In my last blog, I implored our public officials to not just talk the talk, but to really walk the walk. But doctors, nurses, nurse practitioners, physician assistants and other medical professionals must not take a back seat; and in fact, health care professionals have been abdicating their responsibilities! Who better to explain the causes and the solutions to the current opioid epidemic?
I was recently invited to speak to doctors and physician assistant students at Mercer University College of Health Professions. I took this opportunity to discuss a variety of topics, including: defining the difference between Drug Tolerance, Dependency and Addiction and why opioid addiction is a chronic illness – an end organ disease affecting brain structure and function. I emphasized that one may choose to use a drug, but no one chooses to become addicted. The stigma of addiction and the words we use to describe it needs to change. It is not “Substance Abuse”, but rather “Substance Use Disorder”. It is a bio-psycho-social illness that has no socio-economic barriers and has been proven to respond to medication assisted treatment. In fact, the relapse rates of Addiction is similar to that of other chronic illnesses.
Most importantly, I stressed the need for our doctors, nurses, nurse practitioners, physician assistants and other health care professionals to step forward and not abdicate our responsibility to educate.
Consistent Talking Points to Educate
Not an Inner City Disease
Equal Opportunity Disease
Who/What to Blame for Heroin Epidemic
I closed my presentation at mercer University with a quote from an op-ed from the Boston Globe that I wrote several years ago, and remains true today:
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.
Last month, I had the honor of serving as a keynote speaker at the New Hampshire Citizens Heath Initiative Annual Symposium, which was hosted by the University of New Hampshire’s Institute for Health Policy and Practice. During my presentation, I spoke about the pervasiveness of the opioid/heroin epidemic, my reasons for writing Addiction on Trial and special considerations that must be given to adolescents. I concluded my address with a call to action, touching upon approaches and strategies that would help to destigmatize this rampant disease and save countless lives.
As I spoke, Kate Crary, Educational Coordinator at the University of New Hampshire (and an extremely talented illustrator) took graphic notes on the main points of the address. Kate's infographic is a fabulous visual representation of the complexity of the opioid/heroin epidemic, the disease of addiction and the work that I, along with many others, are doing to spread awareness about the problem. Kate’s work is too impressive not to share with you all, and I thought it would be beneficial to frame this blog post around it.
My keynote address was titled The Heroin/Opioid Epidemic: A Call to Arms. Opioid and heroin addiction is a far-reaching, equal opportunity disease that reaches across socioeconomic and geographic boundaries; and this contagion is spreading in a manner unlike any other I have witnessed in my 35 year career in Addiction and Emergency Medicine. The opioid epidemic touches all of us in one way or another, costs society hundreds of billions of dollars each year and will “take a village” and a “thousand points of light” to stop it. We must accelerate our pace of action. Today, the number of yearly opioid-related deaths has surpassed that of gun violence and car accidents. The annual death rate from drug overdoses now exceeds the total number of Americans who died in the Vietnam and Iraq wars combined; and more than 80% of the drug overdose deaths are related to opioids, including fentanyl, heroin and prescription medications. The time to act is now and we must insist that our local, state and federal politicians and public officials treat this for what it is - a life and death priority.
Although I commend President Trump for finally addressing this issue, using words such as “shameful” or not increasing funding in any meaningful manner misses the mark. It is a Public Health Emergency, but let’s not stop there – it is a National Emergency; drug overdoses are responsible for175 deaths every day! It is not enough to just talk the talk; it is time for our public officials to really walk the walk!
President Trump stated in his Afghanistan speech of August 24, 2017 that, “We are not nation building again … But to prosecute this war, we will learn from history”. Fortunately, our news media decided not to publish fake statements without analysis. Thank you Domenico Montanaro, NPR Political Editor, for the commentary to POTUS’ Address on Afghanistan.
As it relates to “nation building”, “learn[ing] from history” and our current opioid epidemic, Montanaro sets the record straight:
Plenty of countries have gotten bogged down in Afghanistan for a reason — it’s very difficult to find socioeconomic and political solutions. It’s a desperately poor country with few to no alternatives to poppy in its economy. Poppy is used to create heroin, and Afghanistan is responsible for 85 percent of the world’s heroin supply, according to a 2015 report from the U.N.
Per Trump, the focus of the United States will be on using Afghanistan as the venue for operations focused on serving American security ends, not building schools or roads or power plants. That hasn’t been the objective of Americans in Afghanistan for several years, but the president apparently believes that decrying “nation-building” resonates with voters exhausted by the years-long commitment there.
Before the war, the Taliban subsidized Afghan farmers to grow food crops rather than opium. Opium poppy is the plant from which heroin is made. When the Taliban fled or went into hiding, the farmers lost their financial support to grow food, and returned to growing heroin, a crop that thrives in regions of Afghanistan. The increased amount of heroin production flooded the European markets. As a result, the heroin being produced in South America and Mexico was no longer needed in Europe and the excess supply flooded the United States.
It may be politically expedient to decry “nation-building” when justifying another surge of troops in Afghanistan, but without our subsidizing Afghan farmers to once again grow food crops, the world-wide heroin market will continue to thrive. The result will be ever more lost lives and increased costs related to treatment or even worse, caring for those who have overdosed with resultant cognitive or physical disabilities.
President Trump has declared that the opioid crisis is a national emergency. “Building upon the recommendations in the interim report from the President’s Commission on Combating Drug Addiction and the Opioid Crisis, President Donald J. Trump has instructed his Administration to use all appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic,” the White House said in a statement.
The President’s Commission is correct that it is important to:
enforce requirements that health plans provide the same level of services for those with mental health and substance use issues
equip all law enforcement officers with the opioid overdose antidote naloxone;
provide federal funds to develop sensors to detect fentanyl; and
increase the use of medication-assisted treatment for opioid addiction in prisons
But is not an ounce of prevention worth a pound of cure? I don’t care if you don’t want to call it nation building – but let’s use common sense and learn from history. We can pay now (to subsidize the Afghan farmers to grow food crops) or we can pay more later (from heroin continuing to flood the European and North American continents).
Thought you might like this excerpt from Addiction on Trial, which serves to reinforce the need to learn from history.
Welcome aboard the Margaret Two, a scalloping vessel headed out to sea with Oxycontin on board!
It was a clear Wednesday afternoon, June 2, 2004, when the Margaret Two set out right on schedule to navigate through the Gulf of Maine to Georges Bank, leaving Portland’s modest skyline behind. The calm, soft ripples etched the water’s surface of this North Atlantic harbor. None of the four crewmembers paid much attention to the water’s beauty as they had all had the experience of leaving a calm port, only to be confronted by angry seas with barely a moment’s notice.
Captain Clode, a soft-spoken gentleman in contrast to his burly body, had been persistent in his nagging to get the crew on board for the early afternoon departure. Since this was their first trip in several months, the men were somewhat lackadaisical. As the crew gathered on the dock, looking a little haggard, Clode cajoled and herded them. He had his job to do, not unlike an owner of a small manufacturing company, encouraging his workers to hustle to their assigned spots so the workday could begin. Time is money and nowhere is this truer than on the high seas. The engine is running, gas is being consumed, and costs are being incurred. The immediate goal was to expeditiously depart port and get out to Georges Bank so the manufacturing could begin. Captain Clode had money on the line, and what he needed to manufacture was fish, specifically scallops. He knew the crew would shift into high gear once the scallop beds were located, but while on dry land, they had little incentive. Leaving loved ones and playful times behind was not the worst of it. Wondering what you might be missing while out at sea was certainly difficult, but somewhere in the recesses of your mind lurks the fear of whether you will ever return to that which you are leaving behind.
“Come on guys; it’s not like we’re heading out for a picnic. Georges Bank isn’t just off the coast, you know. We’ve got a ways to go and some work to get done. Hey, the sooner we get going, the sooner we get back, so if you would please get your lazy asses moving a little faster, it’d be much appreciated.” …
There was less of a problem with alcohol being smuggled on board these days, especially on the Margaret Two under the captain’s watchful eye, than with drugs. Drugs were less easy to detect than alcohol and more easily portable. Heroin, in the class of drugs called opiates, and its first cousin Oxycontin, a long-acting prescription opiate, were rapidly becoming the drugs of choice in virtually all of the fishing villages of coastal New England. Oxycontin pills, referred to as “Oxys,” were easily ingested in contrast to heroin, which customarily was either injected or snorted.
Initially the drugs were mostly limited to large cities but the enormous profits inherent to the drug trade encouraged expansion of markets, and the sociological harm metastasized, weaving an intricate web that encompassed all regions and spared no locales, finding its way into the veins of small cities and rural towns. The New England seacoast cities of Boston, New Bedford, and Portland had become major distribution centers for heroin, while the illicit Oxycontin trade also grew exponentially. Coast Guard patrols seemed more likely to identify and deter terrorists and illegal immigrants from entry into the United States than to intercept drug smugglers….
Heroin was much cheaper, easier to find on the street, and, due to its increased potency in recent years, a more cost-effective drug. The decision to send troops to Afghanistan created a situation whereby the farmers, who previously had been subsidized by the Taliban to cultivate crops other than opium, were left without support or funding. America did not fill the void and as a result there was a return to growing opium, the precursor to heroin. The warlords cranked up their opium production, flooding the market and increasing worldwide availability. The Taliban gradually returned to the fields, but this time as a Mafia-like security force, “protecting” the farmers and taking a cut of the profits from the opium production. This unintended result of the war in Afghanistan kept the heroin supply up and the cost down. Much of the heroin being sold was uncut, making it much more potent.
Too many fishermen had been exposed to these easily obtainable narcotics and varying degrees of use was endemic. Those with an infrequent habit, which were few because of the difficulty in curtailing use once it started, could be physically and mentally functional without the drug. For those addicted, due to higher quantities consumed or more frequent use, a day at sea when heroin or a replacement drug was not readily available was a horrific day in hell. The Margaret Two was not immune to the effects of this contagion as it headed out to Georges Bank.
We have heard a lot lately about “alternative facts” and “fake news” but I have not heard any mutterings about these misgivings as it relates to the current opioid epidemic. But then again, despite the number of deaths being claimed every day by fentanyl and heroin and in contrast to the sound bites heard during the presidential primaries, no one is talking facts about addiction. For that matter, politicians are barely even talking about addiction! We are talking a lot about the murders caused by immigrants, and there is no one doubting that immigrants do murder people, but so do native born Americans, and at a much higher rate than first generation immigrants. So, yes, we need to be concerned why second generation immigrants commit crime at rates much higher than their forefather immigrants and at a rate similar to native-born Americans; but if we are really serious about saving lives, let’s also talk about that which claims more lives than gun crime or automobile accidents – the disease of addiction. Let's not get caught up in the fake news that building a great wall or cutting Medicaid funding and trashing the Affordable Care Act will stop the influx of drugs or assist those afflicted with the disease of addiction. I hope you will read on.
Overall, overdose deaths rose 11 percent last year, to 52,404. By comparison, the number of people who died in car crashes was 37,757, an increase of 12 percent. Gun deaths, including homicides and suicides, totaled 36,252, up 7 percent.
More than 50,000 Americans died from drug overdoses last year — the most ever.
The disastrous tally has been pushed to new heights by soaring abuse of heroin and prescription painkillers, a class of drugs known as opioids.
Heroin deaths rose 23 percent in one year, to 12,989, slightly higher than the number of gun homicides, according to government data released Thursday.
Deaths from synthetic opioids, including illicit fentanyl, rose 73 percent to 9,580
According to data from the Centers for Disease Control and Prevention, 30 states saw increases in overdose deaths resulting from the abuse of heroin and prescription painkillers, a class of drugs known as opioids. New Hampshire saw a 191 percent increase while North Dakota, Massachusetts, Connecticut and Maine had death rates jump by over 100 percent.
“What we’re seeing in the streets right now is fentanyl mixed with heroin, as opposed to heroin mixed with fentanyl.”
“Everything happens for a reason, and I’m thankful it did happen, because I have a new look-out on life,” said Nathan Johnson, who said a recent overdose has him ready to stay clean. “They threw me in the shower, they did 18 minutes of CPR before the cops got there. Nothing was working, so the cop came in and he had to use two Narcans. It brought me back to life,” said Johnson. He can now use naloxone — or Narcan— on others. Kentucky’s ‘Good Samaritan’ law protects people who are administering the drug in an effort to keep someone alive.
“We’re often accused of being enablers, and we are. We are enablers. We enable people to live” said Read.
In 2015, 276,000 adolescents were current non-medical users of pain reliever, with 122,000 having an addiction to prescription pain relievers.
In 2015, an estimated 21,000 adolescents had used heroin in the past year, and an estimated 5,000 were current heroin users. Additionally, an estimated 6,000 adolescents had heroin a heroin use disorder in 2014
Heroin overdose deaths among women have tripled in the last few years.
Overall, there are about 16,000 murders and 10,000 drunk driving deaths a year (the drunk driver is the person killed more than 60 percent of the time)
About 11.1 million unauthorized immigrants accounted for about 3.5% of the total national population in 2014, according to Pew Research Center. Certainly some undocumented immigrants do commit violent crimes
While Trump’s discourse suggests waves of immigrants equals violence, scholars say studies don’t substantiate that message.
Research on immigrants and crime finds that immigrants are not more likely than U.S.-born individuals to take part in crime, said Christopher P. Salas-Wright, an assistant professor at Boston University’s School of Social Work.
"Again and again, we see evidence that they are not," Salas-Wright said. "In fact, it’s the opposite."
Studies show that for the most part, people who migrate are a self-selecting group who want to better their lives, provide for their families back in their home countries and who don’t want to risk getting in trouble with the law, said Kubrin, the criminology professor at University of California, Irvine.
The American Immigration Council, a pro-immigrant nonprofit, analyzed data from the Census’ 2010 American Community Survey and found that about 1.6 percent of immigrant males between 18 and 39 years old were incarcerated, compared to 3.3 percent of the native-born population in that same age group. (The Census does not specify legal status.)
Results suggest that the myth remains; trajectory analyses reveal that immigrants are no more crime-prone than the native-born. Foreign-born individuals exhibit remarkably low levels of involvement in crime across their life course. Moreover, it appears that by the second generation, immigrants have simply caught up to their native-born counterparts in respect to their offending. Implications of the findings for theory and future research are discussed.
It has been quite a journey over the past several years trying to educate many members of the Legislature and the Governor of Maine as it relates to the benefits of Medication Assisted Treatment for Opioid Dependency. I would like to say that they have been as receptive as the Police, the Portland Chamber of Commerce, and many citizens - but unfortunately, I can not say that!
But I must commend Dr. Mary Dowd on a superlative piece, and what makes it so powerful is it could just as easily be titled, "Patients Do Matter"!!! Listen to the Voices of Addiction.