I recently had the opportunity to talk at the Portland Maine Chamber of Commerce monthly meeting. I hope you will listen to my presentation, and let me know if you agree or disagree. But regardless, if we do not aggressively address this scourge to society, we will continue to spend inordinate funds on treating the consequences of addiction. As they say, "You can pay now, or you can pay more later, but you are gonna pay."
Many thanks to Channel 2 WLBZ Portland for allowing me to explain some of the issues regarding the current Heroin/Opioid Epidemic - and don't think for a minute that it is only affecting Maine. In fact, it has become a worldwide issue, so maybe we should more appropriately be refer to it as a Heroin/Opioid Pandemic.
I am honored to have Geoff Kane, MD, MPH as a guest blogger this week.
I have known Geoff for many years and he is not only an extremely competent physician, but also possesses the highest degree of compassion for patients and the utmost commitment to assisting those afflicted with the disease of addiction. Dr. Kane is the Chief of Addiction Services at the Brattleboro Retreat in Brattleboro, VT. He is board Certified in Addiction Medicine and Internal Medicine, a Fellow of the American Society of Addiction Medicine, and Chairs the Medical-Scientific Committee of the National Council on Alcoholism and Drug Dependence.
If you want to learn more about Dr. Kane, please visit: geoffkane.com
Thank you Geoff for permitting me to post your insightful and thought provoking blog, which was also posted by the National Council on Alcoholism and Drug Dependence, Inc. (“NCADD”).
Curbing Addiction Is Everybody’s Business
By Geoff Kane, MD, MPH
Addiction statistics are scary. For example, excessive alcohol causes an estimated 88,000 deaths per year in the United States. Deaths from cigarette smoke exceed 480,000 per year. In 2013, about 100 Americans per day died from drug overdoses. The annual cost to this country of addiction and other substance abuse—including healthcare, crime, and lost productivity—is over $600 billion.
Such damage ought to prompt interventions that are swift and sure, but that is not the case. Not only have severe social and economic consequences of addiction been with us for a long time; some measures are getting worse.
Conflicts of interest impede the prevention and treatment of addiction by inhibiting individuals throughout society from adopting alternative actions that would reduce the toll of addiction. If we attribute all responsibility for addiction to addicted persons themselves, we are like a naïve family member who says, “It’s your problem. Take care of it.”
People in all walks of life contribute to the proliferation of addiction—whether they realize it or not. The clearest conflict of interest, however, may indeed lie within the individual with addiction. More addictive substance will surely forestall withdrawal and ease emotional and physical distress, and perhaps cause pleasure as well. In the “logic” of addiction, competing priorities such as family, career, and citizenship are eclipsed by the drive to obtain more substance.
Yet others’ conflicts are also part of the problem. Such as well-intentioned family members who long for loved ones to get sober but later undermine their loved ones’ sobriety when abstinence reconfigures the distribution of power in the household. Or well-intentioned addiction treatment professionals and mutual-help members who are so attached to specific treatment approaches that they fail to engage newcomers who don’t align with them. Or well-intentioned community members who only support addiction treatment centers located someplace else, making treatment less accessible in their own neighborhoods.
Conflicts of interest often involve money. Do some doctors prescribe controlled substances too freely? Could some addiction treatment facilities provide less than rigorous care so that patients will return? Are some health insurance companies more invested in restricting access to care than providing it? Are some managed care reviewers rewarded when they deny coverage instead of certify it?
In order to be used, addictive substances must first be available. Use increases when these substances are easily obtained, which promotes new addiction along with recidivism among the abstinent. The business interests of large segments of the pharmaceutical, alcoholic beverage, tobacco, and legal marijuana industries are in conflict with the health interests of the public. Might the business interests that boost substance availability also influence decisions of government and other policymakers?
Besides availability, belief that the risk of harm is low or otherwise acceptable is a second condition to be met before many individuals will initiate use of addictive substances. Numerous people who subsequently developed addiction were given a false sense of security from well-intentioned peers, family members, healthcare providers, and the media including advertisers, reporters, and editors.
Respectful, nurturing interpersonal relationships in families and throughout society reduce the vulnerability of young people to addiction and make recovery more attainable for those seeking a way out. Yet people continue to depersonalize one another, reacting to stereotypes rather than appreciating individual human beings.
Addiction statistics are not likely to improve until we all identify and accept our own unavoidable share of responsibility for curbing the problem. Individuals seeking recovery are responsible for accepting support and changing elements of their lifestyle. Communities—meaning everyone, including law enforcement, business, government, healthcare providers, third party payers, and the media—are responsible for reducing the availability of addictive substances and permissive attitudes toward their use; making individualized addiction treatment accessible; reducing barriers to transportation, employment, and housing; and replacing stigma with respect.
A collective desire to be part of the solution may not be sufficient to make a difference. Healthy change proceeds more reliably when individuals are held accountable. For example, recovery from addiction often requires that family, professionals, and recovering peers keep tabs on those entering and maintaining recovery and impose consequences if they get off track. Likewise, we may all better meet our responsibilities if we gently but firmly hold one another accountable to act on addiction in ways that address the overall picture rather than just our own narrow point of view.
To think about: Will manufacturers and distributors of illegal addictive substances ever support the common good? Is accountability under the law the only possible incentive for them to change?
After 10 weeks we are finally finished with blaming, but what a way to end – let’s blame our politicians and our other public officials. Why? - Because if all our public officials showed the leadership and courage of Vermont Governor Shumlin, we would have another solution to curb the heroin epidemic. As I stated in an Op-Ed in the Boston Globe:
There should be just as many public service announcements about addiction as there are Viagra and Cialis commercials. In addition, expansion of addiction treatment services in jails would help to mitigate much of the revolving door phenomenon. Furthermore, we should demand that our medical schools and hospitals improve addiction training of our physicians. While there is plenty of blame to go around, let's focus on the solutions. The scourge of addiction is in all of our yards. The solution is to decrease the demand with bold public initiatives and a change in attitude. It is both the humanitarian and fiscally responsible thing to do.
We need our politicians and public officials to stand up for what is right and bring forward the real facts about addiction. I explained this further in another Op-ed submitted to the Boston Globe:
We must cut back on the demand to stand a chance of limiting the financial damage. And to our politicians, I know this is a politically hot issue, but lives and dollars are at stake and it is time to lead the charge to educate through scientific fact and not out of fear. I commend Governor Shumlin of Vermont for spending his entire state of the state address on this essential economic issue and his call to attack the epidemic on the demand side (treatment); recognizing that putting more people in jail may make us feel good on the short term, but does not solve the problem. Governor LePage of Maine addressed the issue of drug addiction as an economic issue as well, but he unfortunately spoke not of increased funding for treatment and access to care, but only of expanded law enforcement and judicial response.
As the death of Philip Seymour Hoffman’s has again reinforced, drug addiction, including heroin abuse, is an equal opportunity disease affecting all socioeconomic strata; and knows no boundaries. This is not a problem of the welfare state or the poor or less fortunate. It is NOT NIMBY!! The disease is present in our impoverished neighborhoods as well as our wealthy suburban communities and in our resort towns and backwoods … Establishing treatment centers for addiction in one’s own locale should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center; both of which are illnesses that may be related to the disease of addiction. NIMBY no longer works!
We can make great strides to solve the scourge of heroin addiction, but we need to stop blaming and put words into action. As I have discussed over the past ten weeks, there is plenty of blame to go around!
Addiction On Trial exposes many of the reasons why we have a heroin epidemic; Police Chief, François Bergeron, understood the political and emotional realities of heroin addiction. The story may be fiction, but it is based on medical, legal and political truths. IT IS TIME TO STOP BLAMING AND TIME TO START IMPLEMENTING SOLUTIONS! Thank you for continued interest in my blog site and I hope that Chief Bergeron’s insights will make a difference (Chapter 15):
Although Chief Bergeron had witnessed first-hand the increasing influx of drugs into not only his community but into all of Downeast Maine, Annette's death and the likelihood it was drug connected posed challenges never before encountered. Although the chief understood that drug addiction was a complicated topic and a burgeoning problem, this view was not shared by most, many of whom even refused to believe that Downeast Maine had a significant drug issue despite the fact that a methadone treatment center about two hours away had recently opened to treat the epidemic of heroin and Oxycontin addiction in the region. There had been a prolonged battle within the ranks of city government and among the citizens who irrationally opposed the siting of the treatment center, delaying its opening for years. Eventually, there was some acknowledgment that Downeast Maine, no different than innumerable regions and communities up and down the east coast, had a heroin and Oxycontin problem, but it was greatly minimized. The clinic was finally approved after much rancor, but treatment was initially limited to one hundred patients. Since no one ever wants to believe its municipality has a significant drug problem, it was decided that opening up one hundred outpatient slots would more than satisfy the need and help to quell the escalating controversy. The clinic filled all its patient slots within a month and droves of needy patients were placed on waiting lists.
This struggle to establish treatment centers was not unique. There were similar controversial and heated discussions in many cities and towns … Lawsuits between municipalities against well-intentioned medical providers were not unusual. Paradoxically, at about the same time, a New England Governor’s Council Forum had convened … Presentations by illustrious speakers demonstrated the extent of the epidemic …What Bergeron remembers most from the conference was the statement by a prominent elected official that “these are telling times when elementary and middle school children are offered a bag of 70-80 percent pure heroin for the price of a double scoop ice cream cone.” The forum’s mantra was interdiction, education, and treatment. This battle cry was good in theory, but in practice it was a different story at the local level. NIMBY—“Not In My Back Yard”—was the rallying cry of most municipalities. No town would admit to having a significant drug issue; it was always the next town over that had the problem. The rationale was based on the fear that if a drug addiction center was established in one’s own town, which of course did not have a problem to begin with, all the addicts from the neighboring townships would spread the scourge as they migrated for treatment, thereby creating a drug problem that never before existed. Despite the documented epidemic of drug abuse across the nation, hardly any individual town, if you spoke to the locals, had much of a problem.
Chief Bergeron understood the apprehension of the townsfolk, that a drug treatment center in West Haven Harbor would label the town as a drug haven. The tourists would be frightened and stay away, the local economy would falter, and everyone would suffer. As a result, many in need of treatment never got it. Chief Bergeron’s concern for the lack of treatment options was now a secondary issue. He recognized that the townsfolk's anger directed at an addict from away was irrational, especially before all the facts were known, but he also understood their desire for retribution for Annette's murder.
Welcome back to my addiction blog and I hope that as we discuss the final four reasons for the heroin epidemic, you will remember that there are solutions within reach. The issue of Supply & Demand directly relates to both the problem and the solution. Let me explain further.
Heroin production and distribution seems to be an unending saga; especially after the consequences of the War in Afghanistan. No matter how many drug lords and kingpins we kill or arrest, there is always someone willing to fill the void. Money and power is the “addiction” that attracts people to the illicit drug world. Interdiction and attempting to close our borders to drugs is a losing battle; and increasing tax payers’ burden by growing law enforcement and judicial budgets has been unsuccessful. Yes, we can arrest and incarcerate all the current drug pushers, big and small, and we can continue to burn the fields of the countries that produce opium; but the profits of this organized industry of drug production and distribution is so great that there is a continuously replenishable supply of people who want to be the next kingpin or the next local drug pusher.
Let’s look at this from a different perspective, using an economic analysis. If we cannot limit the supply, then we must look at the demand side of the equation. If there is decreasing demand, there will be decreasing profits and therefore decreasing production. I am not saying that we should abandon attempts to bring to justice those who are poisoning our communities with a constant flow of illicit drugs. What I am saying is we should attack the demand side of this problem with greater vigor. We spend $400 Billion Dollars annually dealing with the consequences of addiction. This should be incentive enough to advocate for more preventive programs and more treatment centers to decrease demand.
As I stated earlier in this blog series of the Ten Reasons for the Heroin Epidemic, there is plenty of blame to go around. We must focus on the solutions. The last blog dealt with NIMBY, which is interconnected with the Supply and Demand issue discussed today. Moving forward, over the next several weeks, we will address three more interrelated reasons and pose other solutions. I hope you will stay tuned for Reasons 8 - Physician Training & Biases; 9 - Mental Health Treatment and 10 - Public Officials.
Please enjoy the following excerpt from Addiction On Trial that gives insight into Jimmy’s inner struggles and I hope to see you next week.
What the defense team did not appreciate was the inappropriate loyalty one drug addict feels for another and the risks they will personally take to protect a drug-dependent comrade. As time went on, Jimmy would become more forthcoming, but a degree of brotherly protection persisted…
Jimmy struggled with this dilemma as it ripped away at his core, tossing and turning night after night in the confines of his cell until he felt soulless. He wished he could have just one session with his therapist. He dreamed, mumbling aloud as he conjured up Saul Tolson’s response.
“Saul, I just can’t tell on Travis…. His life is ruined. And then if I rat him out as the one who bought the heroin and the cocaine for Annette and me . . . I can’t do it! Just because he offered me the drugs, I didn’t have to use them. I knew better, or I should’ve. Damn it, if I could trade my life and bring back Annette and make Travis whole again, I’d do it. Why won’t they believe me?...
“Jimmy, I don’t think it’s that simple. And I think what you are saying is that you feel like you really let yourself down.”
Jimmy tossed in his hard cot, with sweat dripping off his body. “Oh, Saul, if I had a belt, I’d hang myself. I’ll never rat on Travis! Even if I did, who would believe me? I just can’t go on.” Jimmy let out a scream, “I want to die!”
“Hey keep the noise down. Just because you killed someone doesn’t mean you need to wake us all up. It’s three o’clock in the morning. If you want to die, then just go do it and shut up!”
Jimmy did not respond to the incarcerated voice a few cells away, but now fully awakened, Jimmy just laid there, crying softly to himself.