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.
NIMBY – Not In My Back Yard – is the rallying cry heard from many politicians and citizens when asked if there is a drug problem in their neighborhood or if they would welcome a drug treatment facility. “Sure, maybe we have a problem, but it’s not that bad” or “it’s really worse in the next neighborhood over”, or “the next town over” or “the next state over.” Baloney – it’s in all of our yards and is as prevalent as the ragweed that grows in all of our lawns! It does not matter if we live in the city, suburbia, the Northeast Kingdom of Vermont, Downeast Maine or in the farmlands of America – it is truly everywhere!
To truly understand the magnitude of this problem we need to examine the economic impact of addiction to society. There have been reports that when one considers the cost of drug use related to law enforcement, crime, judicial costs, incarceration, emergency room visits, hospitalizations, lost worker productivity, and workers compensation; not to mention the deterioration of societal priorities or the overall risk to the public in terms of spread of disease (Hepatitis C & HIV) or secondary health and safety consequences such as domestic abuse or childhood asthma … the overall national annual cost exceeds 400 Billion Dollars. Moreover, as an example, to treat one heroin addict in an outpatient medication based treatment center with admission and yearly annual exams, laboratory screening for HIV and Hepatitis C, group and/or individual counseling on a regular basis, and frequent random drug testing, the cost for this patient is approximately $3,000 - $5,000 per year. Halfway houses can cost $20,000 or more per year and incarceration of this patient costs upwards of $50,000 per year. And even if one wants to ignore the scientific evidence that treating a heroin or “Oxy” opiate addict with a replacement medication such as methadone or buprenorphine is not simply trading one addiction for another, one cannot deny the documented fact that patients who enter into this type of treatment have an approximate tenfold decrease in criminal activity.
State legislators, our local politicians and our neighbors need to look critically at the facts and not adopt a NIMBY approach to drug addiction that is ruining lives and stealing our tax dollars by inadequately treating and preventing this epidemic from expanding. Heroin deaths are rising each year and one of the fastest segments of society developing dependency on opiates and heroin are suburban women in their 20’s and 30’s. The disease of addiction is in all of our back yards!
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 rural areas. 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!
Please enjoy this week’s excerpt from Addiction on Trial. Police Chief François Bergeron is keenly aware that disease of addiction is all around us!
The Chief was perturbed that Annette’s death and some of the circumstances were leaked within minutes, not hours. He had already received calls from the local TV stations. Bergeron did not welcome the added pressure created by the dramatic news reports of a murder with blood splattered all over the deceased’s car and the primary suspect from away in jail for heroin and cocaine possession…
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 throughout New England. 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 at the old City Hall near the waterfront at Faneuil Hall in Boston. Presentations by illustrious speakers demonstrated the extent of the epidemic. New England had a significantly higher heroin use rate than the rest of the country. Portland, Maine, and the Massachusetts cities of Boston and New Bedford were primary ports used for smuggling. Chief Bergeron had attended this forum as a member of Maine’s Drug Task Force Committee. 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 Ten Reasons for the Heroin Epidemic. This is the second and final primer to lay the foundation before launching into the ten reasons we currently have a heroin epidemic raging across our country. But before I proceed, I hope you all will read the recent article published in the New York Times on April 17, 2015 entitled, Serving All Your Heroin Needs. Here are two quotes that are extremely revealing:
“… selling heroin across the United States resembles pizza delivery.”
“… a new home for heroin is in rural and suburban Middle America …”
To better understand why pizza delivery of heroin works and how it found its way into suburban and rural America, there are three related terms that are essential to understand:
Tolerance refers to not getting as much bang for the buck. In medical terms, it is the body’s adapting to a drug which then necessitates consuming more of the drug to achieve the same effect.
Dependency refers to the state of having symptoms in the absence of the drug. Examples of withdrawal symptoms are the “shakes” after a heavy drinker stops drinking; or the chills, nausea, vomiting, abdominal cramping, etc. when a heroin addict is deprived of his/her next “fix”.
Addiction is the drug seeking behavior of an individual. However, a person who is dependent may not necessarily be addicted. Remembering from the last blog that the disease of addiction has bio-psycho-social aspects, a person may become dependent but not have the components of addiction.
For example, if sweet Aunt Tillie ends up in the hospital with severe intractable pain from a tumor pressing on her spinal column, she may be given an opiate such as morphine to reduce her pain until the tumor size can be minimized by radiation or chemotherapy or surgically removed. A few weeks of medication may be needed and during that time Aunt Tillie develops tolerance and dependency to morphine. After the tumor size is reduced and the pressure on the spinal nerves is diminished, the frequency and amount of morphine is gradually decreased to avoid withdrawal symptoms. After a week or so, Aunt Tillie will no longer require an opiate to eliminate her pain and will be showing no signs of withdrawal. After she is discharged home, she is happy taking an occasional non-narcotic pain medication like Tylenol or Ibuprofen. But how about the person who goes home and has some bio, psycho and/or social components of the disease of addiction. He/she may very well start looking for that euphoric “high” and start seeking drugs. That is the essential difference between dependency and addiction!
We are now ready to delve into the 10 reasons we have a heroin epidemic. Next blog we will focus on the injudicious prescribing of opiates by doctors as reason #1. But first let’s get a look at Jimmy, Annette and Travis – they are dependent and also addicted.
Annette laid out several lines of cocaine, one definitively larger than the other two. Everyone knew the “fat line,” as they jokingly called it, was hers. Travis prepared the portions of heroin, which had already been processed to a fine powder for snorting. They were now ready to snort their speedballs, a combination of heroin and cocaine. Annette much preferred an amphetamine rush, so her drug cocktail was heavily weighted with the cocaine powder and contained only a small amount of heroin. The reverse was true for the boys….
Within an hour after the speedball, Annette craved more cocaine, but she wanted to set an example for Travis, who undoubtedly would soon be itching for more heroin. Her cocaine buzz was starting to dissipate and numbing herself with alcohol served as a distraction to the hollow depressed feeling as a result of the depleted levels of the chemical dopamine in her brain. Dopamine, a neurotransmitter, is an essential naturally occurring compound that is required to stimulate the portion of the brain that elicits the feeling of pleasure. The greater the frequency and amount of cocaine used, the greater the amount of dopamine is depleted. This results in longer lag times for the brain to produce sufficient quantities of dopamine and therefore progressively longer periods of pleasure deprivation and sadness. This vicious cycle encourages more use, which only partially rectifies the effects of the depleted dopamine stores. Annette did not need a course in neurochemistry to understand that doing more and more lines was a never-ending journey.
As you may recall, my last blog listed 10 reasons for the current heroin epidemic. Over the next weeks, I will be addressing who and what to blame for this epidemic and the changing demographics of today’s heroin user, which has migrated outside of our major cities to suburban and rural America. But before we engage a detailed explanation of who/what to blame, to better understand the complexity of the issue, let’s review the biological, psychological and sociological aspects of addiction.
To understand the biological aspect of the disease of addiction, let’s look at it from the viewpoint of genetic predisposition. Years ago, Scandinavian studies demonstrated that your biological parents are the predominant factor whether you would develop the disease of addiction. The study followed identical (monozygotic) twins who were adopted into different families. The results demonstrated that the children most likely to develop addictive behavior were those from birth parents with the disease of addiction. Although environmental factors were also shown to be important, the predominant factor on whether determining who would develop the disease of addiction was most highly correlated with parents and genetic predisposition.
Metabolism is another example of a biological component that influences addiction. There is a segment of the Japanese population that rarely drinks alcohol and they also commonly lack an enzyme called alcohol dehydrogenase. In most of us, alcohol dehydrogenase is the predominant substance that breaks down alcohol in to metabolites, which are then excreted by the body. A small amount of alcohol is metabolized by an alternative pathway. However, if one lacks the enzyme alcohol dehydrogenase, the majority of alcohol is metabolized by the alternative pathway. The alternative pathway produces a toxic metabolite which can make one extremely ill.
The symptoms and effects of the toxic metabolite can range from mild nausea and dizziness to losing consciousness from low blood pressure, seizures, heart attacks or other significant consequences. Individuals who lack the enzyme alcohol dehydrogenase typically avoid these unpleasant effects by not drinking alcohol. In fact, the medication called disulfiram (Antabuse) is prescribed to some patients who wish to stop drinking. Antabuse blocks the enzyme alcohol dehydrogenase forcing alcohol to be metabolized by the alternative pathway, thus producing toxic byproducts. This type of aversion therapy using medication and recommended counseling can be effective albeit it does carry a risk if patients are not compliant.
Many substance users consume alcohol or drugs in order to eliminate or minimize feelings, fears, or symptoms. Unfortunately, medical services are not easily obtainable for many people suffering from mental health related illnesses, and they may self-medicate with alcohol or illicit drugs. In addition, people commonly fear the effects of withdrawal and this psychological response continues to drive addictive behavior. There seems to be a relationship between anxiety disorders and alcohol; depression and cocaine or other stimulants; bipolar illness and opiates; and ADHD and marijuana. Treating of underlying mental illness is an important component to curb inappropriate substance use. There have been reports that as many as 50% of patients with substance use disorders have underlying mental illness.
Where we live and how we live makes a difference in our choices. If we live in an environment where there is no alcohol or drugs then we are unlikely develop a substance use disorder, even if we have genetic predisposition or underlying mental illness. If we reside where drugs and alcohol are readily available and dependency is developed and then we wish to stop using, it is more difficult to refrain if we return each and every day to this same neighborhood with the same sociological cues. This is a major factor why Vietnam war veterans who became addicted to heroin abroad tended to do much better in recovery when they returned home, having left sociological cues behind in Vietnam; and why it is more difficult for a drug user to change his/her habits if living with another user of alcohol or drugs.
I wonder what role Mr. Bomer had in his son’s drug and alcohol use. It must have been difficult for Travis to grow up in a household with a father suffering from alcohol addiction. Yes, I am referring to the same Travis, who became dependent on heroin, and despite his addiction, saved a crewmate’s life on the high seas.
Kathy used this interlude to permanently separate the two men. “Frank, dear, why don’t you walk over to the Holiday Inn and get us checked in.” Kathy never confronted Frank about his unpredictable temper, which got worse if he either went too long without a drink or drank too much. It was a fine line between his drinking enough to eliminate the irritability of alcohol withdrawal and not drinking so much that he became belligerently drunk. “It’ll only take you about half an hour and then you’ll be back and we’ll be able to see Travis.”
Kathy knew that Frank would not be able to tolerate the overall situation, and in her heart knew her husband was an alcoholic who needed his beers and shots of whiskey throughout the day. Even if Kathy had been able to face the reality of her husband’s incapacity, this was hardly the time to confront it. All her energies were focused on protecting and supporting her son.
Hope you enjoyed this week’s segment, and next week we will discuss the difference between Tolerance, Dependence and Addiction; and explain why Aunt Tillie may be dependent on opiates but not addicted!
There are ten reasons that I can think of why we have a heroin/opiate epidemic, but before I go into all the reasons, let’s first get a few points established.
A. The disease of addiction has three components:
B. There are three related terms that are essential to understand:
C. And there are ten reasons of who or what to blame for the heroin/opiate epidemic raging through our cities, suburbs and rural America:
1.Injudicious Prescribing by MD’s
3.Internet Sale of Pain Pills
5.War in Afghanistan
7.Supply & Demand - “War on Drugs”
8.Physician Training & Biases
9.Mental Health Treatment
Over the next weeks in a series of blogs, I will explain each of the issues in the three categories. Then we will have a template of understanding to further engage in conversation of how best to approach the heroin/opiate epidemic. I hope you will stay tuned. And as we go along, if you want to put some real faces on this scourge to society, I hope you’ll read about Jimmy, the heroin addict from away who is accused of murdering Annette; and Travis, the hard working fisherman who is able to head out to sea by trading his heroin for oxycontin (“Oxys”); and when called to duty to save another shipmate’s life, he does not fail!
“He would meticulously safeguard his supply of Oxys until out at sea, where it was nearly impossible to snort lines on the Margaret Two without being discovered … Because Oxys can last up to twelve hours, Travis could perform his job at a very acceptable level and in a relatively normalized state of mind and body … Tuned into the first signs of early withdrawal symptoms, he always carried a pink Oxy in his pocket … Before heading topside each morning, Travis secured his dependability for the hard work ahead by making certain his concentration was not distracted by physical discomfort. While brushing his teeth in the confines of the head, he slipped a yellow Oxy into his mouth just before taking the last swig of water.”