https://images.theconversation.com/files/487251/original/file-20220929-14-b4oqas.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man living living on the streets in Johannesburg holding the nyaope (opiod) drug ready to smoke. </span> <span class="attribution"><span class="source">Photo by Bongani Siziba/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>The ways we intervene in curbing addiction to substances has shifted from the medical era, focusing on acute care, to a <a href="https://www.sciencedirect.com/science/article/pii/S0740547207001833?via%3Dihub">comprehensive chronic care model</a>. People need long-term support to stay off substances, as well as immediate help to stop using them.</p>
<p>But in South Africa there is silence on alternative and innovative ways people recover. The country has an over-reliance on the medical model. This is despite an acknowledgement that addiction as a disease has physiological effects that have an impact on other areas of functioning. This calls for the adoption of a <a href="https://ukzn-dspace.ukzn.ac.za/handle/10413/14811">bio-psycho-social approach</a> which proposes that illness and disease conditions are not only biological but have that they have psychological and social dimensions. Managing addiction requires taking account of all these factors.</p>
<p>My PhD <a href="https://researchspace.ukzn.ac.za/handle/10413/20203">research</a> examined alternative and innovative approaches to curbing the use of a heroin variant known locally as whoonga or nyaope. Opiod use has risen exponentially in the country <a href="https://researchspace.ukzn.ac.za/handle/10413/20203">over the past 20 years</a>. Over <a href="https://christiandrugsupport.wordpress.com/most-commonly-used-drugs/sa-statistics/">60%</a> of those confined to rehabilitation centres are <a href="https://www.health24.com/Mental-Health/Living-with-mental-illness/The-changing-face-of-heroin-use-in-SA-20120721">young black South Africans</a>. </p>
<p>I closely examined the experiences of six young African men between the ages of 20 and 33 who desisted from using the opioid for an average of 3.3 years. They were recruited from the communities of Inanda, Ntuzuma and KwaMashu, north-west of Durban in South Africa.</p>
<p>At the core of the study was an attempt to examine alternative and innovative approaches in curbing whoonga addiction that support recovery and promote prevention. </p>
<p>In my research study the six young men took very different routes to recovery. Some recovered with institutional support, some without. Some took the medical route, others didn’t. Some needed familial and community support. Others didn’t. </p>
<p>The experiences of the six individuals showed that people do recover from addiction, but that when this happens away from the medical or institutional world it’s not recorded. </p>
<p>I concluded from my findings that South Africa should manage opioid addiction by incorporating socio-economic factors into the design of any interventions. These include unemployment, a lack of skills, boredom and a norm of cannabis smoking among youth. Policies should also take account of spiritual issues so that they align with <a href="https://doi.org/10.1177/002193402237226">people’s belief systems</a>. There should be an openness to inviting other healing methods, including traditional ones.</p>
<h2>Drug use in South Africa</h2>
<p>Addiction to whoonga or nyaope transforms participants in profound and harmful ways. The drug is extremely potent and addictive, producing an intensely pleasurable high. </p>
<p>The drug can be snorted, inhaled, injected and mixed with other lighter drugs. In cases of opioid addiction in South Africa, the drug is mixed with cannabis. </p>
<p>Whoonga addiction is usually initiated in pursuit of pleasure, escaping difficult life situations and boredom. The influence of friends and peers dominates. </p>
<p>But it soon becomes a burden. The body becomes a site for pain. And the addicted person stops caring about themselves, others and other life concerns. </p>
<h2>Roads to recovery</h2>
<p>Participants in this study provide evidence of overcoming whoonga addiction. </p>
<p>Participants found an inner resolve, an idea that to initiate desistance comes from the internal will inside the person. But that this needs to be supported. This echoes the idea of recovery capital – that recovery can be initiated by an individual, but for it to flourish, both internal and external resources are needed. This means that people who were taking opiods were supported to remain sober and to flourish, and in some cases, to initiate quitting. </p>
<p>Support from the family and the community proved necessary to stay sober and achieve a career and flourish, even for participants who underwent solo dry detoxification. This is the most painful and challenging way of quitting without medication to ease pain or going to a rehabilitation institution. </p>
<p>After desistance, challenges of the “risk environment” remained. These were the threats to the recovery process that were associated with initiating drug use in the first place.</p>
<p>Recovery was welcomed by family, peers and the community, who presented participants as models to those who had not stopped, showing them that it was possible. Participants were offered an opportunity to generate a nationwide trend – using social media – to encourage others to quit. </p>
<p>The study demonstrated the use of multiple and complementary ways – professional, non-professional and sole trajectories – to achieve recovery.</p>
<h2>Next steps</h2>
<p>The government needs a strategy for dealing with opioid addiction. This should guide different agencies, streamline and coordinate resources, and involve multi-sectoral collaborative approaches. </p>
<p>The strategy should include professional and non-professional ways – including innovative ways – of supporting recovery. In the US, organisations such as Alcohol/Narcotics Anonymous have accepted the movement from a focus on acute care to <a href="https://www.chestnut.org/william-white-papers">a focus on chronic care</a>. The UK and Australia have lobbied for legislation and implemented some recovery houses. In the South, Brazil <a href="https://doi.org/10.1590/2237-6089-2017-0084">reported</a> on its first recovery house in 2019.</p>
<p>There should also be a concerted campaign to debunk myths about whoonga or nyaope. For example, that they are opioid-based entities. The campaign should also focus on inviting alternative ways of dealing with drug addiction that are sensitive to local needs and use readily available resources. </p>
<p>The country has very few public rehabilitation centres, and those run by the private sector are expensive. This points to the need to devote attention to the fact that communities can play an immense role, <a href="https://doi.org/10.1016/j.jsat.2008.10.006">including as preventative and after-care agents</a>.</p>
<p>Another innovative approach would be to create peer recovery support groups. These groups would provide communities of former whoonga addicts with a place to go. And participants would present hope to those addicted and the community that overcoming whoonga addiction is a reality. In turn this would alleviate stigma. </p>
<p>Such communities are best positioned to support early recovery experiments in empathic and non-judgemental ways. </p>
<p>Alternative preventative measures should also be put in place. These could, for example, reorientate young people to traditional African ways that support and bolster a sense of pride in who they are. </p>
<p>Instilling mechanisms of earning membership to the community, and guidance on navigating the transition to adulthood, for example, rites of passage among youth, would be necessary. The message is that actions and behaviours reverberate, affecting their communities. For young people to understand the plight of their own communities, teaching individual responsibility for the health and welfare of communities is essential for prevention.</p><img src="https://counter.theconversation.com/content/191524/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thabani Khumalo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The six young men took very different routes to recovery. Their experiences hold important lessons for managing opioid addiction.Thabani Khumalo, Senior Lecturer, Discipline of Psychology, Applied Human Sciences, Pietermaritzburg Campus, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1818202022-06-10T15:10:50Z2022-06-10T15:10:50ZWhy opting out of opioids can be dangerous in the operating room<figure><img src="https://images.theconversation.com/files/467588/original/file-20220607-14-psmm5p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioids can help reduce the amount of medication needed to achieve anesthesia.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-anesthesiologist-during-hard-operation-royalty-free-image/1139854034">gpointstudio/iStock via Getty Images Plus</a></span></figcaption></figure><p>Currently, patients in <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2793282">seven states</a> can tell their physicians they don’t want to be treated with opioids in any health care setting, even during surgery. While unnecessary opioid exposure is a big reason behind the opioid epidemic in the U.S., we believe that <a href="https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2019/03/28/nonopioid-directive-form-helps-fight-opioid-epidemic-by-allowing-patients-to-notify-health-professi">non-opioid directives</a> that allow patients to opt out of opioids in the operating room may lead to unexpected harms.</p>
<p>Non-opioid directives share some common features with <a href="https://medlineplus.gov/advancedirectives.html">advance directives</a>, legally recognized documents that allow patients to list their preferences for what happens at the end of life. Both documents guide care based on the desires of the patient. Non-opioid directives are mandates that a patient must not receive opioids under any circumstances. Exceptions are rare.</p>
<p>Congress is currently considering legislation allowing access to these directives across the nation. While only one of the seven states with non-opioid directives excludes <a href="http://legislature.mi.gov/doc.aspx?2021-HB-5261">care during surgical procedures</a>, both proposed bills in the <a href="https://www.congress.gov/bill/117th-congress/house-bill/4098">House</a> and <a href="https://www.congress.gov/bill/117th-congress/senate-bill/1292/">Senate</a> contain an exclusion specific to care in the operating room.</p>
<p>We are a <a href="https://scholar.google.com/citations?user=mQswfH4AAAAJ&hl=en">team</a> <a href="https://www.uofmhealth.org/profile/1322/paul-edward-hilliard-md">of</a> <a href="https://scholar.google.com/citations?user=FyPUG8cAAAAJ&hl=en">physicians</a> who work with and study the use of opioids in surgical settings. Two of us co-direct the <a href="https://michigan-open.org">Opioid Prescribing Engagement Network</a>, which develops best practices for opioid prescriptions after surgery. We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2793282">difficult if not impossible</a> to avoid harming patients.</p>
<h2>The role of opioids in anesthesia</h2>
<p>Anesthesia is tailored for each patient depending on the surgical procedure, with the appropriate <a href="https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia">degree of sedation</a> varying for each case. At one end of the scale is minimal sedation, which usually allows patients to respond to verbal commands. At the other end is general anesthesia, which keeps patients unconscious even during pain. Different medications make this range of sedation possible. </p>
<p>A concept called <a href="https://doi.org/10.1016/j.jclinane.2003.07.005">balanced anesthesia</a> has guided clinicians in how they care for patients in the operating room for more than a century. The goal is to give a patient different types of medications to obtain loss of pain, memory, movement and consciousness while preserving other essential functions of the body.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/ZSsYjQeK0qg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Scientists are still learning about the biomechanisms behind how anesthesia works.</span></figcaption>
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<p>Relying on only one or two types of medication usually requires higher doses to achieve anesthesia, which can result in bothersome or concerning side effects. Using a <a href="https://doi.org/10.1213%2FANE.0000000000003668">combination of drugs</a>, on the other hand, lowers the amount of drug needed to achieve sedation. Because each drug works on a different set of receptors in the body, the desired effects can be attained with smaller doses of each drug than with one drug given alone. This reduces the risk of side effects and leads to more stable vital signs during surgery.</p>
<p>Opioids stand out among the typical sedatives and anesthetics used in the operating room by <a href="https://doi.org/10.1016/s0952-8180(97)00122-0">significantly reducing</a> the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness. Even small doses of opioids are sufficient to <a href="https://doi.org/10.1097/ALN.0b013e318238bba6">activate areas</a> in the brain that decrease the input of pain signals from other areas of the body.</p>
<h2>Why the operating room is different</h2>
<p>As broader calls to reduce unnecessary opioid use rise, anesthesiology and surgery researchers have asked whether avoiding all opioids in the operating room would lead to better patient outcomes. The first set of published studies on this question suggests that completely eliminating opioids from the operating room may do more harm than good.</p>
<p>In <a href="https://doi.org/10.1097/aln.0000000000003725">one study</a>, researchers randomly assigned patients who needed general anesthesia for surgery to either a group that received an ultrafast-acting opioid or a non-opioid sedative commonly used in intensive care units. After a surprising number of patients in the non-opioid group experienced serious adverse events during surgery, such as dangerously reduced heart rates and low oxygen blood concentration, the researchers stopped the study early because of safety concerns.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of IV drip in operating room." src="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.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>
<figcaption>
<span class="caption">Eliminating opioids in the OR may not have many benefits over reducing dosages.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-iv-drip-bag-royalty-free-image/1347166189">Porta/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>Similarly, a <a href="https://doi.org/10.1097/ALN.0000000000003572">review of studies</a> found that eliminating opioids during surgery did not decrease either patient use of prescription opioids after discharge or provider overprescription of opioids beyond just reducing opioid dosage during the procedure.</p>
<h2>Non-opioid directives and the OR</h2>
<p>Drug overdoses in the United States continue to reach record numbers, with estimates of more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">107,000 deaths</a> in 2021. How best to use pharmaceutical company lawsuit settlement payouts given to <a href="https://www.wsj.com/articles/j-j-settles-with-west-virginia-in-opioid-suit-for-99-million-11650302927">West Virginia</a> and <a href="https://apnews.com/article/health-business-washington-lawsuits-opioids-9de7c4bdf0f3c4360d355bb8da8c740f">other states</a> has been hotly <a href="http://doi.org/10.1001/jamahealthforum.2021.1765">debated</a>. But we believe that approaches that allow patient to opt out of opioids in the operating room may lead to unsafe care. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="White pills spilling out of orange bottle" src="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.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>
<figcaption>
<span class="caption">Non-opioid directives can help reduce unintended opioid exposure but may not be safe when applied to the OR.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pills-pour-out-of-prescription-medication-bottle-royalty-free-image/828608164">DNY59/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>Opioids are useful beyond pain reduction and play a role in helping patients safely emerge from general anesthesia. Avoiding opioids may be a safe option when general anesthesia is not needed, such as procedures on the hand, leg or feet that use only <a href="http://doi.org/10.1097/EJA.0b013e3283349d68">nerve blocks</a> to reduce pain. Prescription opioids may also not be needed when patients recover at home <a href="https://michigan-open.org/prescribing-recommendations/">after many types of surgery</a>.</p>
<p>Opioids are a tool that can complement a thoughtful anesthetic and surgical plan. Whether or not patients receive opioids during surgery doesn’t affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.</p><img src="https://counter.theconversation.com/content/181820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark C. Bicket receives funding from the National Institutes of Health, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the US Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. He received past funding from the Arnold Foundation. He served as a consultant in the past for Axial Healthcare and Alosa Health.</span></em></p><p class="fine-print"><em><span>Jennifer Waljee receives funding from the National Institutes of Health, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the US Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. </span></em></p><p class="fine-print"><em><span>Paul Edward Hilliard 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>Non-opioid directives allow patients to refuse opioids in all health care settings. For surgical procedures that require anesthesia, however, this may do more harm than good.Mark C. Bicket, Co-Director, Opioid Prescribing Engagement Network and Assistant Professor, University of MichiganJennifer Waljee, Associate Professor of Plastic and Reconstructive Surgery, University of MichiganPaul Edward Hilliard, Clinical Associate Professor of Anesthesiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826422022-06-07T14:01:43Z2022-06-07T14:01:43ZMaking video games can help support addiction recovery<figure><img src="https://images.theconversation.com/files/465156/original/file-20220524-24-dgq66e.jpg?ixlib=rb-1.1.0&rect=0%2C418%2C3880%2C2786&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Game jams are powerful spaces for galvanizing creativity in disenfranchised communities.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The opioid epidemic is driven by more than the sale of <a href="https://www.cbc.ca/news/canada/canada-illicit-drug-supply-explainer-1.6361623">illicit drugs</a>, <a href="https://www.hqontario.ca/System-Performance/Specialized-Reports/Opioid-Prescribing">increased opioid prescribing</a> and the <a href="https://www.canada.ca/en/services/health/campaigns/drug-prevention.html">pandemic</a>. </p>
<p>Stigma fills the lives of many people living with opioid addiction, exacerbating hopelessness, <a href="https://newsinteractives.cbc.ca/longform/crystal-meth-addiction-canada">loss of dignity</a> and shame. There is a broad misconception that opioid dependence is a <a href="https://doi.org/10.1001/amajethics.2020.702">personal moral failing</a>, but many people misuse opioids to <a href="https://www.doi.org/10.25318/82-003-x202101200002-eng">manage pain</a>. </p>
<p>Individual failure is not the driver of opioid addiction. It is a complex and intertwined set of root causes <a href="https://doi.org/10.2105%2FAJPH.2017.304187">including poverty, social isolation, disability and physical and psychological trauma</a>.</p>
<p>I am the lead researcher of an <a href="https://www.canada.ca/en/health-canada/services/science-research/science-advice-decision-making/research-ethics-board.html">ethics-approved</a> study investigating the practice of making video games to support addiction recovery. We hope that our work will help fight the stigma of opioid addiction and give support to those struggling.</p>
<h2>Aspects of the study</h2>
<p>The study will give adults living with, or who have a history of opioid addiction, the tools and resources to tell their story, learn about themselves, build community and raise awareness about addiction-related stigma, while also acquiring valuable computer skills. </p>
<p>We will do this by bringing people together to connect in a physical space and make video games informed <a href="https://www.jstor.org/stable/540572">by their stories</a>. We will mentor and teach them about how to make their first game prototype. This includes learning how to tell their story through a video game, create the <a href="https://www.gamedeveloper.com/blogs/12-principles-for-game-animation">art and animation</a>, programming the game and <a href="https://www.techopedia.com/definition/27197/playtesting">playtesting</a> it. </p>
<p>Telling a life story is a profound self-learning exercise because it requires the storyteller to explain and clarify their decision-making processes in life. Rendering a life story through a digital game requires the game maker to tell it computationally, through digital code, which also compels them to think creatively and logically.</p>
<figure class="align-center ">
<img alt="Children play video games at Romics fair in Rome, an international festival of comics, animation, cinema and games." src="https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.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">The practice of making video games could support addiction recovery.</span>
<span class="attribution"><span class="source">(AP Photo/Alessandra Tarantino)</span></span>
</figcaption>
</figure>
<p>We plan on conducting a series of <a href="https://www.gamedeveloper.com/design/a-brief-history-of-game-jams">game jams</a> in Ontario cities affected by the opioid crisis including Brantford, Hamilton and Toronto. </p>
<p>A game jam is a game making workshop where a group of people come together to make games over a short time period, usually between 24 and 72 hours. Game jams are like musical jamming sessions, inviting a kind of furious improvisation that most creators love. But they are also community-building events energized by the spirit of collaboration, which often outweighs the act of making games. </p>
<h2>Autobiographical digital games</h2>
<p>It might seem counter-intuitive to use video games for storytelling, given that many assume gamers are all <a href="https://doi.org/10.1016/j.entcom.2021.100439">violent and antisocial</a> — a <a href="https://www.wired.com/2020/06/geeks-guide-videogame-researchers/">moral panic not supported by evidence</a>. </p>
<p>In the past 10 years, video games have come a long way. The emergence of autobiographical digital games about illness and health, such as Zoe Quinn’s interactive narrative, <a href="http://www.depressionquest.com/#info-section"><em>Depression Quest</em></a>; Green, Green and Larson’s <a href="http://www.thatdragoncancer.com/"><em>That Dragon, Cancer</em></a> and Anna Anthropy’s <a href="https://freegames.org/ca/dys4ia/"><em>Dys4ia</em></a> have shaken up games culture. </p>
<p>Non-traditional game makers — like women and LGBTQ+ designers that don’t fit the typical profile of a developer — have <a href="https://www.nytimes.com/2014/11/23/magazine/twine-the-video-game-technology-for-all.html">reimagined video games as a powerful art for exploring personal trauma</a>. </p>
<p>Free and easy to use software like <a href="http://twinery.org/"><em>Twine</em> </a> have accelerated a cultural awakening of computer games as <a href="https://daily.jstor.org/venn-diagram-of-lgbtq-and-gaming-communities-goes-here/">an expressive vehicle for marginalized creators</a>. Collectives have also sprung up to organize game jams and throw support behind marginalized creators with no design or programming experience — like <a href="https://dmg.to/">DMG</a> in Toronto and <a href="https://pixelles.ca/">Pixelles</a> in Montréal. </p>
<p>Game jams have become powerful spaces for galvanizing creativity in disenfranchised communities and giving them creative agency and voice.</p>
<figure class="align-center ">
<img alt="A girl sits behind a computer screen playing a video game" src="https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A game jam is a game making workshop where people come together to make games over a short period of time.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Rebuilding identity and healing wounds</h2>
<p>I have been researching the topic of making games for mental health for eight years. In 2014, I organized my first game jam study for game designers living with depression, anxiety, bipolar disorder, post-traumatic stress disorder and other mental health conditions. The outcome of that study was my <a href="https://hdl.handle.net/1807/89836">doctoral dissertation</a>, which looked at making games about illness and disability as a rich healing and communal practice. </p>
<p>My research showed that digital game design enables new forms of self-awareness for young people struggling with their mental health. For example, <a href="https://ised-isde.canada.ca/site/choose-science/en/government-canada-and-stem">STEM-rich</a> practices, such as coding, engage a mode of thought called computational thinking. <a href="https://cacm.acm.org/magazines/2017/6/217742-remaining-trouble-spots-with-computational-thinking/fulltext">Although controversial in the computer science community</a>, computational thinking allows game makers to cultivate mindfulness, especially when telling a story about themselves. </p>
<p>When game makers model their characters after themselves and fashion a new self, they have to <a href="https://dulwichcentre.com.au/articles-about-narrative-therapy/illness-narratives/">find coherence</a> in their life story, which can help them rebuild their identity and <a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo14674212.html">heal wounds</a>. When creators render a story as a playable game, it also compels them to act out their characters and embody their newly fashioned self. </p>
<p>Game making is an art form that many aren’t intimately familiar with. Unlike other creative practices, game makers must create the rules and laws that govern and shape player behaviours. This is a powerful practice that has the potential to contribute to recovery for opioid addiction. </p>
<p>I hope that this approach encourages policymakers to take up creative methods to empower hard-to-reach communities and uproot the stigma that is a significant barrier to solving the opioid crisis.</p><img src="https://counter.theconversation.com/content/182642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sandra Danilovic receives research funding from the Social Sciences and Humanities Research Council (SSHRC) and Wilfrid Laurier University. She is also a member of the not-for-profit videogame arts association DMG.to. </span></em></p>Game making is an art form that many aren’t intimately familiar with. Unlike other creative practices, game makers must create the rules and laws that govern and shape player behaviours.Sandra Danilovic, Assistant Professor of Game Design and Development in the Faculty of Human and Social Sciences, Wilfrid Laurier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1649942021-08-13T12:26:10Z2021-08-13T12:26:10ZThe aching red: Firefighters often silently suffer from trauma and job-related stress<figure><img src="https://images.theconversation.com/files/415589/original/file-20210811-13-z6z0us.jpg?ixlib=rb-1.1.0&rect=241%2C607%2C4173%2C2773&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Firefighters regularly face scenes of loss and suffering.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/silhouette-firefighter-standing-by-bonfire-at-night-royalty-free-image/1164532738?adppopup=true"> Mike Dohmen/EyeEm via Getty Images</a></span></figcaption></figure><p>Matthew was exposed to unimaginable scenes of pain and suffering in his job over more than a decade as a firefighter. The last straw came when he witnessed the death of a teenager – who was the same age as his son – from an overdose.</p>
<p>“The worst part is when you see an infant or a child die,” he told me during a visit. “Exposure to their family’s pain – and that you could not save that life – is very heartbreaking.” Matthew, for whom I’m using a pseudonym to protect his privacy, was being treated at my clinic for post-traumatic stress disorder and depression.</p>
<p>Images of tragedy, <a href="https://www.nytimes.com/2018/11/12/us/california-fires-camp-fire.html">loss of entire communities</a> and the terrible destruction wrought by deadly wildfires in the West have sadly become <a href="https://www.theatlantic.com/health/archive/2020/07/mental-health-aftermath-california-wildfires/608656/">all too common</a>. But the public hears relatively little about the suffering of the firefighters who risk their lives and are away from their families for days and weeks at a time. And though firefighters are primarily recognized for responding to fires, they’re also often among the first to arrive at all other manner of disasters and accidents too, as Matthew’s example shows.</p>
<p>While the choice to become a firefighter often stems from a passion for, and a mindset of, helping others and saving lives, being constantly exposed to death, injury and suffering comes with a cost. Cumulative stressors include the physical toll on the body, long working hours, work-related sleep disturbance and an inability to attend to daily family life. </p>
<p>I am <a href="https://scholar.google.com/citations?user=UDytFmIAAAAJ&hl=en">a psychiatrist and trauma expert</a> who often works with <a href="https://theconversation.com/the-aching-blue-trauma-stress-and-invisible-wounds-of-those-in-law-enforcement-146539">first responders</a> <a href="https://theconversation.com/veterans-refugees-and-victims-of-war-crimes-are-all-vulnerable-to-ptsd-130144">as well as refugees</a> and victims of war crimes. While many people think of firefighters as the happy heroes, the real-life, day-to-day experiences of these heroes can have real consequences for their mental health that remain largely invisible to the public eye.</p>
<h2>The life of a firefighter</h2>
<p>Firefighters have their own family-like “culture” and lifestyle, and they have experiences that often only their peers can relate to. Teams often spend whole 24-hour shifts together for years – even decades – and share holiday meals together when they can’t be with their own families.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Firefighters dressed in uniforms, talking at fire station" src="https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415694/original/file-20210811-17-gju6ve.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>
<figcaption>
<span class="caption">Firefighters spend long shifts together and tend to form close-knit bonds.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/firefighters-in-uniform-talking-while-standing-at-royalty-free-image/1180594729?adppopup=true">Maskot/Getty Images</a></span>
</figcaption>
</figure>
<p>Recently, when I spent time with a firefighter team in Dearborn, Michigan, one of the firefighters who was of German descent made a full German dinner, complete with schnitzel, sauerkraut, potatoes and dessert. When I sat at my assigned seat waiting for others to join, the firefighter sitting next to me said, “If you wait, you might never be able to eat your dinner.” Sure enough, five minutes later we had to go out on a call. During the ride, I reflected on how stressful it is to drive at high speeds to a potential disaster where you will have to problem-solve to save a life – or fail at doing so. </p>
<p>The life of a firefighter requires a frequent and immediate switch from laid-back life at the station to racing to unimaginable scenes that could involve anything from a light car accident to horrible car crashes, where first responders have to pull people or bodies from crushed or burning cars.</p>
<p>Exposure to tragic scenes – and the associated risks to firefighters’ lives or their colleagues’ – is a routine part of this job. Often, firefighters are re-exposed to these traumatic experiences via stories in the media or through videos and other posts by bystanders on social media. During the ride along, one firefighter said of this re-exposure, “You see it on all the local TV channels, along with the frequent updates.” </p>
<h2>Mental health impacts of stress and trauma</h2>
<p>PTSD is a condition caused by <a href="https://theconversation.com/veterans-refugees-and-victims-of-war-crimes-are-all-vulnerable-to-ptsd-130144">exposure to traumatic experiences</a> such as natural disasters, war, shootings, motor vehicle accidents and assault. It can result from one’s personal exposure to a trauma, or to someone else’s exposure.</p>
<p>More often, people have heard about PTSD in the context of war, with combat-exposed veterans. While combat veterans often return to the normality of the civilian life after deployment, the job of firefighters, police officers and emergency medical services workers involves regular, routine exposure to all types of traumas, for years and decades of their careers. </p>
<p>The <a href="https://doi.org/10.31887/DCNS.2006.8.4/jbremner">PTSD brain</a> is constantly on alert, screening for danger. Symptoms of PTSD include frequent nightmares, flashbacks, avoiding reminders of trauma and being easily startled and angered. Research shows that <a href="https://doi.org/10.1037//1076-8998.4.2.131">20% of firefighters and other first responders</a> pass the diagnostic threshold for PTSD at some point in their career, <a href="https://www.iaffrecoverycenter.com/blog/trauma-firefighting-and-ptsd/">in comparison with 6.8%</a> <a href="https://www.ptsd.va.gov/professional/treat/essentials/epidemiology.asp">in the general population</a>. A higher number of first responders experience symptoms that do not meet full diagnostic criteria for PTSD. </p>
<p><a href="https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf">Other consequences</a> of cumulative trauma exposure include depression, anxiety, substance use and suicide, all of which are more common among firefighters and other first responders than in the general population. <a href="https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf">Alcohol use</a> often becomes a coping mechanism. A recent study found that more firefighters and police officers <a href="https://rudermanfoundation.org/white_papers/police-officers-and-firefighters-are-more-likely-to-die-by-suicide-than-in-line-of-duty/">die by suicide</a> than in the line of duty. </p>
<h2>The challenges and solutions</h2>
<p>The problem-solving and “being in charge” work attitude that is a strength of firefighters can sometimes become a barrier in seeking help, as they might see vulnerability as a sign of failure. Often I have heard from first responders the feeling of shame and worries that others might see them as weak for discussing these issues. First responders sometimes tell us that they can have a hard time trusting mental health providers, some of whom might not have much firsthand experience with understanding a first responder’s life and challenges. Firefighters often also find it impossible to share their tough work experiences with their families. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Firefighters and police offers move truck at crash scene" src="https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=753&fit=crop&dpr=1 754w, https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=753&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/412888/original/file-20210723-17-18awme.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=753&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Problem-solving and teamwork are a big part of a first responder’s job. Here, firefighters and police officers help move a car at a crash scene in Dearborn, Michigan.</span>
<span class="attribution"><span class="source">Arash Javanbakht</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Left unaddressed, trauma and chronic stress can lead to not only mental health consequences but also <a href="https://theconversation.com/howard-stern-talks-childhood-trauma-and-a-trauma-psychiatrist-talks-about-its-lasting-effects-118027">physical illness</a>, including diabetes, hypertension and heart disease, obesity and chronic pain.</p>
<h2>Steps forward</h2>
<p>Fortunately, serious efforts are being made to spread awareness and fight stigma related to mental health. <a href="https://www.iaffrecoverycenter.com/blog/peer-support-combat-addiction-ptsd/">Peer-support programs</a> are made available to first responders to provide empathetic support and to encourage those in need to seek mental health care. Such programs can help fight stigma by explaining the mechanisms of trauma and stress in the body and brain. This approach can also reframe these experiences as vulnerabilities rather than weaknesses. The “don’t quit” mentality of firefighters can be shifted toward encouraging fighting the mental health consequences of trauma, instead of avoiding and denying it. </p>
<p>There are a growing number of effective treatments and interventions for addressing PTSD, depression and substance use, including <a href="https://www.ptsd.va.gov/understand_tx/talk_therapy.asp">talk therapy</a>, <a href="https://www.cnn.com/2019/02/04/health/life-you-evolved-for-partner/index.html">lifestyle changes</a> and safe <a href="https://www.ptsd.va.gov/understand_tx/meds_for_ptsd.asp">medications</a>. Knowing that the consequences of trauma can be resolved by proper interventions also helps reduce the stigma that can sometimes be associated with mental health problems. This can lead to the mindset that PTSD is a treatable condition rather than a label to live with for the rest of one’s life.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/YO9WjwWD7_0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Researchers are using novel approaches to trauma therapy, including augmented reality, to help first responders, civilians and others heal and improve their well-being.</span></figcaption>
</figure>
<p>Other comprehensive programs are underway nationwide, dedicating resources to providing education, support, prevention and intervention for first responders and their families. <a href="https://today.wayne.edu/medicine/news/2021/03/04/wsu-psychiatry-developing-statewide-mental-health-program-to-address-stress-among-first-responders-and-their-families-41646">One such initiative</a>, which involves <a href="https://psychiatry.med.wayne.edu">my department</a> and <a href="https://www.starclab.org">my research clinic</a>, recently started at Wayne State University with the support of the state of Michigan. This program aims to provide education, prevention, peer support and a statewide network of mental health providers familiar with specific challenges of first responders. We are also developing novel methods for trauma treatment using cutting-edge augmented reality and telemedicine technologies.</p>
<p>Having worked with hundreds of civilians and first responders with trauma over more than a decade, I have time and again seen people recover from PTSD and depression and successfully return to a thriving career and family life. I have high hopes that we can help create awareness and, ultimately, improve the lives and well-being of many first responders.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/164994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht 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>Firefighters are hailed as heroes and pillars of strength, bravery and courage. But the daily stressors and traumas of their jobs take a heavy emotional toll that largely goes unnoticed by the public.Arash Javanbakht, Associate Professor of Psychiatry, Wayne State UniversityLicensed 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>
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<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>
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<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/1307792020-03-04T21:13:21Z2020-03-04T21:13:21ZFuelling a crisis: Lack of treatment for opioid use in Canada’s prisons and jails<figure><img src="https://images.theconversation.com/files/318731/original/file-20200304-66106-13763lm.jpg?ixlib=rb-1.1.0&rect=287%2C8%2C5703%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Incarcerated people are often denied access to treatment for opioid use disorder. This October 2016 file photo shows corrections officer opening the door to a cell in the segregation unit at the Fraser Valley Institution for Women in Abbotsford, B.C. during a media tour.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>The opioid overdose crisis has <a href="https://health-infobase.canada.ca/sutance-related-harms/opioids">killed almost 14,000 Canadians since 2016</a>. </p>
<p>One flashpoint of this crisis is Canada’s correctional facilities. <a href="https://www.csc-scc.gc.ca/research/sr-18-02-en.shtml">Opioid-related deaths are increasing</a> among incarcerated people. Post-release, their prospects are even worse: in the two weeks after release, a prisoner’s risk of overdose is <a href="https://doi.org/10.9778/cmajo.20150098">more than 50 times higher</a> than in the general population. <a href="https://doi.org/10.1371/journal.pone.0157512">One in 10 of all overdose deaths</a> is a prisoner released in the past year. </p>
<p>Despite this, our prisons and jails often delay or deny access to evidence-based treatments for opioid use disorder and fail to ensure appropriate supports on release.</p>
<h2>Opioid agonist therapy</h2>
<p>Governments have brought <a href="https://www.cbc.ca/news/canada/toronto/ontario-opioid-class-action-suit-1.5394066">class-action lawsuits against pharmaceutical companies</a> and <a href="https://www.justice.gov/opa/pr/second-appalachian-region-prescription-opioid-strikeforce-takedown-results-charges-against-13">prosecuted overprescribing doctors</a>. Canada’s federal government is <a href="https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/responding-canada-opioid-crisis.html">taking action on opioids</a>. </p>
<p>But our divergent experiences as a physician, a legal academic and a formerly incarcerated harm reduction activist have taught us that much of the responsibility lies with government itself — specifically, its failure to provide prisoners with timely access to opioid agonist therapy (OAT) and ensure post-release continuity of treatment.</p>
<p>People incarcerated in Canada’s federal prisons and provincial-territorial jails are highly likely to have experienced <a href="https://doi.org/10.2105/AJPH.2018.304855">childhood trauma</a>, poverty and the corrosive effects of <a href="https://www.oci-bec.gc.ca/cnt/rpt/annrpt/annrpt20162017-eng.aspx#s6">racism</a> and <a href="https://www.oci-bec.gc.ca/cnt/comm/press/press20200121-eng.aspx">colonialism</a>. They are highly likely to struggle with <a href="https://doi.org/10.1111/add.13877">addictions</a> and <a href="https://www.cfp.ca/content/62/3/215">mental illness</a>. Incarcerated people, like many on the outside, use drugs as a form of coping.</p>
<p>OAT provides a medication (usually buprenorphine/naloxone or methadone) to prevent drug cravings and withdrawal symptoms. It is the <a href="https://doi.org/10.1503/cmaj.170958">first-line treatment for opioid use disorder</a> and the standard of community-based care across Canada. <a href="https://doi.org/10.1371/journal.pmed.1003002">OAT saves lives</a>, <a href="https://doi.org/10.1016/S0140-6736(16)30769-3">reduces HIV and hepatitis C transmission</a>, improves a host of social and psychological outcomes and is associated with a decreased risk of <a href="https://doi.org/10.1111/add.14059">future criminal charges</a> and <a href="https://www.csc-scc.gc.ca/research/005008-0322-eng.shtml">imprisonment</a>.</p>
<h2>Legal standards for health care</h2>
<p><a href="https://laws-lois.justice.gc.ca/eng/acts/C-44.6/index.html">Canadian</a> and <a href="https://undocs.org/A/RES/70/175">international</a> law obliges prisons to provide incarcerated people with health care at community standards. But <a href="https://doi.org/10.1016/j.drugalcdep.2018.09.003">research</a>, <a href="https://www.mcscs.jus.gov.on.ca/english/Deathinvestigations/Inquests/Verdictsandrecommendations/OCCInquestHWDC.html">coroners’ inquests</a> and <a href="https://cp-ep.org/wp-content/uploads/2019/09/JAIL-Hotline_Q1-Report_Final.pdf">prisoners’ rights groups</a> all tell a similar story: too often, people are not provided addictions treatment on admission, whether or not they were being treated in the community. This means they go into acute withdrawal and are at increased risk of use, relapse and overdose. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cells at the Central Nova Scotia Correctional Facility in Halifax in May 2018. File photo.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
</figcaption>
</figure>
<p>The result? Missed opportunities to provide care to people who desperately need it, and deaths with little oversight or accountability. While we pursue progressive solutions like <a href="https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Decriminalization-Controlled-Substances-Policy-Brief-2018-en.pdf">decriminalization</a> and <a href="http://capud.ca/sites/default/files/2019-03/CAPUD%20safe%20supply%20English%20March%203%202019.pdf">safe supply</a>, we must urgently make OAT available to everyone incarcerated who would benefit.</p>
<p>In Nova Scotia, the provincial health authority is responsible for delivering health care in the province’s jails, rather than Correctional Services, as is common in other provinces. Nova Scotia’s jails have a blanket policy of<a href="https://www.cbc.ca/news/canada/nova-scotia/jail-medication-mental-health-methadone-withheld-1.3708938">not providing prisoners with OAT unless they are already on it when they arrive</a>. Those who are not on therapy suffer through withdrawal or find ways to keep using illicitly inside. This is a clear violation of the government’s legal obligation to provide equivalent health care in detention. </p>
<p>Provinces like Ontario, which have celebrated Nova Scotia’s wisdom in making correctional health care the responsibility of the Department of Health and Wellness instead of corrections, should take note: simply shifting responsibility is not enough to ensure sound policy.</p>
<h2>Feeding a crisis by limiting OAT</h2>
<p>As people who have lived or worked in prisons and with people who have been incarcerated, we have seen first-hand how limiting OAT in prison feeds the opioid crisis inside. It increases the demand for illicit drugs to be smuggled in or diverted. </p>
<p>In some institutions, those receiving OAT are subjected to a <a href="https://impactethics.ca/2019/11/19/methadone-access-in-prisons-stop-strip-searching/">daily strip search: a degrading and re-traumatizing practice</a>. Others who want the medication to prevent their own withdrawal symptoms target prisoners receiving OAT. People soon start diverting their medication, for instance by vomiting it up and straining it through a sock for someone else to use. If someone says no to a demand to divert their OAT, they may be subject to violence. </p>
<p><a href="https://www.cbc.ca/news/canada/nova-scotia/methadone-nova-scotia-jail-burnside-clayton-cromwell-1.3836706">If someone is caught diverting, their OAT is discontinued</a>, placing them at high risk of overdose. If treatment were not so intensely restricted, these adverse events could be reduced or eliminated.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=651&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=651&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=651&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=818&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=818&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=818&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Denying access to opioid agonist treatment using medications such as methadone (above) feeds the opioid crisis in prisons and jails.</span>
<span class="attribution"><span class="source">AP Photo/The Evening News, Chuck Branham</span></span>
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</figure>
<p>There are a few glimmers of hope. Rhode Island implemented a statewide correctional OAT program and saw a <a href="https://doi.org/10.1001/jamapsychiatry.2017.4614">60.5 per cent reduction in one-year overdose mortality after release</a>. In 2016, people incarcerated in British Columbia launched a <a href="https://www.theglobeandmail.com/news/british-columbia/bc-prisoners-get-addiction-therapy-after-settlement-in-charter-challenge/article29648890/">Charter challenge over policies limiting access to OAT in B.C. jails</a>; while that lawsuit settled, it contributed to increased access to the treatment. Access expanded further when the B.C. Ministry of Health took over provincial correctional health services in 2017. </p>
<p>But elsewhere, <a href="https://www.csc-scc.gc.ca/health/002006-2007-en.shtml">access to OAT in federal prisons</a> or provincial jails continues to be denied or unreasonably delayed. This has led B.C.’s Prisoners’ Legal Services to launch a <a href="https://prisonjustice.org/wp-content/uploads/2018/12/OST-rep-complaint-to-CHRC-20180604-narrative-1.pdf">representative human rights complaint on behalf of federal prisoners with opioid use disorder</a>, focused on access to OAT.</p>
<p>Federal, provincial and territorial governments need to step up and tackle the opioid epidemic at its flashpoint: our prisons and jails. Timely access to OAT for every incarcerated person who could benefit is required to turn the tide of death and ill health. Until we make these changes, Canada’s most vulnerable will continue to endure extraordinary suffering at the hands of our government and the body count will continue to rise.</p><img src="https://counter.theconversation.com/content/130779/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Bodkin receives funding from the Canadian Research Initiative in Substance Misuse and is an employee of Hamilton Health Sciences. She is affiliated with the Prison Health Member Interest Group at the College of Family Physicians of Canada. Her views represent only her own opinions.</span></em></p><p class="fine-print"><em><span>Matthew Bonn is an employee of Mainline Needle Exchange as a Frontline Harm Reduction Support Worker. He is the Lead Peer in Peers Assisting & Lending Support (PALS) which is a Harm Reduction Prison Outreach Program funded by PHAC. He is also a Research Assistant with Dalhousie & SMU. Currently receives funding from Gilead & AbbVie for Hepatitis C Elimination. </span></em></p><p class="fine-print"><em><span>Sheila Wildeman is a Vice-Chair of East Coast Prison Justice Society and a member of Dalhousie's Health Law Institute. </span></em></p>Urgently needed treatment for opioid use disorder is often denied to incarcerated people, feeding the crisis in prisons and jails.Claire Bodkin, Resident Physician, Department of Family Medicine, McMaster UniversityMatthew Bonn, Frontline Harm Reduction Worker & Health Promotion Research Assistant, Dalhousie UniversitySheila Wildeman, Associate professor, Schulich School of Law, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1295932020-02-10T13:57:42Z2020-02-10T13:57:42ZA Nazi drug’s US resurgence: How meth is making a disturbing reappearance<figure><img src="https://images.theconversation.com/files/313198/original/file-20200203-41516-vfhkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A drug addict smoking crystal meth on Skid Row in downtown Los Angeles.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Homeless-Crisis-on-the-Coast-Photo-Gallery/854421aedac84655854ae18e015b0021/62/0">AP photo/Jae C. Hong</a></span></figcaption></figure><p>Although I am teaching a course at Indiana University this semester on the opioid epidemic, I can’t get meth out of my mind.</p>
<p>A colleague of mine was recently carjacked. He was forced to drive at extreme speed throughout the city and escaped with his life only by intentionally crashing his car. My colleague told me he believes his gun-wielding assailant was suffering an acute psychosis related to methamphetamine use. </p>
<p>Opioids may get most of the media attention these days, but meth has hardly gone away. <a href="https://www.npr.org/sections/health-shots/2019/07/29/745061185/seizures-of-methamphetamine-are-surging-in-the-u-s">Law enforcement seizures</a> of meth are surging in the U.S., up 142% between 2017 and 2018. <a href="https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-scope-methamphetamine-misuse-in-united-states">Overdose deaths</a> in 2017 were seven times higher than in 2007. </p>
<p>Just what is meth? Why is it such a grave threat to health? And why does its terrible specter seem to loom larger and larger?</p>
<h2>The health effects of meth</h2>
<p>Methamphetamine, a powerful stimulant of the central nervous system, has some <a href="https://books.google.com/books/about/Blitzed.html?id=YN2pDAAAQBAJ">legitimate medical uses</a>, such as the treatment of attention deficit hyperactivity disorder. But it is widely trafficked and purchased for recreational consumption, often as crystal meth (think of the award-winning television drama “<a href="https://www.npr.org/2019/10/11/769312766/breaking-bad-creator-vince-gilligan-reflects-on-meth-and-morals">Breaking Bad</a>”).</p>
<p><a href="https://www.drugabuse.gov/publications/research-reports/methamphetamine/how-methamphetamine-misused">Recreational meth users</a> smoke, snort, ingest or inject the drug. Smoking and injection seem to give the greatest rush, but the effect doesn’t last as long. <a href="https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=166">Users often report</a> euphoria, increased alertness and reduced appetite; chronic users may experience paranoia, delusions and unpredictable mood swings. Addicts may exhibit a “<a href="https://www.drugabuse.gov/publications/research-reports/methamphetamine/how-methamphetamine-misused">binge and crash</a>” pattern, and many try to maintain the rush with continuous consumption. </p>
<p>Chances of addiction are high, and symptoms from withdrawal can linger for months. Treatment is complicated, particularly because many meth users are often also using cocaine, heroin or alcohol. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313199/original/file-20200203-41485-1ka9xnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Law enforcement seizures of meth are on the rise.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/California-Meth-Seizure/f79539f304ff4189af2fffec407a1e68/5/0">US Customs & Border Protection via AP</a></span>
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<p>Meth is directly <a href="https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-are-long-term-effects-methamphetamine-misuse">toxic</a> to the brain; developmental delays are common in meth babies. In adults, it’s associated with an <a href="https://doi.org/10.1016/j.drugalcdep.2018.02.032">increased risk for Parkinson’s disease</a>. Addicts age at an accelerated pace, and commonly acquire “<a href="https://www.mouthhealthy.org/en/az-topics/m/meth-mouth">meth mouth</a>” – tooth loss, tooth decay and tooth blackening.</p>
<p><a href="https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-are-long-term-effects-methamphetamine-misuse">Those who overdose</a> may develop psychosis or abnormal heart rhythms. Unlike opioid overdoses, which can quickly be resolved if the drug naloxone is available, meth overdoses have no “reversal” agent. <a href="https://medlineplus.gov/ency/article/007480.htm">Instead</a>, the meth is suctioned from the stomach. Anti-psychotics can help with psychosis, and anti-hypertensive drugs can reduce acutely elevated blood pressure. </p>
<h2>Meth’s dark history</h2>
<p>During World War II, meth played a sinister role in the Nazi war machine. </p>
<p>The military, along with German civilians, used a <a href="https://books.google.com/books/about/Blitzed.html?id=YN2pDAAAQBAJ">commercial form</a> of the drug – made in Berlin and marketed under the trade name <a href="https://www.spiegel.de/international/germany/crystal-meth-origins-link-back-to-nazi-germany-and-world-war-ii-a-901755.html">Pervitin</a> – to stay awake, alert and energized. With Pervitin, factory workers and homemakers alike found they could work longer and harder. Troops called it “tank chocolate” or “pilot’s salt.” Pervitin fueled the Nazis during their “<a href="https://www.spiegel.de/international/the-nazi-death-machine-hitler-s-drugged-soldiers-a-354606.html">blitzkrieg</a>” invasion of France in 1940. </p>
<p><a href="https://books.google.com/books?id=YN2pDAAAQBAJ&q=everyone+cheerful#v=snippet&q=everyone%20cheerful&f=false%22%22">Wrote one German commander</a> about Pervitin: “Everyone fresh and cheerful, excellent discipline.” Later his assessment became less rosy: “After taking four tablets, double vision and seeing colors.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313200/original/file-20200203-41554-nww6s9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A box of meth from a 2018 Minneapolis drug bust. Law enforcement seized a total of 171 pounds with an estimated street value of $7.75 million.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Meth-Deaths/8d6651c49058456291cdcd7fd8a5fa62/38/0">Cannon River Drug & Violent Task Force via AP</a></span>
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</figure>
<p>The toll meth took on the Germans was <a href="https://books.google.com/books/about/Blitzed.html?id=YN2pDAAAQBAJ">immense</a>. It provoked war crimes, stoked psychosis and triggered suicide. As the war progressed, <a href="https://books.google.com/books/about/Hitler.html?id=v3bWAAAAMAAJ">Adolf Hitler</a> received ever-increasing doses of the drug. </p>
<p>No one should be surprised. After all, the German name Pervitin is related to the word pervert (“ill-turned”). It means corrupted or distorted. Meth, as the Nazis discovered, distorts our nature and turns us away from what we are meant to be.</p>
<p>Now, 75 years after the war, and still without an <a href="https://www.pbs.org/wgbh/pages/frontline/meth/faqs/">effective</a> drug therapy, a meaningful response to methamphetamines requires three things. We in the U.S. must recognize the true scope of the problem. We must make sure meth users have access to counseling and behavioral therapy. Most of all, our society needs to help individuals and families discover healthier ways to find meaning in life. </p>
<p>[ <em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129593/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Gunderman 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>There’s widespread attention on the dangers of opioid addiction, but use of damaging crystal meth continues in the U.S., with police seizures rising.Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225372019-11-03T18:55:46Z2019-11-03T18:55:46ZOpioid dependence treatment saves lives. So why don’t more people use it?<figure><img src="https://images.theconversation.com/files/299607/original/file-20191031-187898-1v815y4.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5597%2C3709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To reduce opioid-related harms, we must ensure treatments for opioid dependence are accessible to those who need them. </span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>In Australia last year, <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2018%7EMain%20Features%7EOpioid-induced%20deaths%20in%20Australia%7E10000">1,123 people</a> died from opioids – illicit drugs such as heroin, and pain relievers such as codeine, oxycodone and morphine. If used regularly, physical and psychological dependence can develop.</p>
<p>In recent years most deaths have been due to <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/table-of-contents">pharmaceutical opioids</a> – that is, overdoses of strong pain medicines. Though heroin-related deaths are <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/data">increasing rapidly</a>, so we need evidence-based responses for both.</p>
<p>One key approach to reducing these deaths is treatment for opioid dependence. Although the evidence shows treatments such as methadone and buprenorphine <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">are effective</a>, people who are dependent on opioids continue to face barriers to accessing them.</p>
<p>These include cost, stigma, restrictiveness of the treatment regime, and a lack of places to go to receive treatment. </p>
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<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">Weekly Dose: Naloxone, how to save a life from opioid overdose</a>
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<h2>Opioid dependence treatment</h2>
<p>The dependence treatment backed by the strongest evidence is called “opioid agonist treatment”. An opioid “agonist” means a drug that produces opioid effects in the body.</p>
<p>Opioid agonist treatment is when a known and legal opioid medicine (the opioid “agonist”) is provided in a therapeutic setting, like a clinic or pharmacy, in a regular dose. This removes the need for using additional opioids by reducing craving and withdrawal.</p>
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<img alt="" src="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=785&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=785&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=785&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=986&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=986&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=986&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="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>Staying in treatment <a href="https://www.ncbi.nlm.nih.gov/pubmed/7259424">longer</a> is associated with better outcomes, with best results seen when treatment is continued <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/FAQ%20Pharmacetuical%20Opioid%20Dependence%20Treatment_0.pdf">for 12 months or more</a>. So this is a longer-term treatment providing an opportunity to make sustainable changes, as opposed to a short-term detox.</p>
<p>The two most common medicines used in Australia are methadone and buprenorphine. Both are available through general practitioners and community pharmacies, as well as specialist clinics. Newer forms such as <a href="https://www1.racgp.org.au/newsgp/clinical/advocates-hail-game-changing-pbs-listing-of-long-a">long-acting buprenorphine</a> have also recently entered the market. </p>
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<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<p>Methadone is what we call a “full opioid agonist”. It mimics the effects of other opioids, such as codeine or morphine, and it can remove the need to take other opioids by preventing opioid withdrawal and craving. Taken in daily oral doses methadone does not produce euphoria, or a “high”. At higher doses, methadone also blocks the effects of other opioids, helping to prevent return to other opioid use.</p>
<p>Buprenorphine (often provided in combination with naloxone, a medicine used to reverse the effects of an opioid overdose) is referred to as a “partial opioid agonist”. It’s less sedating and, unlike methadone and other opioids, is less likely to cause <a href="https://academic.oup.com/bja/article/100/6/747/303263">breathing difficulties</a> and overdose. </p>
<h2>Treatment is effective</h2>
<p>High-quality <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">evidence</a> shows these treatments work. They help reduce opioid use, improve health, prevent the spread of blood borne viruses by reducing the likelihood people continue to inject, are cost effective, and reduce crime. </p>
<p>The most profound effects of these treatments is their ability to save lives. Risk of death while in treatment is <a href="https://www.bmj.com/content/357/bmj.j1550">substantially reduced</a>, by around half compared to when a person is dependent on opioids and not receiving treatment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioids include pain relievers like codeine, oxycodone and morphine, and illicit drugs like heroin.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>These treatments have been shown to <a href="https://ndarc.med.unsw.edu.au/resource/frequently-asked-questions-opioid-agonist-treatment-pharmaceutical-opioid-dependence">work just as well</a> for people who develop dependence to prescribed opioids and people who use heroin. </p>
<p>In 2005 the World Health Organisation put methadone and buprenorphine on their list of <a href="https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/">essential medicines</a>, recognising their importance in treating opioid dependence.</p>
<p>So it might be surprising to learn many people in Australia who could benefit from these treatments choose not to use them, or are not able to access them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-methadone-the-most-effective-treatment-for-heroin-dependence-59814">Weekly Dose: methadone, the most effective treatment for heroin dependence</a>
</strong>
</em>
</p>
<hr>
<h2>4 barriers to treatment</h2>
<p><strong>Cost</strong></p>
<p>Opioid agonist treatments attract some subsidies, but their dispensing fees are not covered by Australia’s <a href="http://www.pbs.gov.au/info/about-the-pbs">Pharmaceutical Benefits Scheme</a>, which subsidises prescription drugs. Where treatment usually adds up to A$35-A$70 a week, cost can be a <a href="https://creidu.edu.au/policy_briefs_and_submissions/10-opioid-pharmacotherapy-fees-a-long-standing-barrier-to-treatment-entry-and-retention">key barrier</a> to access.</p>
<p><strong>Stigma</strong></p>
<p>Some people choose not to access these treatments because they see them <a href="https://www.ncbi.nlm.nih.gov/pubmed/29762767">as being for people who use heroin</a>, or don’t want to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12859">attend services seen as being for people who use illicit drugs</a>. </p>
<p>Other people believe these treatments are just replacing one opioid with another, and are not aware of their strong scientific support. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
</strong>
</em>
</p>
<hr>
<p><strong>Restrictiveness of the treatment regime</strong></p>
<p>The need to attend a pharmacy daily for dosing at the start of treatment can affect work, study or family commitments. </p>
<p><strong>Nowhere to go</strong></p>
<p>Finally, treatment access is limited in some regions because there are not enough GPs who prescribe these treatments. This is despite a change from many state governments in recent years to reduce barriers to prescribing. </p>
<p>In <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/pharmacotherapy/buprenorphine-and-naloxone-prescribing-guidelines">Victoria</a> and New South Wales, for example, all GPs can prescribe buprenorphine treatment without additional training. Nonetheless, prescriber numbers have been slow to increase, with some GPs remaining hesitant to offer these treatments.</p>
<h2>People turning to short-term treatments instead</h2>
<p>As a result of these barriers, many people who are dependent on opioids choose not to seek help, or are not able to access the treatment they need. </p>
<p>Some choose to access shorter-term treatments such as a “detox”, where over the course of seven to ten days they cease opioids while their withdrawal symptoms are treated with medications.</p>
<p>This is concerning because the rates of relapse from short-term treatment are high, and research shows the risk of non-fatal or fatal opioid overdose increases <a href="https://www.ncbi.nlm.nih.gov/pubmed/17280803">following short-term treatment</a>. This means these short-term treatments contribute to opioid-related deaths rather than preventing them. </p>
<p>To stem the loss of life from opioid use in Australia, it’s critical we break down the barriers to the opioid dependence treatments we know are most effective. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-happened-when-codeine-was-made-prescription-only-no-the-sky-didnt-fall-in-124169">Here's what happened when codeine was made prescription only. No, the sky didn't fall in</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/122537/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen has received funding from Indivior and Seqirus, and is the current recipient of an NHMRC Research Fellowship (#1163961) </span></em></p>Treatments for opioid dependence, such as methadone and buprenorphine, are effective. But some people who stand to benefit are missing out.Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed 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/1123632019-03-04T11:39:13Z2019-03-04T11:39:13ZPurdue Pharma taps a Gilded Age history of pharmaceutical fraud<figure><img src="https://images.theconversation.com/files/260820/original/file-20190225-26181-1vgkr3o.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Classified advertisement for Leslie Keeley's Gold Cure.</span> <span class="attribution"><span class="source">ProQuest Historical Newspapers: Chicago Tribune, July 21, 1884</span></span></figcaption></figure><p>Newly unsealed <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">documents</a> from a <a href="https://www.propublica.org/article/oxycontin-purdue-pharma-massachusetts-lawsuit-anti-addiction-market">lawsuit</a> by the state of Massachusetts allege that Purdue Pharma, maker of OxyContin and other addictive opioids, actively sniffed out new, sinister ways to cash in on the opioid crisis. </p>
<p>Despite years of <a href="https://www.cnn.com/2019/01/31/health/purdue-pharma-unredacted-lawsuit/index.html">negative press coverage</a>, unwanted attention from regulators, multi-million dollar <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html">fines</a> and several major <a href="https://www.theguardian.com/us-news/2018/nov/19/sackler-family-members-face-mass-litigation-criminal-investigations-over-opioids-crisis">lawsuits</a>, Purdue staff and owners sought to expand the company’s sights beyond its usual array of opioid painkillers. Purdue planned to become an “end-to-end pain provider,” by branching into the market for opioid addiction and overdose medicines, looking to peddle these medicines even while the company continued to aggressively market its addictive opioids. Internal research materials coldly explained the rationale behind this plan: “Pain treatment and addiction <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">are naturally linked</a>.” </p>
<p>As thousands of Americans continue to <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state">overdose on opioids</a> annually, Purdue’s secret <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">marketing research</a> predicted that sales of <a href="https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/understanding-naloxone/">naloxone</a>, the overdose reversal drug, and <a href="https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine">buprenorphine</a>, a medicine used to treat opioid addiction, would increase exponentially. Addiction to Purdue’s opioids would thus drive the sale of the company’s opioid addiction and overdose medicines. Purdue even planned to target as customers patients already taking the company’s opioids and doctors who prescribed opioids excessively, according to the Massachusetts lawsuit filing. To keep the plan quiet, Purdue staff dubbed the scheme “Project Tango.” </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=756&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=756&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=756&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=950&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=950&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=950&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">According to the Massachusetts lawsuit, Purdue used this graphic in its internal strategy materials to illustrate Project Tango.</span>
<span class="attribution"><a class="source" href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">State of Massachusetts</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The audacity of Project Tango enraged many observers. But considered in historical context, the news that Purdue sought to peddle opioid addiction medicines while continuing to sell opioids seems less surprising. In fact, there is clear historical precedent for Purdue’s business plan. Over a century ago, “patent medicine” sellers pioneered this strategy during the U.S.’s Gilded Age opiate addiction epidemic.</p>
<h2>Opiate addiction in the Gilded Age</h2>
<p><a href="https://theconversation.com/opiate-addiction-and-the-history-of-pain-and-race-in-the-us-97430">Opiates</a> were some of the most commonly prescribed medicines in American history until the 20th century. Pills containing opium, hypodermic morphine injections and laudanum, a drinkable liquid concoction of opium and alcohol, constituted half or more of all medicines prescribed in American hospitals during most of the 19th century, <a href="https://books.google.com/books?id=qlIABAAAQBAJ&printsec=frontcover#v=onepage&q&f=false">according to research</a> by the historian <a href="https://hshm.yale.edu/people/john-harley-warner">John Harley Warner</a>. Opiates were also present in countless “<a href="https://dp.la/exhibitions/patent-medicine/1860-1920/opiates-alcohol-herbs">patent medicines</a>,” over-the-counter panaceas made of secret ingredients, often sold under catchy brand names like <a href="https://www.nytimes.com/1860/12/01/archives/mrs-winslows-soothing-syrup-for-children-teething-letter-from-a.html">Mrs. Winslow’s Soothing Syrup</a>. Americans could choose from <a href="https://books.google.com/books?id=27_cBAAAQBAJ&printsec=frontcover&dq=medical+monopoly&hl=en&sa=X&ved=0ahUKEwiTtb_m9t_gAhWCm4MKHXWVBnsQ6AEIKDAA#v=onepage&q=by%20the%20middle%20of%20the%201880s%20there%20were%20at%20least&f=false">5,000</a> brands of patent medicines marketed for all manner of ailments by the 1880s. In 1904, just before federal oversight began, patent medicines had matured into an astonishingly profitable industry, with <a href="http://sk.sagepub.com/reference/the-sage-encyclopedia-of-alcohol-social-cultural-and-historical-perspectives/n361.xml?fromsearch=true">estimated</a> sales at US$74 million dollars annually – equivalent to about $2.1 billion dollars <a href="http://www.in2013dollars.com/us/inflation/1904?amount=74000000">today</a>.</p>
<p>Opiate-laced prescriptions and patent medicines often caused addiction. The historian <a href="https://davidcourtwright.domains.unf.edu">David T. Courtwright</a> estimates that opiate addiction rates in the U.S. skyrocketed to 4.59 per thousand Americans by the 1890s – a high rate, although lower than the rate of fatal opioid overdoses in recent <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state">years</a>. Most individuals developed addictions through medicines, rather than the infamous smoking variety of opium. Victims of “the habit” cut across <a href="https://books.google.com/books/about/Dark_Paradise.html?id=VxUuPa3cnLMC&printsec=frontcover&source=kp_read_button#v=onepage&q&f=false">demographic</a> lines, encompassing middle-class housewives suffering from menstrual pain, Civil War veterans reeling from amputations and many others in between.</p>
<p>Yet even for those who became addicted to prescription opiates, the condition was socially <a href="https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-66640200R-bk#page/18/mode/2up">stigmatized</a> and physically dangerous. Like today, addiction to opiates often led to fatal overdose, condemnation and sometimes even involuntary commitment to mental asylums. As one doctor <a href="https://babel.hathitrust.org/cgi/pt?id=hvd.li2wt1;view=1up;seq=557">reported</a> to the Iowa Board of Health in 1885, addicted people lived “truly in a veritable hell.”</p>
<p>To avoid these frightful outcomes, desperate, opiate-addicted Americans frequently sought out medical treatment for their condition.</p>
<p>Gilded Age Americans could choose from a range of <a href="https://books.google.com/books?id=_MGJmdV-J4oC&pg=PA64&source=gbs_toc_r&cad=2#v=onepage&q&f=false">therapies</a> for opiate addiction. Wealthy patients frequented plush private clinics, where they could receive inpatient treatment for opiate addiction. The most popular were the <a href="https://daily.jstor.org/inside-a-nineteenth-century-quest-to-end-addiction/">Keeley Institutes</a>, which offered patients injections of the “Bichloride of Gold” remedy, invented by the doctor Leslie Keeley.</p>
<p>Scores of Keeley Institutes sprang up around the <a href="https://archive.org/details/bannerofgold2119reed/page/n35">country</a> in the late 19th century, a testament to the popularity of Keeley’s “Gold Cure,” which he marketed for alcoholism and drug addiction. No up-and-coming Gilded Age city was complete without a Keeley Institute. At the <a href="http://sk.sagepub.com/reference/the-sage-encyclopedia-of-alcohol-social-cultural-and-historical-perspectives/n286.xml?fromsearch=true">height</a> of the Gold Cure craze, there were 118 institutes serving 500,000 Americans between 1880 and 1920. Even the federal government had a <a href="https://books.google.com/books/about/Sing_Not_War.html?id=AgmVvmoeQ_gC&printsec=frontcover&source=kp_read_button#v=onepage&q=keeley&f=false">contract</a> with Keeley to provide the Gold Cure to addicted veterans. Although injections of the Gold Cure had little intrinsic medical value, historians believe that socializing with other like-minded patients in the Keeley Institutes may have helped some patients recover from addiction.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=894&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=894&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=894&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1123&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1123&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1123&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for the main Keeley Center, in Dwight, Illinois, 1908.</span>
</figcaption>
</figure>
<p>Keeley faced stiff competition, however. Other popular therapies for opiate addiction included patent medicine “cures” and “antidotes,” which were cheaper than inpatient care. These could be ordered by mail without a prescription, and consumed in the privacy of one’s home, away from prying eyes. </p>
<p>Fueled by high demand, during its heyday at the turn of the 20th century, addiction cures bloomed into a multimillion-dollar sector of the patent medicine industry. Dozens of pharmaceutical companies peddled their “cures” to willing, opiate-addicted customers, which they marketed through pamphlets, postcards, and newspaper and magazine classifieds.</p>
<p>Ironically, these “cures” for opiate addiction almost universally contained opiates, unbeknownst to hopeful customers, who received little therapeutic benefit by today’s standards. But in an era before federal regulation of medicines and narcotics, there were no effective safeguards to protect addiction patients from medical fraud. </p>
<h2>Pharmaceutical fraud</h2>
<p>Much like Purdue Pharma, which <a href="https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade/">famously</a> marketed Oxycontin as non-addictive precipitating the opioid crisis, Gilded Age patent medicine companies also fraudulently marketed their addiction treatments as non-addictive, targeting and intentionally deceiving addicted customers. For their part, Gilded Age doctors were deeply skeptical of such products, and they often accused proprietors of fraud in medical journals and newspapers.</p>
<p>Samuel B. Collins of La Porte, Indiana, inventor of the “Painless Opium Antidote,” one of the era’s most popular brands, insisted that his <a href="http://lcweb2.loc.gov/service/gdc/scd0001/2006/20060714002th/20060714002th.pdf">product</a> was not addictive. Collins was proven a fraud, however, by a skeptical Maine doctor, who in 1876 sent off a sample of Collins’ product to several chemists for analysis. Their tests <a href="https://www.nejm.org/doi/full/10.1056/NEJM187610260951705">indicated</a> that the Painless Opium Antidote contained enough morphine to perpetuate opiate addiction, actually fueling demand for Collins’s product, rather than curing the underlying addiction.</p>
<p>Despite the overwhelming evidence, however, without any effective medical regulation or oversight, Collins maintained his fraud for decades. His business strategy presaged Purdue’s Project Tango by targeting vulnerable opiate-addicted individuals.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1061&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1061&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1061&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1334&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1334&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1334&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for Theriaki, a painless cure for the opium habit. Exterior view of Dr. Collins’ Opium Antidote Laboratory, LaPorte, Indiana.</span>
<span class="attribution"><span class="source">National Library of Medicine</span></span>
</figcaption>
</figure>
<p>After decades of exposés by doctors and journalists, however, the opiate addiction cure trade collapsed during the Progressive Era under mounting public pressure and new federal legislation. One famous “muckraking” exposé, <a href="https://archive.org/details/greatamericanfr02adamgoog/page/n122">The Great American Fraud</a> by the journalist <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901284/">Samuel Hopkins Adams</a>, pulled back the curtain on the industry of opiate addiction cures for millions of appalled readers. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Collier’s ad, Dec., 1905, after the publication of articles on patent medicine fraud.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Hopkins painted such a scathing portrait of opiate addiction cures, whose proprietors the writer dismissed as “scavengers,” that the American Medical Association <a href="https://www.jstor.org/stable/2710829?seq=1#page_scan_tab_contents">paid</a> to disseminate Adams’s reporting as part of a lobbying campaign for the regulation of patent medicines. This strategy paid off. Although far from perfect solutions, the <a href="https://history.house.gov/Historical-Highlights/1901-1950/Pure-Food-and-Drug-Act/">Pure Food and Drug Act</a> of 1906 and the <a href="http://www.drugpolicy.org/blog/today-100th-anniversary-harrison-narcotics-tax-act">Harrison Narcotics Tax Act</a> of 1914 regulated the ingredients and sale of patent medicines and narcotics, including opiate addiction medicines. These measures ultimately ensured that Collins, Keeley and other patent medicine sellers could no longer prey upon opiate-addicted customers.</p>
<p>Like its Gilded Age predecessors, today’s Big Pharma actively schemes to profit off of vulnerable, addicted customers, even while taking steps to ensure that opioid addiction persists. I believe that only sustained, vigilant oversight can prevent the reemergence of a medical Gilded Age, one in which companies like Purdue Pharma can manufacture an addiction crisis and charge customers for “curing” it.</p><img src="https://counter.theconversation.com/content/112363/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan S. Jones 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>Considered in historical context, Purdue’s plan to peddle opioid addiction medicines to vulnerable people is not so surprising. Gilded-Age pharmaceutical companies used similar strategies.Jonathan S. Jones, PhD Candidate in History, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1043832018-10-15T10:28:59Z2018-10-15T10:28:59ZDispatches from the morgue: Toxicology tests don’t tell the whole story of the opioid epidemic<figure><img src="https://images.theconversation.com/files/240281/original/file-20181011-154542-16imlcg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mortality data show only the final result of opioid overdose, not why it happens.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scene-hospital-morgue-where-corpses-taken-761983000?src=UWs3b11-wDD_bFApQ5lCKg-1-0">Skyward Kick Productions/Shutterstock.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>“Drug overdoses killed more Tennesseans than ever last year, fentanyl deaths up 70 percent,” a recent headline from my hometown newspaper, <a href="https://www.tennessean.com/story/news/2018/08/20/tennessee-overdose-deaths-2017-opioid-fentanyl/1044057002/">The Tennessean</a>, proclaimed. </p>
<p>Variations of this headline have become routine across the U.S. In June 2017, a reporter at <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">The New York Times</a> revealed that opioid overdose deaths in 2016 in the U.S. surpassed the peak number of car deaths, a record that had stood since 1972. <a href="https://www.vox.com/policy-and-politics/2017/7/7/15925488/opioid-epidemic-deaths-2016">Vox</a>, an internet media outlet, announced that “in one year, drug overdoses killed more Americans than the entire Vietnam War did,” while <a href="https://www.cbsnews.com/news/drug-overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/">CBS News</a> claimed that “drug overdoses now kill more Americans than guns.”</p>
<p>These and similar dispatches from America’s morgues sound like an alarm bell. But, what do all these dead opiate users actually tell us about the opioid crisis? Having studied the history of drug screens, I’d say not much as much as we’d hoped, it turns out. </p>
<h2>The world the screens make</h2>
<p>Drug screens serve a number of clinical purposes. For clinicians in methadone programs, drug screens are an <a href="https://www.ncbi.nlm.nih.gov/pubmed/10473015">incomparable, albeit contentious, resource</a> to monitor patient compliance. For pathologists and medical examiners, screens identify chemicals present in a corpse. However, clinical care is only one fraction of why these screens matter. </p>
<p>Epidemiologists, scientists who study populations of people to learn about disease and injury patterns, aggregate machine-assisted, post-mortem diagnoses into the data of public health. Policymakers weigh these stats in forming governmental interventions. Screens, then, form a foundation on which decisions about medical care and governmental responsibility rest.</p>
<p>But, where did drug screens come from, how do they work and how reliable are they in helping us address the opioid crisis?</p>
<h2>Measuring drug addiction</h2>
<p>The first narcotics screens emerged in the <a href="http://jpet.aspetjournals.org/content/109/1/8">mid-1950s</a>. My own unpublished research has turned up two tests that composed most drug screening: the Nalorphine Test and chromatography. </p>
<p>The Nalorphine Test, also called the Nalline Test, comprised two steps. First, subjects received an injection of an opiate antagonist, N-<a href="https://ascpt.onlinelibrary.wiley.com/doi/pdf/10.1002/cpt196126713">allylnormorphine</a>. </p>
<p><a href="https://reference.medscape.com/drugs/opioid-antagonists">Opiate antagonists</a> are chemicals that sit on opioid receptors without activating them, essentially working the opposite of opiates. In the human body, antagonists induce withdrawal symptoms, including pupil dilation. After administering the antagonist, a clinician measured the pupil size against standardized circles – a ruler called the pupillometer.</p>
<p>Jailers and physicians were especially keen on this method. One <a href="https://www-heinonline-org.proxy.library.vanderbilt.edu/HOL/Page?handle=hein.journals/fedpro27&div=28&start_page=32&collection=journals&set_as_cursor=0&men_tab=srchresults">physician</a> remarked that “the test was designed to be and has been used as a club over the head of the addict whom no one should believe.” </p>
<p><a href="https://www.tandfonline.com/doi/abs/10.3109/10826087309048772">Critics</a> reaffirmed that the test was a club, describing the procedure’s painful induced withdrawals and its supposedly inexact methods. Accuracy was not paramount to the Nalorphine test. Its utility was forcing patients and prisoners alike to fear discovery. </p>
<h2>A gold standard emerges</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chromotography has been considered the best way to test for drugs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/illustration-chemistry-chromatography-technique-separating-components-1173724111?src=Fh-PjdNvU9UarRHL9735qQ-1-7">Nasky/Shutterstock.com</a></span>
</figcaption>
</figure>
<p><a href="https://www.britannica.com/science/chromatography">Chromatography</a> involves separating a specimen – urine, blood, hair, even organs! – into its constituent chemicals. </p>
<p>Two types of chromatography exist and serve distinct goals. Thin-layer chromatography identifies the component chemicals in a specimen, while gas-liquid chromatography combined with a mass spectrometer (GLC-MS) identifies and weighs the mass of each substance. </p>
<p>Chromatography, unlike the Nalorphine test, found an early audience among toxicologists and chemists. The benefit of chromatography is its ability to quantify, and, supposedly, to render objective diagnoses.</p>
<p>Eventually, chromatography won out. GLC-MS remains the gold standard in drug testing. Insofar as GLC-MS measures the quantities of a given chemical, these screens work great. However, I remain skeptical of marshaling its results to understand the opioid crisis.</p>
<h2>The pitfalls of a toxicological imagination</h2>
<p>Drug screens aren’t just a means of diagnosing overdoses. They constitute a distinct mode of making and interpreting biological data using specialized laboratory measuring devices, a perspective I call the “toxicological imagination.” That perspective imports pitfalls into individual, and, by extension, aggregate cases alike.</p>
<p>First, GLC can never prove conclusively that this or that drug is responsible for an individual death. GLC belches out results in milligrams/milliliter, but the significance of these numbers is relative. And there is no universal lethal dosage. GLC-MS can’t account for individual tolerance levels, which affect the dose at which a drug becomes lethal. </p>
<p>Screens have to be juxtaposed against other data: patient history, anatomical and histological observation, and social setting of the death. Synthesis of all this data reinjects the human, and all of its subjectivity, into diagnosis.</p>
<p>Second, screens overemphasize misleading concerns, especially drug potency levels. Remember when we thought crack was going to kill us all because it was supposedly so much stronger than cocaine? Fentanyl currently sits on crack’s vacated throne in this regard.</p>
<p>When we evaluate the opioid crisis by confirmed overdose deaths, we advance the kinds of interpretations that colored reactions to, for example, crack.</p>
<h2>An alternative to the toxicological imagination?</h2>
<p>Instead, I think we need to discern the medical landscapes that turn an overdose into a mortality. What is the availability of <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">Narcan</a>, an opiate antagonist that reverses an overdose? Where is the nearest ER? How easily can drug users access in-patient rehab? </p>
<p>I choose these questions specifically to raise the point that when we see individual and aggregate deaths, or observe the potency of x, y or z drug, we miss out on distal causes that produce an overdosing death. Using overdose deaths or drug potency as a basis to address the opioid crisis is akin to responding to Hurricane Katrina knowing only its wind speed or inches of rain.</p>
<p>Let me be plain: I’m trying to say that drug screens, regardless of their sensitivity, can never reconstruct the social relations that underwrite individual mortalities.</p><img src="https://counter.theconversation.com/content/104383/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justin Wade Hubbard 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 toll of the opioid epidemic is often derived from toxicology reports. These rely on drug tests. A medical historian explains these tests and how they fall short of capturing why people are dying.Justin Wade Hubbard, Doctoral Candidate, Medical History, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1015332018-08-21T12:42:25Z2018-08-21T12:42:25ZThe problems for babies born to opioid-addicted mothers<figure><img src="https://images.theconversation.com/files/232683/original/file-20180820-30581-1h9qrcp.jpg?ixlib=rb-1.1.0&rect=0%2C18%2C6016%2C3989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/163775183?src=PXTyYr8Txha6T4EITiiGZQ-1-20&size=huge_jpg">wong yu liang/Shutterstock</a></span></figcaption></figure><p>The number of babies born to opioid-addicted mothers in the US more than quadrupled during 1999-2014, according to a recent <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm?s_cid=mm6731a1_w">report</a> from the Centers for Disease Control and Prevention. The health impact on these children is huge and lifelong.</p>
<p>The US is in the midst of an opioid epidemic with the country accounting for <a href="http://journals.sagepub.com/doi/full/10.1177/2049463716684055">80% of the world’s opioid use</a> even though it accounts for just 5% of the world’s population. The epidemic is being fuelled by a rise in opioid prescribing, for painkillers, such as oxycodone, as well as a rise in the sale of illegal opioids, such as heroin and <a href="https://adf.org.au/drug-facts/fentanyl/">fentanyl</a>. </p>
<p>In 2016, <a href="https://www.hhs.gov/opioids/about-the-epidemic/index.html">11.5m</a> people misused prescription opioids and each day, 116 people died from opioid-related drug overdoses. But it’s not just the US, there were also <a href="https://theconversation.com/record-level-of-drug-deaths-in-england-and-wales-latest-official-figures-99710">record numbers</a> of drug deaths in parts of the UK, including <a href="https://www.theguardian.com/politics/2018/apr/04/seaside-towns-are-hotspots-for-heroin-deaths-says-ons">Swansea and Blackpool</a>.</p>
<p>Opioid addiction has a devastating impact on the user, but when the user is a pregnant woman, the impact is compounded as the child is affected by the drug, too. Opioids are passed to the baby via the placenta.</p>
<h2>Withdrawal</h2>
<p>The first and most obvious impact of being born to an opioid-addicted mother is withdrawal. This is known as <a href="https://www.nejm.org/doi/full/10.1056/NEJMra1600879">neonatal abstinence syndrome (NAS)</a> and it includes excessive tremors, sweating, fever, vomiting and insomnia. The most harrowing symptoms are seizures and an inconsolable, high-pitched cry. </p>
<p>The severity of withdrawal may depend on the nature, extent and complications of maternal drug use, such as whether any other drugs are being used alongside the opioids, which may mask or worsen symptoms. <a href="http://pediatrics.aappublications.org/content/early/2015/04/08/peds.2014-3299">Withdrawal symptoms</a> from prescribed opioids can be just as severe as withdrawal from illicit opioids. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729086/">NAS symptoms</a> usually occur in the first two or three days following birth, but they can start up to four weeks later. The symptoms usually last a few weeks but have been known to still be present when the baby is several months old.</p>
<p>In some cases, opioids are given to the baby to reduce the symptoms of NAS and the babies are then weaned off these. But many babies go “<a href="https://www.collinsdictionary.com/dictionary/english/cold-turkey">cold turkey</a>” and suffer severe withdrawal symptoms. </p>
<p>Treatment to reduce the severity of withdrawal in affected babies traditionally involved swaddling and minimal interaction, including from the mother. But recently <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/apa.12378">breastfeeding</a> alongside <a href="https://news.aamc.org/patient-care/article/caring-babies-opioid-withdrawal/">touch and comfort from mothers</a> (or other caregivers) has been shown to be effective, reducing the use of medication and reducing hospital stays.</p>
<h2>Lifelong problems</h2>
<p>There are other complications at birth, including low birth weight, <a href="https://www.sciencedirect.com/science/article/pii/S030121150500432X">preterm delivery</a> and <a href="https://www.hindawi.com/journals/jp/2014/906723/abs/">stillbirth</a>. What is not clear is whether these effects are due to drug exposure in pregnancy or living in poverty and other stresses after birth that often accompany parental drug use.</p>
<p>Opioid use during pregnancy has also been associated with <a href="http://journals.sagepub.com/doi/abs/10.1177/0009922814549545?journalCode=cpja">development delays</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/17728081">intellectual impairment</a>. But most studies were conducted before the use of synthetic opioids and scientists don’t yet know the long-term implications of these substances on babies.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232466/original/file-20180817-165961-t8ve60.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">The use of drugs during pregnancy can lead to babies being premature or even stillborn.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/486542008?src=IgZCSlxkZXw5FsDNRMXJBQ-1-0&size=huge_jpg">Kristina Bessolova/Shutterstock</a></span>
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<p>While some opioid users – particularly those addicted to prescribed medications – live relatively stable lifestyles, others have a chaotic lifestyle involving <a href="https://www.tandfonline.com/doi/abs/10.1080/09595230500286039">risk-taking</a>, crime, poor self-care or social isolation. Children raised in this <a href="https://research-repository.griffith.edu.au/bitstream/handle/10072/23288/54821_1.pdf?sequen">environment</a> are at <a href="https://www.communitycare.co.uk/2017/08/18/parental-substance-misuse-affects-children-key-points-research/">risk of harm</a>, including both physical and emotional neglect, and are often placed into <a href="https://www.yahoo.com/news/hidden-victims-opioid-addiction-children-foster-care-090003617.html">foster care</a>.</p>
<p>These children are also likely to face <a href="http://www.ryantunnardbrown.com/wp-content/uploads/2012/11/RiP-PSM.pdf">broader health and social inequalities</a> associated with this lifestyle, such as lower life expectancy, more health problems, and poorer education and employment prospects. Children may also be <a href="http://pediatrics.aappublications.org/content/early/2017/02/16/peds.2016-2887">accidentally exposed</a> to the opioids themselves, which can lead to their own addictions and potential overdose.</p>
<h2>Support for mothers</h2>
<p>Thankfully, there is evidence to suggest that with appropriate, timely support for mothers, the <a href="https://research-repository.griffith.edu.au/bitstream/handle/10072/23288/54821_1.pdf?sequen">outcomes for children</a> can be <a href="https://www.sciencedirect.com/science/article/pii/S0190740906001782">improved</a>, including children being more likely to be reunited with parents after foster care.</p>
<p>Getting addicted mothers to engage with support services is also key for both mother and child in the long run. Mothers who engage can access drug treatment programmes and take <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5457836/">substitute medications</a>, such as methadone or buprenorphine, with the aim of becoming drug free.</p>
<p>This can be difficult with many addicted mothers feeling guilty and ashamed about the harm they are doing to their baby, together with the <a href="https://www.sciencedirect.com/science/article/pii/S0277953608002980">public scrutiny</a> and <a href="https://arro.anglia.ac.uk/700038/">stigmatisation</a> they face from healthcare professionals. But pregnancy can also be a significant motivator for change in addicted mothers, making investment in support services worthwhile.</p>
<p>However, like any drug abuse, maternal opioid use is a complex problem with no simple solution. Given the negative impact on affected children, though, we must at least try to provide a better support system for both the mothers and children.</p><img src="https://counter.theconversation.com/content/101533/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Hooks does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The opioid crisis in the US has quadrupled the number of babies born addicted to drugs.Claire Hooks, Senior Lecturer of Midwifery, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/959952018-05-15T10:27:30Z2018-05-15T10:27:30ZHow understanding pain could curb opioid addiction<figure><img src="https://images.theconversation.com/files/218868/original/file-20180514-100693-18g212o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Helping people with pain, whether it be physical or emotional, could limit the need for opioids. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-sad-face-crying-expressionsad-emotiondespairsadnesswoman-529171864?src=3wBkopW8qPfwMK8g0pjXTQ-1-9">eldar nurkovic/Shutterstock.com</a></span></figcaption></figure><p>The Senate Health, Education, Labor and Pensions Committee unanimously approved a bill in April 2018 designed to address the opioid crisis. The bill called the <a href="https://www.help.senate.gov/imo/media/doc/S.2680%20Summary.pdf">Opioid Crisis Response Act of 2018</a> covers much of the same territory as the 138-page report released in November 2017 by a commission appointed by <a href="https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf">President Donald Trump</a>.</p>
<p>Both the Senate bill and the commission document, unlike the president’s own March 2018 <a href="https://www.washingtonpost.com/news/the-fix/wp/2018/03/21/trumps-proposal-to-execute-drug-dealers-has-some-fearing-people-of-color-will-be-harmed-most/">call for executing drug dealers</a>, recognize addiction as a health problem and focus on treatment rather than punishment.</p>
<p>All of this is important, but as a medical sociologist, I am particularly interested in developing better understandings of the root causes of the current crisis. Why are so many Americans willing to ingest substances that, they most likely know, can lead to grievous harm? In other words, I am interested in the demand side of opioid overuse.</p>
<h2>A little prevention, but how much cure?</h2>
<p>For prevention, the Senate bill calls for expanding prescription monitoring programs, amping up the ability to seize illegal drugs at U.S. borders, training health care providers in proper prescribing practices, and improving drug disposal systems. All of these measures are what we sociologists consider “secondary prevention”; that is, they are directed toward supply reduction.</p>
<p>Primary prevention – which deals with the reasons that people turn to opioids in the first place - is mentioned in the Senate bill in only a few places but is not developed either in terms of a research plan nor in terms of public health strategies. The president’s commission report briefly deals with prevention in terms of school and media programs designed to inform children and parents about the dangers of opioid use. </p>
<p>In my experience, this does not address many of the issues that lead people to opioids. The <a href="http://susan.sered.name/blog/category/cant-catch-a-break/">Massachusetts women</a> with whom I have been conducting research for the past decade began their substance abuse careers in pain, either mental or physical. In some cases, the pain was a consequence of childhood or intimate partner abuse. In other cases, the pain set in because underlying health problems were not attended to properly or in a timely manner. </p>
<p>Often, the pain wasn’t taken seriously by employers, who insisted that minimum wage workers show up even when they are unwell, family members or health care providers. While substantive help often wasn’t available, psychotropic and pain medication was easy to get hold of, whether from doctors or drug dealers or both.</p>
<p>Following these women in and out of drug treatment for years, I have come to think that America must deal with our pain epidemic if we have any hope of dealing with the painkiller epidemic.</p>
<p>Though it is only a brief reference, it is heartening that the Senate bill calls upon the NIH “to improve scientific understanding of pain, including how to prevent, treat, and manage pain.”</p>
<p>Medical science primarily focuses on the physiological and neurological pathways associated with pain in the individual body. Social science pays more attention to pain in the “social body” – in the environmental, economic, political and cultural conditions that give rise to collective experiences of suffering, hopelessness or exclusion. The social science approach is particularly appropriate in the case of a crisis that, at least to some observers, has reached “epidemic” proportions.</p>
<h2>Gender, race and class</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/218887/original/file-20180514-100713-wbd012.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&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">Kyle Graves, who struggles with opioid addiction, at home in Franklin, Tenn., June 7, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Overcoming-Opioids-Struggles-for-Recovery/75c45c3d7993452aacd4aa58a2f5fa6e/1/0">AP Photo/David Goldman</a></span>
</figcaption>
</figure>
<p>The Senate bill acknowledges that not all states have been equally affected by the opioid crisis, but it does not explicitly call for research into why particular communities and demographic groups are harder hit than others.</p>
<p><a href="https://www.samhsa.gov/data/population-data-nsduh/reports?tab=33">Data</a> indicate that opioid abuse is primarily a male problem, concentrated in working class and low-income white communities, and rapidly expanding to Hispanic communities. That does not mean that women or professional class Americans are not affected by opioid overuse. It does mean that particular groups seem to have developed particularly fertile ground for opioid misuse to take root.</p>
<p>According to a Massachusetts <a href="http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/publications/hpc-datapoint-4-opioid.html">report on opiate-related hospital discharges by ZIP code</a>, low-income and working-class neighborhoods have substantially higher rates of opioid problems than upper-middle-class neighborhoods. <a href="https://www.mass.gov/files/documents/2018/02/14/opioid-demographic-february-2018.pdf">Department of Public Health data</a> for the state also show a pronounced gender difference in death rates from opioid-related causes: Men are four times more likely than women to die from opioids. And while the current opioid crisis tends to be described a problem of white communities, in Massachusetts the opioid-related overdose <a href="https://www.mass.gov/news/opioid-related-overdose-deaths-in-2017-fell-by-more-than-8-percent">death rate for Hispanics</a> tripled from 2014 to 2016.</p>
<p>Information of this sort lays the groundwork for primary prevention. What is it about being male in a white low-income community that causes pain and makes opioid use attractive as a means of dealing with pain? Are there occupational or educational policies that encourage or discourage substance abuse? And can those policies be adjusted in ways that reduce pain as well as substance abuse?</p>
<p>Recent preliminary research points to a number of directions that may be useful in terms of getting at root causes. I am particularly interested in several <a href="https://www.ncbi.nlm.nih.gov/pubmed/28182980">quantitative</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26868674">qualitative</a> studies that link low social capital, social isolation, weak community ties and economic <a href="https://www.brookings.edu/bpea-articles/mortality-and-morbidity-in-the-21st-century/">despair</a> to higher opioid abuse rates. Overall, however, considering the extent of the opioid crisis, there is surprisingly little written addressing root causes. It will be interesting to track the outcomes of projects such as the San Francisco initiative to train low-income and formerly incarcerated women as <a href="https://www.emeraldinsight.com/doi/abs/10.1108/IJPH-07-2016-0026">birth doulas</a> or the Boston area <a href="http://haleyhouse.org">Haley House</a> that includes formerly incarcerated men in community kitchen and garden enterprises.</p>
<p>Regardless of what proposals become official policy, I believe that better understanding why people turn to opioids in the first place can be an important part of our national response.</p><img src="https://counter.theconversation.com/content/95995/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Sered 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>A bill to deal with the opioid crisis recently came out of a Senate committee. While some of its recommendations are good, some key points are missing.Susan Sered, Professor of Sociology, Suffolk UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/957322018-04-30T10:38:24Z2018-04-30T10:38:24ZThe deadliest drug in America at center of VA nominee withdrawal: Alcohol<figure><img src="https://images.theconversation.com/files/216687/original/file-20180427-135825-1nml6eu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alcohol abuse leads to more deaths each year than opioid addiction.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/glass-whiskey-ice-his-hand-231807016?src=Ka1x8gueeiNppG_mCYpSfg-1-7">Malochka Mikalai/Shutterstock.com</a></span></figcaption></figure><p>For the first time in a while, pundits and politicians were talking about the drug that kills more people than any other each year in the U.S.</p>
<p>I’m talking about alcohol, which upstaged opioid abuse in news coverage recently, but only after <a href="https://www.nytimes.com/2018/04/25/us/politics/ronny-jackson-veterans-affairs-nomination.html">Rear Adm. Ronny L. Jackson</a> withdrew his name for consideration to head Veterans Affairs, in part because of allegations that he has abused alcohol. Jackson has denied any problem with alcohol.</p>
<p>This provides an opportune time to discuss the seriousness of alcohol abuse.</p>
<p>Alcohol <a href="https://www.ncbi.nlm.nih.gov/pubmed/24967831">contributes to 88,000 deaths</a> in the U.S. each year, more than double the number of people, 42,000, killed by <a href="https://www.cdc.gov/drugoverdose/index.html">heroin and opioid prescription drug overdose</a> in 2016. <a href="https://www.ncbi.nlm.nih.gov/pubmed?cmd=search&term=24967831">Excessive drinking accounted for one in 10 deaths among working-age adults</a>. </p>
<p>In addition, <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf">more than 66.7 million Americans reported binge drinking</a> in the <a href="https://addiction.surgeongeneral.gov/executive-summary">past month in 2015</a>, according to a <a href="https://addiction.surgeongeneral.gov/executive-summary">report</a> by the surgeon general.</p>
<p>As someone who has studied alcohol use disorder for over 15 years and who has treated thousands of patients who have it, I think it’s a major, yet often poorly understood, public health problem. </p>
<h2>A social lubricant</h2>
<p>Alcohol can be a quick and easy way to get into the spirit of a celebration. And it feels good. After two glasses of wine, the brain is activated through complex neurobiochemical processes that naturally release dopamine, a neurotransmitter of great importance. </p>
<p>When the dopamine molecule locks on to its receptor located on the surface of a neuron, or basic brain cell, a “buzz” occurs. It is often desirably anticipated before the second glass is empty. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=600&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=600&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=600&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This image shows an illustration of a man drinking a pint of beer, indicating how the body metabolizes alcohol and the organs that this alcohol affects.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/wellcomeimages/5814717084/in/photolist-9RPWNQ-prynUg-q6U6Mc-9RM2SX-BCnTop-BKEKNT-rxzDNi-rg2ekq-q635KG-dxxovQ-9RPXyq">Wellcome Images via Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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</figure>
<p>There are those, however, who drink right past the buzz into intoxication and, often, into trouble. For them, the brain starts releasing the same enjoyable dopamine, no different than what happens in the casual drinker’s, but it doesn’t stop there. A compulsion to binge drink can result. </p>
<p>Binge drinking, defined as drinking five or more drinks for men and four for women on the same occasion on at least one day in the past 30 days, is a <a href="https://addiction.surgeongeneral.gov/executive-summary">medical condition</a> that victimizes the comparative malfunction of the pleasure circuits in the brain.</p>
<h2>The three stages of addiction</h2>
<p>The alcohol addiction process involves a <a href="https://www.ncbi.nlm.nih.gov/pubmed/9311926">three-stage cycle</a>: binge-intoxication, withdrawal-negative affect, and preoccupation-anticipation. </p>
<p>It begins in the neurons, the basic type of brain cell. The brain has an estimated 86 billion of these cells, which communicate through chemical messengers called neurotransmitters. </p>
<p>Neurons can organize in clusters and form networks in order to perform specific functions such as thinking, learning, emotions and memory. The <a href="https://addiction.surgeongeneral.gov/executive-summary">addiction cycle disrupts the normal function</a> of some of these networks in three areas of the brain – the basal ganglia, the extended amygdala and the prefrontal cortex. </p>
<p>The disruptions do several things that contribute to continued drinking. They enable drinking-associated triggers, or cues, which lead to seeking alcohol. They also reduce the sensitivity of the brain systems, causing a diminished experience of pleasure or reward, and heighten activation of brain stress systems. Last, they reduce function of brain executive control systems, the part of the brain that typically helps make decisions and regulate one’s actions, emotions and impulses. </p>
<p>These networks are critical for human survival. Unfortunately for the binge drinker, <a href="https://addiction.surgeongeneral.gov/executive-summary">they become “hijacked,”</a> and the bingeing continues even after the harmful effects have begun. </p>
<p>Because binge drinkers’ brains feel intense pleasure from alcohol, there is a powerful motivation to binge drink again and again. What may begin as social binge drinking at parties for recreation can cause <a href="http://jamanetwork.com/journals/jama/article-abstract/193144">progressive neuro-adaptive changes in brain structure and function</a>. The brain is no longer well enough to function normally. Continued partying can transition into a <a href="http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(03)00130-2/references">chronic and uncontrollable daily pattern</a> of alcohol use. <a href="http://jamanetwork.com/journals/jamapsychiatry/fullarticle/481765">These maladaptive neurological changes can persist</a> long after the alcohol use stops. </p>
<h2>Your brain on alcohol</h2>
<p>During the binge-intoxication stage, the basal ganglia rewards the drinker with pleasurable effects, <a href="http://www.nature.com/neuro/journal/v8/n11/full/nn1578.html">releasing dopamine, the neurotransmitter responsible for the rewarding effects</a> of alcohol and creating the desire for more.</p>
<p>With continued bingeing, the <a href="https://addiction.surgeongeneral.gov/executive-summary">“habit circuity” is repeatedly activated</a> in another part of the basal ganglia called the dorsal striatum. It contributes to the compulsive seeking of more alcohol. This explains the craving that is triggered when a binge drinker is driving by a favorite bar and can’t resist pulling in, even after a promise to go directly home after work. </p>
<p>During the withdrawal-negative affect stage, there is a break from drinking. Because the reward circuit has a diminished ability to deliver a dopamine reward, there is far less pleasure with natural, safe experiences such as food and sex, compared to alcohol.</p>
<p><a href="http://www.nature.com/npp/journal/v35/n1/abs/npp2009110a.html">During abstinence from alcohol</a>, stress neurotransmitters such as corticotropin-releasing factor and dynorphin are released. These powerful neurochemicals cause negative emotional states associated with alcohol withdrawal. <a href="https://www.ncbi.nlm.nih.gov/labs/articles/11120394/">This drives the drinker back to alcohol</a> to gain relief and attempt to reestablish the rewards of intoxication. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=345&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=345&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=345&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=433&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=433&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=433&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Regions of the brain are affected differently by alcohol.</span>
<span class="attribution"><span class="source">Surgeon General's Report on Addiction</span></span>
</figcaption>
</figure>
<p>After a period of abstinence from alcohol, which may last only hours, the drinker enters the preoccupation-anticipation stage. This involves the prefrontal cortex, where executive decisions are made about whether or not to override the strong urges to drink. This part of the brain functions with a “go system” and “stop system.” </p>
<p>When the go circuits stimulate the <a href="https://www.ncbi.nlm.nih.gov/pubmed/22011681">habit-response system of the dorsal striatum</a>, the drinker becomes impulsive and seeks a drink, perhaps even subconsciously. The stop system can inhibit the activity of the go system and is important especially in preventing relapse.</p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/hbm.22913/abstract">Brain imaging studies</a> show that <a href="http://www.jneurosci.org/content/27/46/12700.full">binge drinking can disrupt the function</a> in both the go and stop circuits. This interferes with proper decision-making and behavioral inhibition. The drinker is both impulsive and compulsive. </p>
<h2>An illness that can be treated</h2>
<p>Scientific evidence shows that this disorder can be treated.</p>
<p>The FDA has approved <a href="http://jamanetwork.com/journals/jamapsychiatry/fullarticle/482282">three medications for treatment that should be offered whenever appropriate</a>. There is well-supported scientific evidence that behavioral therapies can be effective treatment. This includes recovery support services, such as Alcoholics Anonymous. </p>
<p>Most importantly, it is important to know that alcohol use disorder is a brain disorder causing a chronic illness. It is no different from diabetes, asthma or hypertension. When comprehensive, continuing care is provided, the recovery results improve, and the binge drinker has the hope of remaining sober as long as lifelong treatment and maintenance of sobriety become a dedicated lifestyle choice.</p><img src="https://counter.theconversation.com/content/95732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Smolen 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>Opioid addiction is a serious public health problem, killing more than 42,000 people a year and ruining families. But alcohol is still the deadliest drug in the US. An addiction expert tells why.Jamie Smolen, Associate Professor of Medicine, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/908052018-02-27T11:28:55Z2018-02-27T11:28:55ZHow your brain is wired to just say ‘yes’ to opioids<figure><img src="https://images.theconversation.com/files/207945/original/file-20180226-140200-19bst2o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Philadelphia man, who struggles with opioid addiction, in 2017.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Addicted-Without-ID/adcb4b23ab414c9dba8220d049ded453/69/0">AP Photo/Matt Rourke</a></span></figcaption></figure><p>The mid-1980s was the era of cocaine and marijuana, when <a href="https://www.nbcnews.com/news/us-news/just-say-no-ag-sessions-cites-old-school-anti-drug-n733961">“Just Say No”</a> was the centerpiece of the war on drugs and the government’s efforts to stem drug use and addiction. Since then, <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">prescription opioids</a> have become the nation’s drug scourge. The idea that mere willpower can fight this public health emergency is not only outdated, it’s scientifically misguided.</p>
<p>Medical history tells us that almost as long as there have been opioids – their use dates back to the <a href="https://www.ncbi.nlm.nih.gov/pubmed/17152761">third century</a> – there have been opioid addicts.</p>
<p>Thirty years ago, I was a research scientist focused on addiction when I was asked to co-author a volume on prescription narcotics for the <a href="https://www.librarything.com/series/The+Encyclopedia+of+Psychoactive+Drugs">“Encyclopedia of Psychoactive Drugs.</a>” I wrote the same assessment of opioid abuse then that I would write today: For many people, opioids are substances their brains are wired to crave in ways that make personal resolve nearly impossible. </p>
<h2>Your brain on opioids</h2>
<p>Our understanding of the human brain’s mechanisms make a compelling argument for a national research effort to develop non-opioid painkillers and new medical devices to treat chronic pain, which remains <a href="https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57">the nation’s number one cause of disability.</a> The good, if somewhat little noticed, news is that there is meaningful action on this front led by the National Institutes of Health, which is working in conjunction with pharmaceutical companies <a href="https://www.ncbi.nlm.nih.gov/books/NBK458655/">to develop nonaddictive, non-opioid pain killers</a> that might finally end our somewhat tortured dependence on this formidable drug.</p>
<p>Brain scientists have known for decades that opioids are complex and difficult substances to manage when it comes to addiction. The National Institute on Drug Abuse <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis">reports</a> that more than 20 percent of the patients prescribed opioids for chronic pain misuse them, and between 8 and 12 percent of those who use prescription opioids develop a use disorder.</p>
<p>Given how addictive these drugs are, doctors should have foreseen the looming danger of prescription opioids long before their use was liberalized for non-cancer related pain in the 1990s. Opioid abuse has instead ballooned over the last decade. In 2014, <a href="https://www.cdc.gov/drugoverdose/data/overdose.html">federal officials estimated nearly 2 million people</a> in the United States suffer from substance use disorders related to prescription opioid pain medicines. Each day, more than <a href="https://www.cdc.gov/drugoverdose/data/overdose.html">1,000 people are treated</a> in emergency rooms for misusing prescription opioids, the CDC reports. </p>
<p>The reason? Many people’s brains are wired to want this drug.</p>
<h2>How opioids affect the brain</h2>
<p>The simplified explanation of this complex brain science is this: When opioids enter the brain, they bind to receptors known as μ (mu) opioid receptors on brain cells, or neurons. These receptors stimulate the “reward center” of the brain. This occurs in a part of the brain known as the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24887956">ventral tegmental area</a>, which results in the release of the neurotransmitter chemical dopamine. Over time, those receptors become less sensitive, and more of the drug is needed to stimulate the reward center.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=509&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=509&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=509&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=639&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=639&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207692/original/file-20180223-108119-jpk8yd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=639&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Overview of reward structures in the human brain.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Overview_of_reward_structures_in_the_human_brain.jpg#/media/File:Overview_of_reward_structures_in_the_human_brain.jpg">By Oscar Arias-Carrión, Maria Stamelou, Eric Murillo-Rodríguez, Manuel Menéndez-González and Ernst Pöppel./Wikimedia.org</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>A brain that has become dependent on opioids can produce a strong desire to avoid the very real physical pain of <a href="https://medlineplus.gov/ency/article/000949.htm">withdrawal</a>. When opioids are absent in the body after the person has become dependent, another neurotransmitter called noradrenaline is produced in excess. Excessive production of NA results in <a href="http://www.els.net/WileyCDA/ElsArticle/refId-a0001401.html">withdrawal symptoms</a> that include shaking, tremors, anxiety, muscle cramps, and other uncomfortable and painful physiological responses. Users self-correct this brain chemistry by continuing to take the drug to stimulate dopamine production in their brain.</p>
<p>Our learning and memory processes also become engaged in addiction to a substance. A few brain areas are involved in the continued use of opioids after the pleasure factor has subsided and the person is still using the drug in order to avoid withdrawal. These areas include the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24765071">paraventricular nucleus of the thalamus</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011829/">bed nucleus of the stria terminalis</a>, the amygdala and other areas. A user’s brain can literally create a strong aversion to opioid withdrawal and compel them to keep using even if they know they are nearing an overdose.</p>
<h2>The research community responds</h2>
<p>Brain science is only one part of an addiction problem, but, I believe an important one deserving of more consideration than we’ve shown in past drug abuse crises. NIH Director <a href="https://directorsblog.nih.gov/2017/05/31/all-scientific-hands-on-deck-to-end-the-opioid-crisis/">Francis S. Collins</a> has recognized this in his leadership of the medical and scientific response to the opioid use epidemic.</p>
<p>The <a href="https://www.nih.gov/about-nih/who-we-are/nih-director/testimony-addressing-opioid-crisis-america-prevention-treatment-recovery">NIH is taking important steps</a> in building a public-private partnership that will seek scientific solutions to the opioid crisis, including the development of non-opioid painkillers. Collins has committed his agency’s resources in this quest, including implementing the Fast Track and Breakthrough Therapy designations that exist to facilitate development and expedite review of products that address an unmet medical need. The agency is calling for more emphasis on <a href="https://www.nih.gov/about-nih/who-we-are/nih-director/testimony-federal-response-opioid-crisis">non-drug alternatives</a> for pain, such as medical devices that can deliver more localized analgesia.</p>
<p>Expediency and proper funding of this effort is critical to get effective alternatives to those who need it most – the people fully intending to “Just Say No” but whose brains will fight them every step of the way.</p><img src="https://counter.theconversation.com/content/90805/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors 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>As the nation grapples with its opioid addiction epidemic, an understanding of how the drugs affect people is important. The powerful class of drugs actually can change the brain.Paul R. Sanberg, Senior Vice President for Research, Innovation & Knowledge Enterprise, University of South FloridaSamantha Portis, Doctoral candidate, medical sciences (neuroscience), University of South FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/872572018-01-17T23:33:24Z2018-01-17T23:33:24ZThree claims used to justify pulling codeine from sale without a prescription, and why they’re wrong<p>From February 1, 2018 all products that contain codeine will only be available for sale in pharmacies with a prescription. This means you won’t be able to buy brands like <a href="https://www.nps.org.au/medical-info/medicine-finder/nurofen-plus-tablets">Nurofen Plus</a>, Panadeine or <a href="https://www.nps.org.au/medical-info/medicine-finder/panadeine-extra-caplets">Panadeine Extra</a> over the counter at your local pharmacy without a prescription from your doctor.</p>
<p>The decision was made by Australia’s drug regulator the <a href="https://www.tga.gov.au/codeine-info-hub">Therapeutic Goods Administration</a> (TGA). It was based mainly on the fact that codeine can cause dependence, and its misuse has led to addiction and even death. These facts are not in dispute.</p>
<p>But claims withdrawing such products from sale without a prescription will reduce codeine use are misleading. Nor is it correct to say, as some do in applauding the TGA’s decision, there is no evidence painkillers combined with lower doses of codeine aren’t any more effective in providing pain relief than the painkillers alone. Here are three common claims made about codeine-containing products that are untrue. </p>
<h2>1. Low-dose codeine doesn’t improve pain relief</h2>
<p>Painkillers such as codeine, ibuprofen and paracetamol act in different ways to reduce pain, and they are sometimes combined into the one tablet to produce greater pain relief. Products such as Nurofen Plus and Panadeine Extra contain 15mg or less of codeine (considered a low dose) combined with either ibuprofen or paracetamol in the one tablet.</p>
<p>Some <a href="https://ama.com.au/media/transcript-dr-gannon-2gb-codeine">doctors</a> and <a href="http://www.painaustralia.org.au/static/uploads/files/painaustralia-codiene-fact-sheet-october-2017-wfxosgjjccah.pdf">organisations</a> have claimed that painkillers, such as ibuprofen and paracetamol, are just as effective when used alone, as when they are combined with a low dose of codeine. Evidence does not support this claim.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-different-painkillers-are-only-effective-for-certain-types-of-pain-41035">Why different painkillers are only effective for certain types of pain</a>
</strong>
</em>
</p>
<hr>
<p>In fact, few clinical trials have been carried out to assess how effective it is to add low dose codeine to either ibuprofen or paracetamol. And of these, some have tested doses not generally used in Australia. However, two trials have shown products containing paracetamol and codeine, and ibuprofen and codeine, in concentrations equal to those in Panadeine Extra and Nurofen Plus respectively, are effective.</p>
<p>An <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1834-7819.2002.tb00319.x/full">Australian study</a> showed after dental surgery, 1000mg of paracetamol combined with 30mg of codeine phosphate (equivalent to two Panadeine Extra tablets) produced significantly greater pain relief than 1000mg of paracetamol alone (equivalent to two Panamax or two Panadol tablets). </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/2726279">Another study</a>, also looked at pain following dental surgery. It showed 20mg of codeine combined with 400mg of ibuprofen (equivalent to two Nurofen Plus tablets) produced significantly greater pain relief than 400mg of ibuprofen alone (equivalent to two Nurofen tablets). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202019/original/file-20180116-53292-1v27xtl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Only a very small percentage of opioid use, that includes drugs like oxycodone and codeine, is not from prescription.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>2. Making codeine products prescription-only will reduce codeine use</h2>
<p>Department of Health data give an idea of doctors’ patterns when it comes to prescribing <a href="http://medicarestatistics.humanservices.gov.au/statistics/do.jsp?_PROGRAM=/statistics/pbs_item_standard_report&itemlst=%2701215Y%27,%2704170L%27,%2704171M%27,%2710186D%27,%2704275B%27,%2708785J%27&ITEMCNT=6&LIST=1215Y,4170L,4171M,10186D,4275B,8785J&VAR=SERVICES&RPT_FMT=1&start_dt=201607&end_dt=201706">codeine-containing products</a> to patients under the Repatriation Benefits Scheme. Under this scheme, low dose codeine products can be obtained by veterans for a concession price with a prescription. </p>
<p>The data show that when doctors have the option to prescribe paracetamol combined with either 30mg, 15mg or 8mg of codeine, more than 90% of prescriptions are written for a 30mg codeine product. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-codeine-doesnt-work-for-some-people-and-works-too-well-for-others-58067">Weekly Dose: codeine doesn't work for some people, and works too well for others</a>
</strong>
</em>
</p>
<hr>
<p>Judging by this, if current users of low dose, codeine-containing products for the short-term treatment of acute pain are forced to visit a doctor, they may potentially receive a prescription for a higher strength codeine product. This may not reduce codeine use, but could increase it. </p>
<p>In 2015-2016, there were more than 3.7 million <a href="https://www.pbs.gov.au/statistics/expenditure-prescriptions/2015-2016/exp-prs-2015-16-table-13.pdf">prescriptions written in Australia</a> for products containing 30mg of codeine and 500mg of paracetamol. It has <a href="http://onlinelibrary.wiley.com/doi/10.1002/pds.4329/abstract">also been reported</a> most opioid (a drug that acts on the opioid receptors, such as codeine and oxycodone) use in Australia is from prescription products, with over the counter codeine products accounting for only 6% of total opioid use. </p>
<h2>3. Taking paracetamol and ibuprofen in combination is a better way to treat pain</h2>
<p>It <a href="https://www.racgp.org.au/yourracgp/news/media-releases/put-patient-health-first-in-regulating-codeine-use-health-ministers-urged/">has been claimed</a> a combination product containing ibuprofen and paracetamol would fill the gap left by the unavailability of low dose codeine-containing painkillers. But there are many people who should not take ibuprofen, or only take it with caution. These include people</p>
<ul>
<li><p>with aspirin sensitive asthma (ibuprofen may worsen their asthma symptoms, and potentially cause an acute asthmatic attack)</p></li>
<li><p>with gastrointestinal disorders such as Crohn’s disease, and those with kidney impairment (ibuprofen may make their condition worse) </p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ibuprofen-just-because-its-freely-available-doesnt-make-it-safe-56346">Weekly Dose: ibuprofen – just because it's freely available, doesn't make it safe</a>
</strong>
</em>
</p>
<hr>
<p>It also includes people taking medicines that may have a serious drug interaction with ibuprofen. These include:</p>
<ul>
<li><p>Warfarin and other medications used to prevent blood clots (ibuprofen may increase the risk of bleeding) </p></li>
<li><p>some medicines used in the treatment of high blood pressure or heart failure (ibuprofen may increase blood pressure and reduce kidney function) </p></li>
<li><p>low dose aspirin for protection against heart attack and stroke (ibuprofen may reduce the protective effect).</p></li>
</ul>
<h2>Real-time monitoring</h2>
<p>Making codeine-containing products only available with a prescription is unlikely to help those who may be misusing codeine. Pharmacies have introduced a real-time monitoring system for over the counter sales of codeine-containing products, which allows the pharmacist to identify and help those people who may be misusing them. </p>
<p>There is no such monitoring of prescription codeine-containing products in doctors’ surgeries. So, there is no way of identifying and helping those people who may be doctor shopping to obtain multiple prescriptions for the products. </p>
<p>It makes no sense to change from a system where the small percentage of people who may be misusing the products can be identified and helped, to one where they cannot.</p><img src="https://counter.theconversation.com/content/87257/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Carroll is President of the NSW branch of the Pharmaceutical Society of Australia, which is lobbying against the removal of codeine-containing products from sale without prescription.</span></em></p>The claim there is no evidence painkillers combined with lower doses of codeine are more effective in treating pain, is misleading. As are others in this debate.Peter Carroll, Honorary Professor, Pharmacology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/797302017-10-02T00:52:24Z2017-10-02T00:52:24ZDon’t take opioids off the market - make it harder to abuse them<figure><img src="https://images.theconversation.com/files/180429/original/file-20170731-28521-1jfe8fg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Schedule 2 narcotics: Morphine Sulfate, OxyContin and Opana.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Database-Oregon/98a6ea692aa449bebde1afa5fe752780/3/0">Rich Pedroncelli/AP Photo</a></span></figcaption></figure><p>How can we combat the <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">opioid epidemic</a>?</p>
<p>One of the government’s most recent suggestions is to take Opana ER, an opioid indicated for very severe pain, <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm562401.htm">off the market</a>. The request, filed by the U.S. Food and Drug Administration in June, was linked to concerns of abuse-related HIV and hepatitis C outbreaks.</p>
<p>But removing access to opioids altogether isn’t the solution. There are individuals suffering from chronic pain who need or strongly benefit from these drugs. The National Center for Health Statistics estimates that <a href="https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57">a fourth</a> of the nation’s population suffers from pain lasting longer than 24 hours. Millions more suffer from acute pain.</p>
<p>As a researcher who studies how pharmaceuticals are used and what effects they have, I believe it makes more sense to reduce both the supply and demand side of prescription drug abuse – without interfering with their safe and appropriate use. We can do this by reimagining how we design and prescribe addictive drugs.</p>
<h1>Redesigning the pill</h1>
<p><a href="https://doi.org/10.1177/2049463712438493">Opioids such as morphine</a> typically relieve pain by acting on opioid receptors distributed throughout the central nervous system. </p>
<p>The FDA has come up with a number of ways to deter abuse by changing the way drugs work. For example, manufacturers could include an opioid antagonist in the formulation. This is essentially a drug that blocks the opioid’s effect by binding to the same receptors in the brain that the opioid would. Changing the formulation in this way would reduce the chances of experiencing the euphoric high that leads to addiction.</p>
<p>A good example of an opioid that does this is <a href="https://www.fda.gov/Drugs/DrugSafety/ucm406290.htm">Targiniq ER</a>. If Targiniq ER is crushed or dissolved, it releases Naloxone, an opioid antagonist that blocks the effect of the opioid.</p>
<p>Another option is to redesign the drug so it must be injected or implanted, instead of taken orally. That way, the drug would potentially have to be delivered under medical supervision. Requiring the drugs to be delivered under medical supervision could also potentially reduce the improper use of needles and related outbreaks.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=422&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=422&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=422&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180430/original/file-20170731-22144-1j0c8th.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Paul Wright shows a picture of himself in the hospital after a near-fatal overdose in 2015.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Medicaid-Cuts-Opioid-Epidemic/2e3bf787f50d4b0aa7161ad9618e4239/5/0">David Dermer/AP Photo</a></span>
</figcaption>
</figure>
<p>Even so, no method is foolproof; abusers can sometimes manipulate a changed drug. For example, Opana ER was designed to be difficult to crush, but abusers began to dissolve the drug into a solution and injecting it. To deter drug abuse, Opana ER’s manufacturer, Endo Pharmaceuticals, devised a new medication formula that made the coating more difficult to crush or dissolve. Unfortunately, abusers still found a way to remove the coating and inject the drug.</p>
<h1>Required prescription monitoring</h1>
<p><a href="https://www.cdc.gov/drugoverdose/pdmp/index.html">Prescription drug monitoring programs</a> have shown considerable promise in tracking potential abusers.</p>
<p>These programs provide emergency departments and physicians with information about a patient’s past use of controlled substances at the point of care. This can immediately flag any potential for abuse, making the doctor’s decision to prescribe opioids – or not – much easier.</p>
<p>Now, the U.S. Substance Abuse and Mental Health Services Administration has funded at least nine states to combine their prescription monitoring programs with <a href="https://www.cdc.gov/drugoverdose/pdf/pehriie_report-a.pdf">local hospital electronic health records</a> and other systems already in place. These collaborations provide clinicians with a comprehensive history of controlled substance, so they can make informed decisions about patient health.</p>
<p>This has already had some success. For example, <a href="https://www.cdc.gov/drugoverdose/pdf/pehriie_report-a.pdf">Illinois</a> saw a 22 percent decrease in number of opioid prescriptions issued by prescribers and a 41 percent decrease in the number of patients who received at least one opioid prescription.</p>
<p>More information on the nature of the epidemic – particularly its link to rural areas – could yield clues about where and how to intervene. However, publicly available data have limited geographical information and <a href="https://doi.org/10.1097/AAP.0000000000000022">don’t cover</a> all information we might need, such as data about dose or treatment duration. What data are available are restricted to protect the identity of individuals.</p>
<p>Rather than look at patients with opioid issues, we decided to look at the doctors who prescribe the drugs. Our group has been working with the state of South Carolina to combine our prescription drug monitoring program, called South Carolina Reporting and Identification Prescription Tracking System, or <a href="http://www.scdhec.gov/Health/FHPF/DrugControlRegisterVerify/PrescriptionMonitoring/">SCRIPTS</a>, with Medicaid data.</p>
<p>While we were able to combine only two years’ worth of data, our research led to important insights into the abuse potential within <a href="http://dx.doi.org/10.1016/j.jval.2015.03.1761">South Carolina</a>.</p>
<p><iframe id="5BrLE" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/5BrLE/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>By <a href="http://www.asph.sc.edu/news/qureshi.html">geocoding state prescription information</a>, we found that a relatively small percentage of providers, concentrated in a few counties, accounted for most opioid prescriptions. In 2010, the top 10 percent of prescribers wrote more than half of all opioid prescriptions.</p>
<p>This group represents a potential target for physician education and engagement in handling pain management and appropriate use of opioids.</p>
<h1>Rethinking how we assess patients</h1>
<p>Many solutions to the opioid crisis tend to focus on how far it has come and how to mitigate it. However, a more sustainable approach would be to rethink the process of care and engage the patient – who is at the center of it all.</p>
<p>When patients are engaged in the care process, they tend to adhere more to their prescribed regimens and experience <a href="http://catalyst.nejm.org/optimize-patients-medication-adherence/">better health outcomes</a>.</p>
<p>In most primary care settings, it is considered standard practice to ask patients to rate their pain on a scale from one to 10. This is a very crude measure, but now we need a more sophisticated method. Medical care should consider not only the providers’ preferences, but the patient’s, too. </p>
<p>We need a tool that gets at not only the level of pain an individual experiences, but also their preferences in dealing with pain. <a href="https://doi.org/10.1016/S1090-3801(02)00042-3">Studies show</a> that patient-provider communication plays an important role in <a href="https://doi.org/10.4103/0019-5049.179450">pain management</a>. If patients could share their specific concerns regarding their pain and their goals for treatment, then clinicians would be able to find the best treatment plan that is tailored to individual patient preferences.</p>
<p>Rather than using a standardized approach that matches pain level to doses of an analgesic or opioid, clinicians should <a href="http://apps.who.int/iris/bitstream/10665/37896/1/9241544821.pdf">assess each patient individually</a>, looking at their tolerance for pain, their priorities for treatment and how they value outcomes. </p>
<p>By centering pain management on individual patients, we can give them a voice in the decision-making process. Given the issues with opioid abuse, I think such a pain management tool would yield a multitude of benefits, such as cutting down unnecessary prescriptions, matching the therapy to the patient’s needs and improving outcomes.</p><img src="https://counter.theconversation.com/content/79730/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zaina Qureshi 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>How can we fight the opioid epidemic? Redesign the drugs, rethink how we assess patients and mandate prescription monitoring.Zaina Qureshi, Assistant Professor Department of Health Services Policy and Management; Adjunct Professor Department of Clinical Pharmacy and Outcomes Sciences; Principal Investigator William Jennings Bryan Dorn Veterans Affairs Medical Center, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/835432017-09-08T00:24:00Z2017-09-08T00:24:00ZWhy more grandparents are raising their grandchildren<figure><img src="https://images.theconversation.com/files/184972/original/file-20170906-9875-1rj6j07.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Grandmother and child walking in the park.</span> <span class="attribution"><span class="source">www.shutterstock.com</span></span></figcaption></figure><p>Sunday, Sept. 10, 2017 is <a href="http://grandparentsday.org/">Grandparents Day</a>. Many grandparents will receive loving cards, calls and emails from their grandchildren.</p>
<p>However, a significant number of grandparents – <a href="http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/11/02/why-more-grandparents-are-raising-children">approximately 2.9 million</a> – will do exactly what they do every day. They will make their grandchildren breakfast, organize their activities and help with homework in the evening. </p>
<p>So-called “custodial grandparents” have primary responsibility for raising one or more of their grandchildren. As researchers and health and social service professionals, we know that this is a <a href="http://www.pbs.org/newshour/rundown/more-grandparents-raising-their-grandchildren/">growing group of often invisible caregivers</a>.</p>
<p>Grandparents Day is a fitting moment to take a closer look at the social contribution grandparents are making and the impact of unexpected caregiving – often in later stages of life.</p>
<h2>Not a new phenomenon but a changing one</h2>
<p>Custodial grandparents are represented in all races and ethnicities. However, grandparents in racial and ethnic minority groups <a href="https://www.census.gov/library/visualizations/2016/comm/cb16-ff17_grandparents.html">are overrepresented</a> in the population of caregivers. It’s also worth noting that 67 percent are younger than age 60, and 25 percent <a href="https://www.census.gov/content/dam/Census/library/publications/2014/demo/p20-576.pdf">live</a> in <a href="https://www.healthcare.gov/glossary/federal-poverty-level-FPL/">poverty</a> despite the fact that about <a href="https://census.gov/library/visualizations/2017/comm/grandparents-support-grandchildren.html">half of custodial grandparents are in the labor force</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184992/original/file-20170906-17089-kwc1tz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Barack Obama with the grandparents who raised him.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/senorglory/3219359111/">Senor Glory</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Grandparent caregiving is not a new phenomenon: Kin care has historically been part of family life. Former President Barack Obama <a href="http://www.penguinrandomhouse.com/books/123909/dreams-from-my-father-by-barack-obama/9780307383419/%22">chronicled</a> his early life experiences being raised by maternal grandparents. In a <a href="https://www.harpercollins.com/9780062300546/hillbilly-elegy">bestselling book</a>, JD Vance writes about his childhood in Appalachia being raised by his “Mamaw.”</p>
<p>While it’s not a new trend, the reasons for and experience of raising grandchildren have changed over recent decades.</p>
<p>Consider, for example, the African-American community. In her 2010 Pulitzer Prize-winning book, <a href="http://isabelwilkerson.com/the-book/">“The Warmth of Other Suns</a>,” Isabel Wilkerson documents the great migration of African-Americans from the South to other regions of the United States between World War I and the 1970s. During this time, grandparents and other relatives served as substitute parents as families resettled and secured employment. In this <a href="https://www.naswpress.org/publications/children/caregiving-care-sharing.html">care-sharing tradition</a>, grandparents and other families were available during times of transition and relocation.</p>
<p>Since the mid-1990s, several social conditions have caused the number of grandparents who are raising their grandchildren to increase.</p>
<p>Addiction and incarceration, child abuse and neglect, and economic factors all have contributed to a rise in the number of custodial grandparents. A recent <a href="http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/11/02/why-more-grandparents-are-raising-children">Pew Trusts report</a> documents how the current opioid epidemic is contributing to this trend. <a href="https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf">According to the CDC</a>, drug overdose deaths in the United States have more than tripled from 1999 to 2015, and often leave children parentless. </p>
<p>The number of <a href="https://www.nytimes.com/2017/01/16/opinion/young-victims-of-the-opioid-epidemic.html">children placed in foster care</a> has sharply increased, partially fueled by opioid and other drug use. When children are removed from their birth parents, federal law requires that state child protective services give preference to placement with relatives who, more often than not, are the grandparents.</p>
<p>Additionally, increased incarceration rates for women have changed family life. In the 1990s, female incarceration rates <a href="http://www.bjs.gov/content/pub/pdf/iptc.pdf">skyrocketed</a> compared to the rate for fathers. Incarceration, addiction and neglect are often interconnected.</p>
<h2>How caregiving affects health</h2>
<p>In addition to dealing with the challenging dynamics of child care, many of these grandparents are starting to experience their own age-related changes in <a href="http://onlinelibrary.wiley.com/doi/10.1002/jclp.22272/full">health and functioning</a>.</p>
<p>Compared with noncaregiving peers, grandparents who are raising their grandchildren have more extensive health problems. When there are limited resources – whether financial, time or energy – grandparents <a href="http://onlinelibrary.wiley.com/doi/10.1002/nur.21542/abstract">prioritize their grandchildren over themselves</a>. This situation can lead to undiagnosed health problems, untreated chronic diseases and undesirable health practices such as poor nutrition and lack of exercise.</p>
<p>In addition, grandparents can experience depression and anxiety from the stress of child care. In <a href="http://onlinelibrary.wiley.com/doi/10.1002/nur.21542/abstract">one study</a> of grandmothers raising grandchildren, approximately 40 percent scored in the clinically elevated range on measures of psychological distress.</p>
<p>In spite of these challenges, grandparents report rewards and joys that give them a sense of purpose. One grandparent <a href="http://familiesinsocietyjournal.org/doi/pdf/10.1606/1044-3894.177">put it this way</a>:</p>
<blockquote>
<p>“And she’ll come around once in a while and she’ll say, ‘I’m so glad. I’m so lucky I have you and Grandma.’ And I’ll say, ‘We’re lucky we have each other.’”</p>
</blockquote>
<p>Keeping grandchildren in their own cultural community is another important motivation for many. For example, <a href="http://familiesinsocietyjournal.org/doi/pdf/10.1606/1044-3894.40">research</a> has demonstrated the historical commitment to care-sharing in African-American families:</p>
<blockquote>
<p>“Because I came from a bonded family, a really bonded family… We always pitched in and took care of each other. My mother, my grandmother took care of me. Let me see. There was my nannie, my nina, my mother, my uncle and aunt. We all lived together…”</p>
</blockquote>
<h2>Grandparents and policy</h2>
<p>From a policy perspective, grandparents provide the safety net for children who might have otherwise entered the foster care system. Nationally, it is estimated that grandparents and other kinship care providers save the government more than <a href="http://www.gu.org/Portals/0/images/Infographic/12-grandparent-infograph-full.jpg">US$6 billion annually</a>.</p>
<p>But in caring for these children, grandparents <a href="https://www.hindawi.com/journals/cggr/2015/630717/">pay a high price</a>, especially those who are raising the children alone.</p>
<p>What can be done to support these grandparents?</p>
<p>Because of increased recognition of both the prevalence and urgent needs of grandparents raising grandchildren, many communities have created grandparent support groups and “<a href="http://www.nysnavigator.org/">kinship navigator</a>” programs that help identify and access much-needed public and private resources.</p>
<p>Programs such as <a href="http://phg.snhp.gsu.edu/">Project Healthy Grandparents at Georgia State University</a> offer support and health interventions to help grandparents remain healthy and effective care providers. Support includes home visits, early intervention services for children with developmental disabilities (which are often related to prenatal substance abuse exposure) and support groups and parenting classes. Other programs are growing such as Grandhousing, which provides apartments specifically for grandparent-headed families.</p>
<p>Programs for grandchildren are also crucial. In one initiative that replicates our Atlanta-based model in rural Georgia, a van transports the children to an activity day so they can be with others who are are cared for by grandparents. As the driver pulled up to the second house, the two sisters already in the van exclaimed:</p>
<blockquote>
<p>“Look – those girls are being raised by their grandma, too!”</p>
</blockquote>
<p>Clearly, seeing other children in families like theirs was surprising and important to the sisters!</p>
<p>For many, Grandparents Day is celebrated one time per year. And grandchildren’s visits <a href="https://www.naswpress.org/publications/children/caregiving-care-sharing.html">are a “delight”</a> lasting just a few hours. But for about three million children, being with grandparents is a daily fact. </p>
<p>We believe it is time for these families to be recognized more formally by policymakers and service providers. Without more extensive official responses, grandparents may receive little or no support until they experience a physical or mental health crisis.</p><img src="https://counter.theconversation.com/content/83543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors 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>Millions of American children are being cared for by grandparents. To honor Grandparents Day we ask: What are the social and health impacts of this often unexpected turn of events?Nancy P. Kropf, Dean and Professor of Social Work, Byrdine F Lewis College of Nursing and Health Professions., Georgia State UniversitySusan Kelley, Associate Dean and Chief Academic Officer for Nursing and Director, Project Healthy Grandparents, Byrdine F. Lewis College of Nursing and Health Professions, Georgia 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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<p>
<em>
<strong>
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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</em>
</p>
<hr>
<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>
<figcaption>
<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>
</figcaption>
</figure>
<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>
<hr>
<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/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>
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<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.tag:theconversation.com,2011:article/695442016-12-16T03:23:04Z2016-12-16T03:23:04ZHow to know when holiday drinking is hurting your brain<figure><img src="https://images.theconversation.com/files/150389/original/image-20161215-26074-1nghn38.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Holiday drinking brings good cheer, but it can also be a sign of problem drinking.</span> </figcaption></figure><p>For many, the holidays are indeed the most wonderful time of the year. Families and friends come together and enjoy food, good cheer – and, often, alcohol. </p>
<p>Commercially speaking, alcohol and the holidays seem to be made for each other. Alcohol can be a quick and easy way to get into the spirit of celebration. </p>
<p>And, it feels good. After two glasses of wine, the brain is activated through complex neurobiochemical processes that naturally release dopamine, a neurotransmitter of great importance. </p>
<p>When the dopamine molecule locks on to its receptor located on the surface of a neuron, or basic brain cell, a “buzz” occurs. It is often desirably anticipated before the second glass is empty. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=600&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=600&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149742/original/image-20161212-26063-i2ccwu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=600&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">This image shows an illustration of a man drinking a pint of beer, indicating how the body metabolizes alcohol and the organs that this alcohol affects.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/wellcomeimages/5814717084/in/photolist-9RPWNQ-prynUg-q6U6Mc-9RM2SX-BCnTop-BKEKNT-rxzDNi-rg2ekq-q635KG-dxxovQ-9RPXyq">Wellcome Images via Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>There are those, however, who drink right past the buzz into intoxication and, often, into trouble. For them, the brain starts releasing the same enjoyable dopamine, no different than what happens in the casual drinker’s, but it doesn’t stop there. A compulsion to binge drink can result. </p>
<p>As someone who has studied alcohol use disorder for over 15 years and who has treated thousands of patients who have it, I think it’s a major, yet often poorly understood, public health problem. Our culture seems to be moving beyond the point of labeling those with opioid addictions as “weak,” and I hope we can do the same for those with alcohol use disorder, too, which is more widespread than people may appreciate. <a href="https://www.ncbi.nlm.nih.gov/pubmed?cmd=search&term=24967831">Excessive drinking accounted for one in 10 deaths among working-age adults</a> in the United States.</p>
<h2>Moving beyond judgment</h2>
<p>Although alcohol can feel as though it is relieving stress, it <a href="https://www.ncbi.nlm.nih.gov/pubmed/24967831">contributes to 88,000 deaths</a> in the United States each year. That is more than double the number of people killed by <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">heroin and opioid prescription drug overdose</a>, another major public health crisis, in 2014.</p>
<p>In addition, <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf">more than 66.7 million Americans reported binge drinking</a> in the past month in 2015, according to the <a href="https://addiction.surgeongeneral.gov/executive-summary.pdf">recent report</a> on addiction by the surgeon general.</p>
<p>The consequences to the individual and the family are staggering, affecting physical and mental health, an increased spread of infectious disease, reduced quality of life, increased motor vehicle crashes and abuse and neglect of children, to mention a few. </p>
<p>Scientific study of the brain has helped explain binge drinking even if it may be hard for family and friends to understand. It’s defined as drinking five or more drinks for men and four for women on the same occasion on at least one day in the past 30 days.</p>
<p>Binge drinking is a <a href="https://addiction.surgeongeneral.gov/executive-summary.pdf">medical condition</a>. It happens through no fault of the individual, who is victimized by the comparative malfunction of the pleasure circuits in the brain. This causes the drinker to want more and more alcohol. Brains of binge drinkers have a disease, acknowledged by the American Medical Association since the 1950s, yet binge drinkers are often vilified. </p>
<p>Americans typically want to know and are willing to make some lifestyle changes out of fear and common sense when it comes to diseases such as heart disease, obesity and cancer. We as a society are not quite at the same point with substance abuse disorders, but researchers are desperately trying to bring that same willingness for prevention and treatment to substance use disorders. </p>
<p>Science understands the cause well enough to explain it and treat it so that lives can be saved and spared the devastating consequences for the millions who suffer with these conditions, their families and communities. This has become an urgent matter of national importance for scientists and medical practitioners.</p>
<h2>The three stages of addiction</h2>
<p>The alcohol addiction process involves a <a href="https://www.ncbi.nlm.nih.gov/pubmed/9311926">three-stage cycle</a>: Binge-Intoxication, Withdrawal-Negative Affect, and Preoccupation-Anticipation. </p>
<p>It begins in the neurons, the basic type of brain cell. The brain has an estimated 86 billion of these cells, which communicate through chemical messengers called neurotransmitters. </p>
<p>Neurons can organize in clusters and form networks or circuits in order to perform specific functions such as thinking, learning, emotions and memory. The <a href="https://addiction.surgeongeneral.gov/executive-summary.pdf">addiction cycle disrupts the normal function</a> of some of these networks in three areas of the brain – the basal ganglia, the extended amygdala and the prefrontal cortex. </p>
<p>The disruptions do several things that contribute to continued drinking. They enable alcohol or drinking-associated triggers (cues) which lead to seeking alcohol. They also reduce the sensitivity of the brain systems, causing a diminished experience of pleasure or reward, and heighten activation of brain stress systems. Last, they reduce function of brain executive control systems, the part of the brain that typically helps make decisions and regulate one’s actions, emotions and impulses. </p>
<p>These networks are critical for human survival. Unfortunately for the binge drinker, <a href="https://addiction.surgeongeneral.gov/executive-summary.pdf">they become “hijacked,”</a> and the bingeing continues even after the harmful effects have begun. </p>
<p>Because binge drinkers’ brains feel intense pleasure from alcohol, there is a powerful motivation to binge drink again and again. What may begin as social binge drinking at parties for recreation can cause <a href="http://jamanetwork.com/journals/jama/article-abstract/193144">progressive neuro-adaptive changes in brain structure and function</a>. The brain is no longer well enough to function normally. It’s getting sick. Continued partying can transition into a <a href="http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(03)00130-2/references">chronic and uncontrollable daily pattern</a> of alcohol use. <a href="http://jamanetwork.com/journals/jamapsychiatry/fullarticle/481765">These maladaptive neurological changes can persist </a>long after the alcohol use stops. </p>
<h2>Your brain on alcohol</h2>
<p>During the Binge-Intoxication Stage, a part of the brain called the basal ganglia rewards the drinker with pleasurable effects, <a href="http://www.nature.com/neuro/journal/v8/n11/full/nn1578.html">releasing dopamine, the neurotransmitter responsible for the rewarding effects </a>of alcohol and creating the desire for more.</p>
<p>With continued bingeing, the <a href="https://addiction.surgeongeneral.gov/executive-summary.pdf">“habit circuity” is repeatedly activated </a>in another part of the basal ganglia called the dorsal striatum. It contributes to the compulsive seeking of more alcohol. This explains the intense desire (craving) which is triggered while a binge drinker is driving by a favorite bar and can’t resist pulling in, even after a promise to go directly home after work. </p>
<p>During the Withdrawal-Negative Affect Stage, there is a break from drinking. Because the reward circuit has a diminished ability to deliver a dopamine reward, there is far less pleasure with natural (safe) experiences – such as food and sex – compared to alcohol.</p>
<p><a href="http://www.nature.com/npp/journal/v35/n1/abs/npp2009110a.html">During abstinence from alcohol</a>, stress neurotransmitters such as corticotropin-releasing factor (FRC) and dynorphin are released. These powerful neurochemicals cause negative emotional states associated with alcohol withdrawal. <a href="https://www.ncbi.nlm.nih.gov/labs/articles/11120394/">This drives the drinker back to alcohol</a> in order to gain relief and attempt to reestablish the rewards of intoxication. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=345&fit=crop&dpr=1 600w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=345&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=345&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=433&fit=crop&dpr=1 754w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=433&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/150386/original/image-20161215-26051-1xivd3e.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=433&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Regions of the brain are affected differently by alcohol.</span>
<span class="attribution"><span class="source">Surgeon General's Report on Addiction</span></span>
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<p>After a period of abstinence from alcohol, which may last only hours, the drinker enters the Preoccupation-Anticipation Stage. This involves the prefrontal cortex, where executive decisions are made about whether or not to override the strong urges to drink. This part of the brain functions with a “Go system” and “Stop system.” </p>
<p>When the Go circuits stimulate the <a href="https://www.ncbi.nlm.nih.gov/pubmed/22011681">habit-response system of the dorsal striatum</a>, the drinker becomes impulsive with a craving and seeks a drink, perhaps even subconsciously. The Stop system can inhibit the activity of the Go system and is important especially preventing relapse after being triggered by stressful life events.</p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/hbm.22913/abstract">Brain imaging studies</a> show that <a href="http://www.jneurosci.org/content/27/46/12700.full">binge drinking can disrupt the function </a>in both the Go and Stop circuits. This interferes with proper decision making and behavioral inhibition. The drinker is both impulsive and compulsive. </p>
<h2>An illness that can be treated</h2>
<p>There is good news, as scientific evidence shows that this disorder can be treated.</p>
<p>The FDA has approved <a href="http://jamanetwork.com/journals/jamapsychiatry/fullarticle/482282">three medications for treatment that should be offered whenever appropriate</a>. There is well-supported scientific evidence that behavioral therapies can be effective treatment. This includes recovery support services, such as Alcoholic Anonymous. </p>
<p>Most importantly, it is important to know that alcohol use disorder is a brain disorder causing a chronic illness. It is no different from diabetes, asthma or hypertension. When comprehensive continuing care is provided, the recovery results improve, and the binge drinker has the hope of remaining sober as long as lifelong treatment and maintenance of sobriety become a dedicated lifestyle choice.</p><img src="https://counter.theconversation.com/content/69544/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jamie Smolen 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>Alcohol contributes to close to 90,000 deaths a year. Because repeated binge drinking damages the brain, it’s hard to know when we’ve developed a problem. Here are some things to consider.Jamie Smolen, Associate Professor of Medicine, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/614832016-08-09T22:56:05Z2016-08-09T22:56:05ZSome good news on opioid epidemic: Treatment options are expanding<figure><img src="https://images.theconversation.com/files/133572/original/image-20160809-18053-sqop7b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Governor Charlie Baker of Massachusetts and unidentified woman at a rally in November aiming to destigmatize addiction. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/massgovernor/22759413106">Joanne DeCaro/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>In the past two decades, the devastation associated with <a href="https://www.cdc.gov/drugoverdose/epidemic/">opioid addiction</a> has escaped the relative confines of the inner city and extended to suburban and rural America. Due in large part to the proliferation of <a href="https://www.cdc.gov/drugoverdose/epidemic/">prescription pain relievers</a>, rates of opioid abuse, addiction, overdose and related deaths have increased dramatically. This has affected families and communities that once felt immune to this crisis.</p>
<p>On Aug. 1, an analysis of health care claims for treatment of opioid dependence showed a <a href="http://www.npr.org/sections/health-shots/2016/08/01/487940139/many-more-people-are-seeking-medical-help-for-opioid-abuse">3,000 percent</a> increase from 2007 to 2014.</p>
<p>The knowledge that many are <a href="http://www.forbes.com/sites/cjarlotta/2016/06/05/how-princes-death-can-help-abolish-the-stigma-of-opioid-addiction/#3ed047f467b2">afflicted or affected</a> has helped people understand the powerful psychological and physiological grip of addiction. As a result, stigma has decreased.</p>
<p>What was once relegated to the back burner of public concern has become a <a href="http://www.bloomberg.com/politics/articles/2016-07-12/painkiller-abuse-epidemic-awaits-a-place-on-u-s-party-platforms">top public health priority</a>.</p>
<p>We addiction experts also have gained better understanding of the illness, and we see reasons for hope. </p>
<h2>Shifts in public policy</h2>
<p>The Affordable Care Act and the Mental Health Parity and Addiction Equity Act combined to finally <a href="https://www.mentalhealth.gov/get-help/health-insurance/">require</a> insurance companies to cover treatment for patients suffering from addiction. Insurance companies can no longer deny treatment or significantly limit treatment for psychiatric disorders, including addiction, as they had in the past. </p>
<p>President Obama recently proposed US$<a href="https://www.whitehouse.gov/the-press-office/2016/02/02/president-obama-proposes-11-billion-new-funding-address-prescription">1.1 billion</a> in funding to expand access to treatment for opioid addiction and overdose prevention. </p>
<p>In July, the House <a href="http://fortune.com/2016/07/08/congress-mental-health-bill/">passed</a> a bill that would further expand access to care for addiction and other mental health conditions. </p>
<p>Then, on July 22, the president <a href="https://www.whitehouse.gov/the-press-office/2016/07/22/statement-president-comprehensive-addiction-and-recovery-act-2016">signed into law</a> the Comprehensive Addiction and Recovery Act of 2016.</p>
<p>If adequately funded by Congress, the law will help to <a href="http://www.chicagotribune.com/suburbs/lake-county-news-sun/news/ct-lns-localized-obama-opioid-law-st-0726-20160725-story.html">strengthen prevention, treatment and recovery efforts</a>. </p>
<p>This improves treatment options for individuals in the criminal justice system, which may decrease rates of return to crime and prison. It also expands access to naloxone, a lifesaving drug that emergency medical workers and even family and friends, in certain cases, can administer to someone who has overdosed. </p>
<p>This stepped-up policy response is giving doctors the means to better treat people with opioid addiction. When combined with improvements in public understanding that addiction is a disease requiring treatment, we as a society are creating an environment that supports treatment. We believe this will save many thousands of lives.</p>
<h2>A societal effort</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=519&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=519&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=519&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=652&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=652&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133576/original/image-20160809-18053-1pli1sx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=652&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">Doctor with pill bottle talking to patient.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-342696572/stock-photo-a-black-female-physician-prescribing-pills-to-an-older-black-male-patient.html?src=se5WmeOhAU8MLsqOcpQHwQ-1-17">From www.shutterstock.com</a></span>
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<p>Physicians are re-examining their own <a href="http://www.supportprop.org">prescribing practices</a> to decrease the likelihood of medication diversion or misuse and to minimize the development of <a href="http://www.psychiatrictimes.com/psychopharmacology/iatrogenic-opioid-use-disorder-issue-ignored">iatrogenic addiction</a>, or addiction that stems from medical treatment. </p>
<p>Law enforcement officials have worked to close down hundreds of <a href="https://www.statnews.com/2015/12/21/opioid-florida-crackdown/">“pill mills,”</a> or clinics purporting to serve patients with chronic pain disorders. In reality, they serve as primary access points for dealers selling prescription drugs on the black market. </p>
<p>In all states except Missouri, <a href="https://gcn.com/articles/2016/08/08/nga-drug-abuse-road-map.aspx">prescription drug monitoring programs</a> have also helped to identify patients in need of intervention.</p>
<p>More patients have access to treatment than ever before, including many in the criminal justice system who participate in drug court diversionary programs. Such programs save taxpayer money and <a href="http://www.nadcp.org/learn/facts-and-figures">decrease recidivism</a>. </p>
<h2>Greater understanding and knowledge</h2>
<p>The field of addiction medicine has matured and expanded, recently acquiring recognition as a <a href="http://alcoholrehab.com/drug-addiction-treatment/addiction-medicine-new-medical-specialty/">dedicated medical specialty</a>.</p>
<p>According to the American Society of Addiction Medicine, the <a href="http://www.asam.org/quality-practice/definition-of-addiction">disease of addiction</a> is best understood as a single condition. There is no distinction made depending on the preferred drug(s) of abuse.</p>
<p>Addiction specialists conceptualize addiction as a bio-psycho-social-spiritual disease. They understand that continued use of psychoactive substances interferes with active participation in psychosocial treatment. Such usage prevents development of a personal program of recovery. </p>
<p>Therefore, successful treatment of opioid addiction begins with <a href="https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse">abstinence from all substances of abuse</a>. Patients should not expect to quit using oxycodone, fentanyl or heroin but continue to drink alcohol or to smoke marijuana. The same holds true for treatment of addiction to alcohol, marijuana, cocaine or any other drug.</p>
<p>Some patients require medically supervised detoxification to abstain. Accessing the right treatment is crucial to success. Some will need a more intensive treatment setting. Even individuals who were unsuccessful maintaining abstinence with outpatient treatment may achieve recovery in a more intensive treatment setting. </p>
<p>Addiction, like other medical conditions with significant behavioral components, is a chronic condition. <a href="https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery">Relapse may occur</a>. Thus, most patients need to learn skills that help them cope adaptively with stressors in their daily lives. Often, they need to address issues from their past that relate to substance abuse. </p>
<p>People with addiction may have other psychiatric conditions. They need to be treated for those, too. In many areas, publicly funded treatment programs are available for individuals lacking insurance or who cannot afford private treatment. </p>
<h2>Support from family and 12-step programs helpful</h2>
<p>Family members should encourage patients suffering from addiction to seek a professional evaluation. This will help determine the appropriate level of care, which could range from outpatient management to long-term residential treatment. </p>
<p>In addition, physicians and other treatment specialists highly encourage participation in a 12-step recovery program, such as Alcoholics Anonymous or Narcotics Anonymous. Such programs are free, and they offer many benefits. Research has documented significantly <a href="https://www.hazelden.org/web/public/vcsum0research.page">reduced risk of relapse</a> with increased likelihood of successful outcome among patients treated for opioid addiction in this way. </p>
<p>Family members often benefit from 12-step programs, too. Al-Anon or Alateen can help them learn how best to support their loved one without enabling the addiction.</p>
<h2>Medications also helpful</h2>
<p>Patients with opioid use disorders may also benefit from <a href="http://www.samhsa.gov/medication-assisted-treatment">medication assistance</a>. Currently, four types of prescription medication are approved to assist with treatment of opioid addiction.</p>
<p>The opioid antagonist medication, <a href="http://www.samhsa.gov/medication-assisted-treatment/treatment/naltrexone">naltrexone</a>, is available as a daily oral pill or as a monthly intramuscular injection. It helps patients by decreasing cravings. It also blocks patients’ ability to “get high,” even if they use an opioid drug. Naltrexone has no abuse potential, and can be safely used by most patients.</p>
<p>Second, the opioid partial agonist medication <a href="http://buprenorphine.samhsa.gov">buprenorphine</a> is available as an oral pill, dissolving tablet or filmstrip. It also reduces cravings and reduces and prevents withdrawal symptoms. It, too, blocks the ability to “get high.” </p>
<p>Buprenorphine has some abuse potential, however. It should be used only under guidance and careful monitoring by a physician with sufficient expertise. In fact, doctors must receive a waiver to be allowed to prescribe buprenorphine. </p>
<p>Third, the opioid agonist medication <a href="http://www.samhsa.gov/medication-assisted-treatment/treatment/methadone">methadone </a>prevents withdrawal symptoms, reduces cravings and interferes with the ability to “get high” from other opioids. </p>
<p>Methadone also has abuse potential and risk of overdose if used inappropriately, however. As a result, methadone is typically dispensed in liquid form on a daily basis, and only from specialized methadone maintenance treatment clinics. </p>
<p>Finally, for individuals at high risk of relapse, new measures are in place to help prevent death in the event of accidental overdose.
The opioid antagonist medication <a href="http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone">naloxone</a> is now available in an automatic injector formulation for use by police, EMTs and other first responders. Naloxone has long been used by medical professionals in emergency rooms to reverse opioid overdose.</p>
<p>Naloxone is also available by prescription for patients with opioid addiction and their families to keep on hand as a safety precaution. In some states it is also available over the counter at certain pharmacies. It can be viewed much like an Epi-pen, which patients with severe allergies keep on hand for emergencies. A naloxone nasal spray is newly available, which may further facilitate access to this lifesaving medication.</p>
<p>These changes to public policy and advances in opioid treatment have greatly improved the prognosis for patients suffering from opioid addiction. Research and clinical evidence have demonstrated that long-term recovery is not only possible, but expected, following adequate treatment with appropriate follow-up care. </p>
<p>Now, more than ever, there is hope for healing from addiction.</p><img src="https://counter.theconversation.com/content/61483/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Merlo is affiliated with the Professionals Resource Network, Inc., the impaired practitioners monitoring program for the State of Florida. </span></em></p><p class="fine-print"><em><span>William Greene 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 nation is still in the grip of an opioid addiction epidemic, but there is some good news. Treatment options are expanding, as professionals learn more about the illness.William Greene, Assistant Professor, Psychiatry, University of FloridaLisa J. Merlo, Associate Professor, Psychiatry, University of FloridaLicensed as Creative Commons – attribution, no derivatives.