Opiates and Politics

Opiates and politicsIn the last decade opiate use has risen significantly. Overdoses and deaths from opiate use are increasing at a frightening rate. Whether it’s opiates like heroin or morphine or synthetic opioids like Percocet or Oxycodone, there’s no difference when considering the consequences of addiction and misuse and possible solutions. When a person develops tolerance and addiction, the body doesn’t know the difference from heroin bought off the street or Oxycodone that comes from a pharmacy.

I’ll just use the term opiate for the sake of simplicity. Opiates like heroin and morphine are nothing new. This is from Wikipedia:

The Mediterranean region contains the earliest archeological evidence of human use; the oldest known seeds date back to more than 5000 BCE in the Neolithic age[8] with purposes such as food, anaesthetics, and ritual. Evidence from ancient Greece indicate that opium was consumed in several ways, including inhalation of vapors, suppositories, medical poultices, and as a combination with hemlock for suicide.[9] The Sumerian, Assyrian, Egyptian, Indian, Minoan, Greek, Roman, Persian and Arab Empires all made widespread use of opium, which was the most potent form of pain relief then available, allowing ancient surgeons to perform prolonged surgical procedures.[citation needed] Opium is mentioned in the most important medical texts of the ancient world, including the Ebers Papyrus and the writings of Dioscorides, Galen, and Avicenna. Widespread medical use of unprocessed opium continued through the American Civil War before giving way to morphine and its successors, which could be injected at a precisely controlled dosage.

Countries like China have had wars over opium, and the U.S. declared a War on Drugs in the 60s, when opiates were referred to mostly as narcotics. Opiate and politics are a big concern now, although the mindset of making war against opiates still prevails. All attempts to eradicate opiates have failed. Just recently government ordered a reduction in the production of synthetic opioids. Government, to its favor, has also called for treatment of opiate addiction, and government supports the use of Buprenorphine as a regulated replacement drug that allows addicts to get into treatment without overwhelming withdrawal symptoms — however, treatment resources and access to resources are sadly insufficient.

Our society seems to favor  symptomatic law and order solutions over long term, fundamental solutions like education, prevention,  treatment and ongoing support. Waging war against drugs has created drug cartels and deadly battles for domination. Addiction, drug misuse and the demand for illicit drugs are the fundamental problems. All efforts so far to change minds and hearts about drug use have come up short. As a society we’re confused about drugs. Thinking clearly and objectively about drugs would be a great first step. If we can remove the fear and stigma, maybe we’ll find fundamental solutions.

If all the resources wasted on waging war against drugs were channeled into education, prevention, treatment and ongoing support, we’d gradually experience a change. Fearing drugs and fighting drugs with weapons have not changed our relationship with drugs. I know it’s a huge problem with no easy solutions, but I have to believe that understanding the problem through real, comprehensive education and prevention efforts will lead us in the right direction.

The Presidential Election and Addiction

Presidential election and addictionI would like to think that whoever becomes our next President will have a good understanding of our nation’s problem with addiction, but I haven’t heard much at all about the subject from the candidates — they appear to have lots of other things on their minds. I’m not convinced the solution to addiction problems, such as the nation’s heroin epidemic, must necessarily come from government, and I tend to think that local communities might find better solutions than top down federal government solutions, but it’d be good if representatives making all the funding decisions in DC really understood addiction.

So much could be done to save lives if only government officials would handle fundamental problems with fundamental solutions rather than wasting money applying symptomatic solutions to symptomatic problems. It appears that most efforts to deal with addiction have created unintended consequences, like the War on Drugs. After decades of treating drug addiction as if it’s a part of an enemy plot to destroy America, the problem is arguably worse than when the “war” started. Locking up drug users along with drug dealers has only ruined the lives of many good people who could have received treatment and gone on to live productive lives. The money it costs to house drug users in prison where they learn criminal behavior is mind-blowing.

I don’t have much hope that the next President will do much that’s different from what other Presidents have done, but it doesn’t hurt to hope. Drug court programs are successful government efforts, although it’s more of a local solution. As middle class and upper class mothers and fathers lose children to heroin overdose, maybe the nation will wake up and pay attention to addiction in general, thus creating a path to apply fundamental solutions. We’ve wasted enough time, money, effort and lives battling drugs as if we can make an imaginary Drug Invader surrender. As along as the demand for drugs grows, the supply will follow. We need innovation, creativity and perseverance to find true, lasting solutions

Treating Heroin Addiction

ndc-logoThe good news in the midst of the heroin epidemic is that treating heroin addiction is possible and recovery is likely if a comprehensive treatment plan is followed long term. There are many recovering heroin addicts in Narcotics Anonymous who’ve been drug free for decades. NA is not the only way to maintain long term recovery, but it’s one of the best, proven ways. Treatment of heroin addiction has a long history as we’ve found our way to where we are today.

One of the earliest attempts at heroin treatment was in 1935 at the Public Health Service Narcotic Hospital in Lexington, Kentucky. This facility was a combination of hospital, farm and prison. The recovering doctor who started an inpatient treatment facility that I worked at in 80s had gone through this treatment decades before when he was legally forced into treatment. This early treatment model tried to modify the patient/prisoner’s behavior. The idea was to instill a sense of responsibility and values through hard work and the isolation of a prison. The problem with this idea is that the doctor I referenced above had these qualities instilled in him from his childhood and medical training and became addicted to narcotics anyway. The doctor addict did not lack a good work ethic. I’m sure working on a farm helped his gigantic ego, but this wasn’t the cure for addiction. The treatment also proved ineffective for tough street addicts from the inner cities — they didn’t respond too well to milking cows and slopping the hogs.

The early failures hardened ideas that heroin addicts and alcoholics and such were incorrigible — they were irresponsible thrill seekers — they were mentally ill — they just wanted to escape — on and on. Synanon was one of these failures — at first, Synanon was based on Alcoholics Anonymous, but it took an ugly turn toward aversion therapy, shaming the addicts, shaving their heads and making them carry around disparaging signs, and really crazy stuff. Eventual discoveries in neurobiology regarding addiction changed the nature of treatment, although old ideas still abound that aversion therapy or religious conversion or jail time or talking therapy, etc, will resolve the problem. The better understanding of addiction created the Hazelden/Minnesota model of basically 28 day inpatient treatment based on addiction as a disease. Heroin treatment mainly went the way of maintenance through Methadone clinics until Suboxone, and other Buprenorphine products.

Currently, inpatient treatment has shared the load with outpatient treatment. Intensive outpatient programs utilize group therapy, education, medically assisted treatment and individual sessions to prepare the client for long term recovery management. Outpatient treatment is less disruptive, and the clients can attend treatment around their daily schedules and work. With medically assisted treatment, a heroin addict can get past the withdrawals and attend treatment long enough to learn long term coping skills and how to avoid relapse. This has been a major improvement. Although withdrawals from heroin won’t kill a person, the withdrawal is so painful that most people will not make it through the withdrawals without using heroin. Then, because they remember the pain of the withdrawal, they don’t try, or they go to a Methadone clinic to get maintenance doses. There are pros and cons to Methadone treatment, and I won’t get into that here. The good news from my perspective is Buprenorphine. Suboxone, the most popular form of Buprenorphine, acts on the opiate receptors and stops withdrawal (an oversimplification)– it’s an amazing drug, and you have to read the scientific explanations to really understand it. When a heroin addict can enter treatment without the fear of withdrawals, they can learn the same coping skills as the alcoholic to start a long term recovery management program. Addiction treatment which aims at drug free recovery is similar for alcohol, cocaine, opiates, benzos, etc.

No drug like Buprenorphine is a cure-all, it’s just a beginning, a tool that allows the heroin addict to enter treatment and establish a recovery routine that’s life long. The goal is to wean off the Buprenorphine once the person is established in recovery. We’ve seen great results with this model. Yes, heroin addiction is a huge national problem, but treatment works. Relapse happens, as in all medical conditions, but relapse is not a necessary part of the recovery process – it doesn’t have to happen. Many heroin addicts enter treatment and never use again — it can happen and it does. The old idea that treatment doesn’t work, especially for heroin addicts, has to be smashed. Treating heroin addiction is the fundamental solution to the heroin epidemic. The problem is that not all treatment efforts are equal — we must establish very strong national standards of treatment based on what works.  I’ll write about the stigma of heroin addiction in the next few days.

Understanding Heroin

Understanding heroinIt’s difficult to find fundamental solutions when a problem is misunderstood as symptomatic of something else – the application of symptomatic solutions to perceived symptomatic problems leads in circles with no real resolution. Heroin, though it’s been around since at least 3400 BC, is still misunderstood. How can this be? Drug smugglers and dealers have a better grasp than our officials tasked with dealing with the heroin problem. They understand the fundamental nature of an addictive drug. They know that addicts come from all walks of life, and that once addicted will pretty much do anything to get the drug. When there’s a demand for a product there’ll eventually be supply. Government efforts to deal with addictive drugs have focused on supply, trying to stop the supply. A current Presidential candidate wants to solve the heroin problem by building a wall at the southern border. Heroin addiction is a not a problem that’s created by porous borders.

Fundamental solutions to heroin addiction, and addiction in general, will originate on the demand side. Prohibition ended in failure because the demand for alcohol overwhelmed restrictions on supply. It’s my sincere belief that if all the money now put in the War on Drugs were put into education, prevention and treatment, we’d be much further along in the development of fundamental solutions.

There are few real conversations taking place across the US that deal with fundamental solutions to the fundamental problems of addiction. Addiction is mainly misunderstood, especially heroin. Below is a list of myths and old ideas from www.alcoholrehab.com that don’t hold true with all addicts:

Drug Addicts Fit a Stereotype

The stereotypical drug addict is somebody who:

* Spends a great deal of time in alleyways in the bad side of town.
* Have legal problems and a criminal history.
* Steal from family and friends.
* An individual who wears dirty unkempt clothing and doesn’t invest much time into personal hygiene.
* They move from low paid job to low paid job or are more likely unemployable.
* Estranged from their family.
* Sad people who have nothing good in their life.
* Drug users are stereotypically under 40 years of age.
* Junkies have no ambition in life.
* They are usually homeless and live in derelict buildings with other junkies.
* They are unable to maintain a healthy romantic relationship.
* They are usually looked upon as a lowlife in their community.

The reality of drug users can differ greatly from the stereotype. Many substance abusers have a well maintained addiction. These are often individuals who:

* Never visit back alleyways in the seedier parts of town. The person supplying them with drugs may even be wearing a suit and working in an office.
* Have never had any legal problems or be on the police radar.
* Most addicts have never needed to steal money from family and friends.
* They may wear expensive clothing and be perfectly groomed.
* They may have a successful career and by highly respected by their peers.
* Many addicts are loved and cherished by their family and friends.
* They can appear at least outwardly happy and be extremely positive about the future.
* Drug addicts can be of any age. There are an increasing number of elderly people who are abusing drugs – it has even been referred to as a hidden epidemic.
* These individuals can be highly ambitions and driven people.
* They may live in a big expensive house.
* They can have a loving partner
* Many addicts are highly respected in their community. Most of the people who know them would not even guess that they had even tried recreational drugs.

The stereotypical image of the drug addict can have negative implications. It makes it easier for people to hide their substance abuse problems. They can kid themselves that so long as they do not fit the stereotype they do not really have a problem.

Understanding the problem as one that can affect anyone, forces the realization that it can be a brother, a daughter, yourself,  a next door neighbor, a boss, a physician, etc. Education and prevention entail deep understanding and a change of mind regarding mood-altering drugs. It takes addiction away from moral judgment to a place where reason, understanding and choices play a larger role. Maybe kids should understand that they don’t have to drink alcohol or smoke pot when they grow up, that a life of abstinence is a good choice. It also means that just because someone chooses to use drugs, it doesn’t make them a terrible, immoral, weak person. If someone develops an addiction problem, it’s a medical concern that will respond to treatment. Once we take the mystery and the myths away, we can rationally, intelligently and objectively search for and find fundamental solutions. Heroin seems like a new, scary problem, but heroin addiction is an old problem – is the same as painkiller addiction to an opioid — both can happen to anyone — both are treatable.

Heroin Epidemic

prescribed pain-killers

Opiates

 

Concern for the expanding heroin epidemic grows as more people become addicted and seek treatment. As of now only 11% percent of those in need of treatment seek treatment, yet there are still waiting lists at federally-funded rehab facilities.

According to the article linked above, jails are becoming detox centers. Jail is counter-productive, to say the least. It’s questionable whether government can solve the heroin problem, but politicians are beginning to talk about the problem more and more. Because there’s been such a poor response to addiction in general in the U.S., not many in D.C., if any, have a good answer. There are plenty of symptomatic solutions from government and the healthcare field, such as clean needle programs, Suboxone, and law enforcement to attack the supply, but the fundamental problem is demand caused by addiction, and there’s a shortage of efforts to apply fundamental solutions.

Also, the problem is not isolated to heroin. Heroin is an opiate, and opiates are sold by pharmacies. Too many doctors are too freely prescribing opiates when alternative pain management methods are available. As millions use legally prescribed opiates, some become addicted — then when they ‘re cut off by the doctor, or the pharmacy won’t fill prescriptions that are gathered by doctor shopping and getting prescriptions from more than one doctor, the person goes into withdrawal and seeks opiates wherever they can be found. This is how many get on heroin.

But the addiction problem goes far beyond heroin and prescription opiates. Because heroin is perceived as an evil street drug by so many, when the use of heroin increases it creates a  great deal of concern, but addiction is addiction and a drug and is a drug. The national concern over alcoholism is mild compared to the concern over the heroin epidemic, but there are far more alcoholics and far more deaths caused by alcohol. Alcohol just happens to be legal, but, as a health concern, alcoholism is so much worse than heroin that it’s an act of denial to call one an epidemic and not the other which is a greater problem by far.

Addiction is a huge problem affecting millions of individuals and their families. Perhaps as politicians and healthcare spokespeople sound the alarm about the heroin epidemic, they’ll include the greater problem of addiction in general. Then maybe one day we won’t need specialized solutions in emergency situations to meet an epidemic of drug use — the treatment infrastructure can be in place to deal with the ongoing problem of addiction to a number of drugs. Addiction is a problem that the healthcare field can effectively deal with, once there’s enough societal awareness and enough smart people seeking fundamental solutions.