Knowing the science behind addiction, does not accurately describe the intense despair of those who are living it. Today we look at how people involved in substance abuse view their lives. The following article consists entirely of quotes from online videos and books relating the experiences of those in addiction; WARNING: May be too graphic for some readers.
“Before my brother’s death I was just a normal kid, playing video games and sports. Going through the grief of my brother’s death, his friends told me, just take this drug and you won’t have to feel anything anymore. When I took it I felt numb. Any problem I had went away. My addiction got worse, I stole more and hurt more people I had no one. I wasn’t even getting high at this point, I was just not being sick. It cost me around $300 a day. The mental addiction to this takes over your mind. I had no choice, I just needed to feel ok. And so that was the first time I tried heroin and there was no going back after that. I ended up overdosing, almost dying only a few feet from where my brother was found dead. It took four shots of Narcan to bring me back.” (The Dark Path by Andrew D., Brendan P., Joshua M. in McDonald PA: from the operationprevention.org)
“I saw myself as a pathetic creature, a fool, so completely obsessed with a stupid drug. I was in trouble because my sickness called for a cure that only made it worse: more ominous, more dangerous. I was in trouble because, though I didn’t quite get it yet, some part of me would erode further every time I came into contact with opiates in the future. My attraction would burgeon with alarming suddenness, my control would give way, and I would take risks that I couldn’t yet imagine. Opioids made me feel safe and warm, cared for, soothed and I would need them all the more to combat the shame and depression they themselves engendered.” Memoirs of an Addicted Brain
“Drugs took my mind over and made me do things that I’d been brought up not to do. It turned me into a monster.”
“Drugs became my full time job. The needle was my boss, a very demanding boss. My whole day revolved around it. It’s a never ending vicious cycle. The same thing over and over and over. You go to sleep doing it. You wake up and are dope sick, so you got to do it all over again. You got to at least do enough just to where you are not sick anymore.”
“I stole checks from my grandma. Anything that wasn’t nailed down I stole and pawned. I stole my mom’s debit card. Heroin cost me $300 a day. You don’t think about anything. You don’t think about the people you are hurting or the lies you tell. You don’t think about getting arrested. All you can think about is getting another fix. I didn’t care what it was going to do to me later on, I just wanted the feeling of it right then and there.”
“It’s not worth it. And it will get you. You are no different than anyone else. It will destroy your life. You will end up in jail or dead or in some institution for the rest of your life.” Quotes above are from Chasing the dragon: The Life of an Opiate Addict: justthinktwice.gov
These testimonials give you a sense of the power of addiction and the difficulty of achieving recovery. But there is hope. Treatment works. Recovery is possible.
In these articles, we have presented a very neutral view of people involved in substance misuse/addiction, but their families and the people around them will tell quite a different story. They will tell you that the person addicted to a substance is not the person they used to be. Things that interested them in pre-addiction days, no longer have any appeal. Their loved one is consumed with obtaining drugs and maintaining the drug supply. Drugs overpower every other motivator in life: family, job, hobbies, work, even children.
Brain research backs this up. “Drug addiction isn’t as simple as a person making bad choices. Rather, it reflects a disease of the very system that makes good choices possible.” Dr. Nora Volkow
In their book, The Molecule of More: How a Single Chemical in Your Brain Drives Love, Sex and Creativity—And Will Determine the Fate of the Human Race (BenBella Books, 2018,) Daniel Lieberman and Michael Long describe the major role of dopamine in the chemistry of addiction. They explain how the dopamine desire circuit is designed to promote behaviors that lead to survival with an eye on the future. Dopamine urges you to possess and accumulate anything that might help keep you alive—whether you need it or like it—dopamine doesn’t care. It makes us want it right now.
Dopamine activation in the desire circuit triggers motivation, energy, enthusiasm, and hope. It feels good. Dopamine turns on the imagination, producing visions of a rosy future. But, it is the salesman in no position to make the dreams come true, only making promises it cannot keep.
Addictive drugs hit the dopamine circuit with an intense chemical blast, hijacking the brain. Nothing else can match it, stimulating it far more intensely than natural rewards like food or sex. The substance misuser’s entire life becomes focused exclusively on the drug. Drugs become the most important thing, overwhelming all other motivation and concerns. From the outside it looks like substance misusers are making irrational choices, but their brains are telling them that their choices are perfectly logical. The euphoria of drugs provides a bigger dopamine dose than just about any experience you can name. Substance abusers take drugs until they pass out, get sick, or run out of money; the gnawing craving is never satisfied.
Many of the decisions that substance misusers make are impulsive, because they can only think of the immediate pleasure, not long-term consequences. Desire for dopamine overpowers the more rational parts of the brain, causing the user to feel powerless to resist. It’s as though their free will has been comprised by an overwhelming urge for the immediate pleasure of drugs. Addiction is not a sign of weak character or lack of will power. Instead it is a vicious cycle of the desire circuits getting thrown into a pathological state, powerfully demanding more stimulation, consuming all attention and motivation, and profoundly influencing a person’s will.
In spite of these neurological changes, treatment works, and recovery is possible. People do recover from the snares of addiction with treatment and support.
Last time, we discussed the policies at the state and national level that are creating positive change related to substance abuse. In addition to those discussed last week, Indiana has also implemented these legislative and policy changes.
Aaron’s Law was passed in 2015, allowing Hoosiers to obtain a prescription for Naloxone if they believe someone they know is at risk of an opioid overdose. This was recently updated to allow individuals to purchase Narcan without a prescription at pharmacies. Some Medicaid and private insurance companies may pay for Narcan. Check with your insurance provider.
Indiana's Aaron's Law also contains Good Samaritan provisions that offer some legal protections to individuals who administer Narcan and call 911 at the scene of an overdose. Grants are available to county health departments to provide training and increase the availability of Narcan to law enforcement and families with loved ones involved in substance abuse. The White County Health Department is participating in this grant program, providing training and Narcan to the White County sheriff’s department.
Removing unused opioid prescriptions is another important step in combating the opioid crisis. As mentioned in previous articles, the White County Sheriff and Monticello Police Department have drug take back containers that are available 24/7 for the safe disposal of unused medications. They do not take sharps, syringes or liquids.
Indiana Medicaid and HIPP are increasing coverage of MAT for substance and alcohol abuse allowing more people to access these services.
In White County, the United Council on Opioids (UCO) was developed to coordinate efforts and services centered around opioid and substance abuse. The UCO includes more than seventy community members who are actively engaged in creating solutions to the local substance abuse crisis . These members are working in emergency medicine, law enforcement, health care, education, the judicial system, probation, mental health care, city government, health navigation, peer recovery, or are families of those involved in substance abuse, those in recovery, community agencies, health department, treatment and interested citizens.
The UCO has three task force groups; prevention, treatment, and recovery. Each group has specific action oriented short-, mid-, and long-term goals. They are achieving their goals and making a difference in our community. They have completed a working directory of treatment and recovery support services, and obtained funding for a billboard campaign to promote prevention and awareness of substance abuse. They are working on prevention activities for local schools and protocols for helping people transition from jail, hospitalization, and treatment into long term recovery. In conjunction with these efforts, White County was selected to be a part of the North Central Quick Response Team, which begin services in September.
Exciting things are happening nationally and locally to combat the opioid crisis.
In previous articles we discussed how the current opioid crisis did not happen overnight. A series of events, perceptions and policies brought us to this place where Americans are more likely to die of an overdose than a car accident. The death toll is equivalent to a fully loaded 737 falling from the sky and killing everyone on board 365 days a year. https://www.clarionledger.com/story/news/2018/01/26/opioid-epidemic-solutions-naloxone-overprescribing-overdose-deaths/964288001/. As a local school counselor asked in the face of this crisis: “What can we do to make a difference?” The good news is exciting things are beginning to happen nationally, at a state level, and locally.
Development in brain research began exploring the effects of substance abuse on the structure and wiring of the brain. Scientists have learned how substances such as opioids change the chemistry of brain synapses, creating a chemical desire for the drug. Drug use changes the areas of the brain related to motivation, problem solving, and impulse control. This better understanding of how addiction affects the brain is aiding in the development of evidence-based treatment options.
On a policy level, many things are happening to decrease the negative impacts of substance use in Indiana. The INSPECT prescription monitoring system keeps track of the number of opioid prescriptions written by doctors and filled by patients. Just the awareness that someone is watching, has led to a 35% decrease in the number of opioid prescriptions doctors have written since 2013. https://www.ibj.com/articles/74228-report-indiana-opioid-prescriptions-down-35-since-2013
Narcan is saving lives. Narcan is an opioid overdose reversing agent. If used within six minutes of an opioid overdose, restore breathing and prevent death. As the mother of an addicted child said, “Dead people don’t enter recovery.” Narcan is now available without a prescription and can be purchased at local pharmacies. Many health departments can provide it free to families of those involved in substance use disorder. With the prevalence of fentanyl, some say that it is prudent for families with a loved one using any illicit drugs to have Narcan on hand.
There are more and more opioid treatment centers opening around the state. In 2018, there were 18 opioid treatment programs in Indiana. By 2020, ten additional sites will open. Governor Holcomb’s goal is to have an opioid treatment program within an hour’s drive of every Hoosier.
In addition to reducing the number of opioid prescriptions written, another positive response is the number of drug take-back containers and programs. Over 50% of people who misuse substances get them from the medicine cabinets of friends and family. Here in White County, there are drug take back containers in the lobbies of the Monticello City Police as well as the White County Sheriff’s Department.
Indiana Medicaid/HIPP is providing coverage for substance abuse treatment and MAT (medication assisted treatment, providing more access to those in need of services.
Probably, most importantly, people are becoming educated about opioids, addiction and treatment. Public opinion is beginning to accept the disease model of addiction, understanding how brain chemistry and changes influence behavior in addiction.
Last time, we discussed the history of opioids in the United States during the 1800’s. We learned of the pendulum swing from completely unregulated opioid use during the mid-1800s to the tight regulations of the early 1900s when drug use was criminalized to the point that even those suffering from extremely painful illnesses such as terminal cancer were denied opioid prescriptions.
During the last half of the twentieth century, the pendulum swung back again. In the 1980’s, the American Pain Society as well as the Veteran’s Administration introduced the concept of pain as the fifth vital sign. Physicians were mandated to treat pain aggressively, and opioids were viewed as an easy solution for pain management.
Soon, hospital and provider reimbursements were connected to patient satisfaction surveys which incorporated pain management as a component. Medical providers felt pressured to begin prescribing opioids in spite of their fear of their patients becoming addicted. With advent of the pain score, patients began to think that the idea of zero pain was the goal.
Pharmaceutical companies began developing and aggressively marketing more powerful opioid pain killers such as OxyContin® in response to the increased demand for pain relief. Insurance companies began refusing coverage of non-medical approaches to pain management in favor of prescription pain medications.
As more and more people began taking prescription opioid medications, a black market of abuse flourished. Those caught in addiction found heroin to be easier and cheaper to obtain than illicit opioid pain killers.
Changes in the American culture also contributed to the problem. As consumers, Americans developed the view that instant gratification and quick fixes were to be expected. The breakdown of the traditional family, lack of connection to neighbors, sense of entitlement and the view that parents should protect their children from every kind of pain, discomfort or convenience further contributed to the epidemic. Changes in the treatment of mental health and an increase in mental health issues added another layer.
In 1959, the development of Fentanyl in 1959 (a pain killer and anesthetic), changed the landscape of substance abuse. Fentanyl is one of the deadliest opioids developed and is 50-100 times more potent than morphine. It is cheap and often mixed with other drugs. This mix causes drug users to become addicted very quickly, increasing the demand for additional drug sales. Each year thousands of Americans die of a fentanyl overdose, many of them unaware that the substance they were using was spiked with fentanyl.
All these factors have contributed to the increase in opioid abuse and dramatic increases in opioid overdose death. Americans make up 5% of the world’s population but consume 30% of the world’s opioids. More than 72,000 Americans died of drug overdose in 2017, two thirds of these deaths involved opioids. The average American life expectancy decreased in 2016 and 2017 due to increased drug overdose and suicide. American’s are now more likely to die of a drug overdose than a car accident.
In spite of these dire statistics, the pendulum is beginning to swing back again.
 Beth Macy, Dopesick: Dealers, Doctors and the Drug Company that Addicted America, (New York, Little, Brown and Company, 2018), page 29.
A Brief Overview of the Opioid Epidemic (Part One)
You may be surprised to learn that the United States has a long history of opioid use. The pendulum of public policy and perception towards opioid use has swung widely from one extreme to the other. In the 1800’s, cocaine and morphine were completely unregulated and widely used in treating a variety of common ailments from diarrhea to toothaches. Morphine was used extensively to treat terrible battle injuries of the Civil War. Thousands of soldiers became addicted to the drug and remained addicted after the end of the war. Addiction to morphine became known as the “Soldier’s Disease.” In 1874, heroin was introduced as a ‘non-addictive’ replacement for morphine. Heroin was touted as the miracle cure for many common ailments, including colicky and teething babies, coughs, pain, indigestion, insomnia and pneumonia. Many middle class women were addicted to laudanum (an elixir of opiates mixed with alcohol) for the treatment of female afflictions. Opiates were given as freely as aspirin is used today. In 1859, cocaine was also developed by drug makers and sold to help morphine addiction. It cleared nasal passages, too, and became the official remedy of the Hay Fever Association.
In the early 1900’s the pendulum swung the other way resulting in an “opio-phobia.” Public opinion of the increasing problems associated with addiction at the turn of the century brought about the Harrison Act of 1914, which made sales of cocaine and heroin as prescription only. Heroin could no longer be used in over-the-counter remedies or in consumer products. However, a clause applying to doctors allowed distribution "in the course of his professional practice to treat disease." This clause was interpreted after 1917 to mean that a doctor could not prescribe opiates to treat addiction, since addiction was not considered a disease. A number of doctors were prosecuted, imprisoned and lost their medical license for treating substance abuse. Doctors so feared prescribing opioids that even patients suffering the excruciating pain of end stage cancer were denied opioid treatment. Many people who had begun use of opioids prior to 1917 turned to illicit drugs.
Substance use began to be criminalized and the War on Drugs began. More legislation was passed with increasingly harsh penalties for drug sale and use. People involved in substance abuse were viewed as morally weak, skid row bums, wrongdoers and perpetrators of their own problems. The public believed that when someone overdosed, “they got what they deserved.”
Next time we will continue our discussion of how a variety of factors brought us to the opioid crisis of today.
One of the most difficult aspects of overcoming addiction is the drug cravings. These cravings are caused by the addiction induced changes in brain circuitry and chemistry, lasting weeks or months after substance use has stopped. One way to overcome these cravings and improve treatment outcomes is medication assisted treatment or MAT. The US Surgeon General considers MAT as the gold standard of opioid use disorder treatment. (https://addiction.surgeongeneral.gov/) MAT has been proven successful in reducing relapse, and criminal activity, while increasing survival, treatment compliance, and employment--allowing the person to focus on aspects of life that were neglected during addiction.
Medication assisted treatment is not limited to opioid addiction. It has been around for a long time. For example, nicotine patches are a form of MAT often used in smoking cessation programs to alleviate the physical cravings for tobacco use.
MAT is not a cure for opioid addiction, but can be an effective component of treatment when combined with behavioral therapy and social support. MAT is carefully regulated and only administered by certified medical personnel in controlled clinical settings.
There are three different types of medication assisted treatments for opioid addiction.
Methadone is the oldest and most common form of MAT. It has decades of proven success in helping people overcome addiction. Individuals taking methadone are required to receive daily liquid doses at a methadone clinic. After a certain length of treatment, patients can receive take home doses for up to two weeks.
Naltrexone is an office-based treatment used to treat opioid and alcohol abuse. It can be administered as a daily pill or monthly injection (Vivitrol). Naltrexone requires 7 to 10 days of drug abstinence before beginning treatment. One danger of this treatment is that if the patient takes an opioid, they will not feel high but can still overdose.
Buprenorphine (Suboxone) is another office-based treatment that blocks opioids while reducing withdrawal risk. It can be administered as a daily dissolving tablet, cheek film, or six-month implant under the skin. Health care providers must be certified to administer it in a certified opioid treatment program.
There are several MAT clinics in Lafayette. At press time, they were Clean Slate, Innovative Medicine, Limestone, Riggs Community Center, Sycamore Springs and Valley Oaks. More information about each can be found at https://www.logansportmemorial.org/UserFiles/File/Community%20Resource%20Guide.pdf The minimum length of MAT is a year but varies from person to person. Brain circuits that have been altered by prolonged substance abuse take time to recover. Some patients may require MAT for the rest of their lives. At this time, there is no known MAT for cocaine, methamphetamines or benzodiazepines.
Although MAT is successful for many, it is not without controversy. Some insist MAT just substitutes a new drug for the old one and that some forms of MAT are easily diverted and misused. Others object to the expense of MAT. A monthly Vivitrol injection can cost up to $2000 per dose. Methadone costs about $20 a day. Some addiction specialists believe MAT should only be used in those who are resistant to other forms of treatment. There is even debate among those in the recovery community as to whether MAT counts as sober living.
There are many forms of treatment for substance abuse. Each person must be evaluated by professionals to determine which course of action will best meet individual needs. MAT can be a beneficial form of treatment for those overcoming opioid addiction.
As discussed last week, addiction treatment addresses the many issues related to learning to live without drugs. It can take a variety of forms and there is no one path to recovery.
Depending on the length and severity of addiction and type of substance used, different lengths, and types of treatment are available.
The most intense treatments are residential or inpatient programs where the person goes away for a period of time to live at a treatment facility. Some people find it helpful to be removed from the environment where they were involved with drug use to begin recovery. During this time the individual is under constant supervision, receiving multiple daily sessions of group and individual counseling and therapy, as well as a variety of support services. Residential treatment can last anywhere from thirty days to two years. Research on addiction treatment suggests that programs less than 90 days rarely achieve long term success. https://www.drugabuse.gov
The next level of treatment is IOP or intensive outpatient services. In IOP, the individual can live at home, maintain a job and rebuild his life within his community with the support received from the program. The person is required to attend counseling sessions daily or several times a week. The number of sessions required generally decreases as the person progresses.
The next step down is outpatient services where the individual attends weekly sessions for counseling and support. The advantage of outpatient therapies can be that the individual learns and practices living in recovery in the community where he lives.
Some individuals find it very difficult to maintain recovery surrounded by the people and places where they used drugs and for them a residential treatment center may be most appropriate.
Within these categories are faith based and secular treatments. There are abstinence-based programs and ones that use medication assisted treatment.
Cognitive based therapy is widely used in treating addiction in individual and group therapy. A central element of CBT is anticipating likely problems and enhancing patients’ self-control by helping them develop effective coping strategies. Specific techniques include exploring the positive and negative consequences of continued drug use, early recognition of cravings, identifying situations that might trigger drug use, and developing strategies for coping with cravings and avoiding those high-risk situations.
Other treatments focus on motivation such as contingency management principles which give tangible rewards to reinforce positive behaviors such as abstinence. These can be highly effective in keeping people in treatment and maintaining sobriety.
Regardless of the treatment form, the goal is to provide the person with counseling, support and connections to necessary services to maintain the hard work of recovery.
There are several stages of recovery from drug addiction. After detox, when the active drug is eliminated from the person’s body and the person is medically stable, comes the next stage of recovery when other addiction issues are addressed.
There is much debate as to the definitions of substance abuse treatment and recovery. Some take a broad view of all the steps involved in overcoming addiction as part of recovery. Others delineate treatment as detox and what happens at a treatment/rehab center. They define recovery as what happens after the treatment program is complete and the person rejoins society.
For the purpose of these articles, we will define recovery as the broad view: everything that happens when people leave addiction, beginning with detox and continuing for the rest of their lives. Treatment will be defined as the initial stage of recovery, where the physical dependence is eliminated and the initial stages of dealing with addiction are begun.
There are many paths to recovery. There is no cookie cutter, one-size-fits-all method. What works for one person, may not work for another. Some are more successful in a residential or inpatient program. Some thrive in a faith-based program. Others prefer a more secular, cognitive-based approach. Group and individual therapy are available. Some find medically-assisted treatment as their best option. Counseling for the entire family may be necessary as they begin to rebuild trust and reestablish a healthy relationship with their loved one. Regardless of the path, relapse is often a part of the recovery process, showing the extreme difficulty and hard work required to overcome addiction.
An important part of treatment and recovery is helping people learn to live without drugs. It can take months or years for the brain to recover and return to pre-addiction functioning. Those involved in substance abuse have to learn/relearn how to function without drugs. In recovery they must learn new ways to interact and develop support networks to replace drug-centered ones. Learning how to live a healthy lifestyle needs to be developed as drugs move from the center of their lives.
Relapse prevention is another important component. Often there are multiple relapses before an individual is able to maintain recovery. This is not a sign of weakness or lack of willpower, but illustrates the power of addiction over the brain. Developing a plan to avoid temptation will decrease the likelihood of relapse. For many, becoming involved in a recovery community such as AA, NA, Celebrate Recovery, or Smart Recovery is essential for long term support and sobriety.
When people involved in opioid misuse are ready to stop using, they often enter into recovery/treatment/rehab. The next few articles will discuss the stages of recovery: detox, treatment and long-term recovery. Recovery is defined as living life without the addictive substances. Treatment is the initial stage of that process. With many addictive drugs including opioids, the first step is detox.
Once a person has developed physical dependence/addiction to opioids, stopping opioids will cause a condition called withdrawal. Some people compare substance withdrawal to ‘the worst flu in your life’ but that does not accurately captures the agony, depression, hopelessness, pain and despair. Symptoms start with anxiety, yawning, sweating, eyes tearing, goosebumps, runny nose, and hot/cold flashes, the progress to nausea, vomiting, diarrhea, restlessness, muscle and bone pain, and may even include hallucinations, delirium, seizures, altered sensory perceptions, psychosis, suicidal thoughts and more. Specific symptoms and severity differ for each individual. But, withdrawal and fear of withdrawal are definitely reasons why some people continue to use opioids despite wanting to stop. https://www.smartrecovery.org
Detox is the process of ridding the body of the addictive substances. It is painful and can be dangerous. The purpose of detox is to safely manage the withdrawal symptoms and stabilize the individual to proceed to further treatment.
Detox looks different depending on the drug used. Benzodiazepines and alcohol require medical supervision to safely detox as seizures, severe dehydration and death can occur. Detox from opioids is generally not life-threatening, but the anguish and misery of the symptoms make it difficult to do ‘cold turkey.’ Under medical supervision, the worst of the symptoms can be minimized.
Detox can take days, weeks, or months depending the substance used, length of use, severity of the addiction and underlying medical conditions. Even after the physical withdrawal is over, psychological desire for the substance continues. It can take up to a year for the person to recover brain function and overcome the effects of addiction. Because addiction is both psychological and physical, patients benefit from therapy and counseling to address the i changes made in the brain resulting from substance abuse. Detox alone might help the patient to stop abusing drugs and alcohol in the short term, but without follow-up care and therapy, the risk of relapse back into substance misuse increases greatly.
Travis Reider, research scholar at Johns Hopkins' Berman Institute of Bioethics, recently shared his experience of opioid withdrawal in a Ted Talk. He describes the physical and mental anguish of withdrawal and the struggle of getting accurate medical advice and treatment. It is an interesting view offering insight into the difficulty of untreated withdrawal. https://www.ted.com/talks/travis_rieder_the_agony_of_opioid_withdrawal_and_what_doctors_should_tell_patients_about_it?language=en
Lynn Saylor is the AmeriCorps member working with the United Against Opioid Abuse Initiative alongside the White County United Way. She is a major facilitator of the United Council on Opioids serving White County and a regular contributor to local media.