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
#14 Factors involved in addiction
There are many underlying factors that increase vulnerability to addiction. Childhood trauma, genetic factors, experimentation with drugs, medical conditions, style of coping skills, impulsivity, a desire to escape difficulties in life are a few factors that can contribute to addiction. In addition, mental health issues and addiction often go hand in hand. These underlying factors must be addressed to attain lifelong recovery.
For some people, addiction is a way of coping with the difficulties of life. Addiction fills an emptiness and helps them escape sadness or anxiety. The Anxiety and Depression Association of America reports about 20 percent of substance abusers have an anxiety disorder or a mood disorder, such as depression. https://adaa.org/understanding-anxiety/related-illnesses/substance-abuse
For many, drug use starts with youthful experimentation. This can stem from peer pressure curiosity about what it’s like to be high. The earlier people begin experimenting, the more likely they are to have life-long issues with substance abuse. One dose of opioids before the age of fifteen, makes a person five times more likely to abuse drugs. https://osepideasthatwork.org/sites/default/files/IDEAslIssBrief-Opioids-508.pdf
According to the website addictionsandrecovery.org, you are eight times as likely to be an addict if one of your parents was an addict. Merely growing up in a household where drug abuse takes place — even in the absence of addiction — can have the same effects. https://pubs.niaaa.nih.gov/publications/arh312/111-118.htm
Childhood trauma is often associated with substance use. The CDC’s Adverse Childhood Experiences Study (ACE Study) uncovered a stunning link between childhood trauma and the chronic diseases people develop as adults, as well as substance abuse and mental health issues. ACE risk factors include: Abuse: physical, emotional or sexual; Neglect: physical or emotional; and Household Dysfunction: mental illness, mother treated violently, divorce, incarcerated relative or substance abuse. There are forty long term health consequences related to having three or more ACE events in childhood including heart disease, lung cancer, diabetes and autoimmune diseases, as well as mental health issues, violence, being a victim of violence, suicide and substance abuse. High ACE scores are also correlated with limited opportunities for education, employment and income. As ACE scores increase, so does the risk of disease, social and emotional problems. Early trauma has a lasting impact, including setting the person on a trajectory to substance abuse. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/index.html
For many Americans, drug use starts with a prescription. Opioids are notorious for their addictive properties and many people don’t realize their pain pills are actually opioids. Four out of five heroin users started with prescription drugs. https://www.drugabuse.gov
Treatment of substance abuse is complex and far reaching. Even more complicated than the physical issues of addiction are the underlying factors and causes. Next time we will discuss detox, the beginning of treatment.
#12 Harm reduction
As you read about opioids and drug use, you may have heard the term “Harm Reduction” and wondered what it was. Harm Reduction is one of the most controversial concepts related to dealing with drug use and treatment.
Harm reduction is “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.1” The purpose of harm reduction is to “keep people alive and encourage positive change in their lives.2” Examples of harm reduction for drug use include using Narcan to prevent overdose death, needle exchange programs to prevent the spread of HIV and HepC, and safe use education to reduce infection.
Drug use is not the only place where harm reduction has been instituted. “In alcohol policy, harm reduction (though not labeled as such) has long been successful and relatively uncontroversial. The “designated driver” is a harm reduction approach. It accepts that people will drink to excess and works to cut drunk driving and not drinking.3”
Harm reduction advocates list seat belt laws, speed limits, child safety seats, air bags, legal blood alcohol limits for drivers, sunscreen, bug spray, bike helmets, nonsmoking laws and nicotine patches as examples of harm reduction.
Proponents of harm reduction emphasize the importance of reducing harm for those involved in drug use until they are willing to accept treatment. Their philosophy is that “no society will ever be completely drug free. And since that is the sad-but-true reality, public health efforts should focus on reducing the harms and negative consequences associated with drug abuse, without judgment or condemnation.”4
Opponents to harm reduction believe that harm reductions such as needle exchange programs and Narcan only encourage drug use by sending the wrong message and encouraging others to begin drug use. They believe that harm reduction practices actually encourage drug use by eliminating the negative consequences: disease and death. In addition, they fear that harm reduction’s underlying intention is to promote the legalization of drugs. Some people contrast the expense of an EpiPen or insulin to readily available Narcan provided to people who are intentionally injecting poison into their bodies.
In her book The Unbroken Brain, author Maia Szalavitz recounts her twenty five years of addiction and how harm reduction practices affected her struggle for recovery. She states “Critics who say that such programs ‘send the wrong message’ could not be more wrong. When people start to be valued by others, they start to value themselves. Harm reduction nearly always increases the amount of warm, social contact that the most traumatized and marginalized people have.5” She believes that harm reduction communicates to drug users that they are not alone, that someone cares, that change is possible, and that compassion and respect have healing power.
Sources for this article: 1 Harmreduction.org 2 https://www.hri.global/what-is-harm-reduction, 3https://www.ashwoodrecovery.com/blog/harm-reduction-strategies-good-or-bad-for-recovery/, 4,5 Szalavitz, Maia, The Unbroken Brain, St. Martin's Press. 2016, pages 233, 236-237
Recently a local agency experienced the realities and difficulties of initiating treatment for opioid addiction. I want to share this journey with you.
At 11:00 on a Thursday morning, the agency received a call from a man who needed transportation to a Detox center in Indianapolis. He had been involved in using prescription opioid drugs. He had been through rehab in the past. He had burned all the bridges with his family. He had no insurance. He had no car or driver’s license. On his own, he contacted a treatment center in Indianapolis, negotiated the price for admission, and arranged a bed if he could get there by 7:00 pm that night.
I hope you are noticing the complexity of the details. This man was ready to initiate treatment. This is huge. Until a drug user is willing to accept help, it is unlikely that treatment will work. This is the frustration of many of the agencies who deal with people struggling with drug use and addiction as well as family members. They can offer programs, the courts can order attendance in programs, but until the person is willing to engage, it does little good.
There is a very small window of time where someone involved in drug use is willing to accept treatment. This man was ready and willing.
He found a treatment center that had an open bed. Local EMTs tell heartbreaking stories of going on a call for an overdose, dealing with the immediate situation and the person begging them to help get into treatment. Conservative estimates indicate there is a need for 66,000 beds for drug treatment in Indiana. Currently there are less than 2,000. (Larry Blue, President of Indiana Association Recovery Residences, Indiana Rural Development presentation, August 2, 2018.)
When you consider the narrow time frame when someone is willing to initiate treatment with the likelihood of there being an open bed, you get a sense of the intensity of the problem.
He had been in rehab before. His family was no longer willing to provide assistance he needed. Addiction is a chronic brain disease with multiple relapses. Statistics show that on average, a person involved in substance abuse will go to rehab/treatment multiple times before sustaining long term recovery. (https://americanaddictioncenters.org/the-addiction-cycle)
He had no insurance. Treatment for drug use is expensive. Medicaid and private insurance are beginning to pay for drug treatment, but many who use drugs are not aware of this or don’t know how to sign up. Without insurance or Medicaid, many treatment centers require cash upfront to walk in the door.
In this case, the agency found outside funding for the initial payment of $250 for detox.
He had no transportation. Even though he was able find a treatment site with an open bed and arrange for payment, he had no way to get there. He was in rural White County and the treatment center was seventy miles away. Local transportation covered his journey into Monticello and a volunteer drove him to Lafayette. Eventually a 211 LYFT driver was located and able to transport him to the treatment center.
The entire process took two people five hours and more than thirty phone calls to locate funding and arrange transportation. The system can be daunting to those who need services. With the help of a local agency familiar with available resources, the ability to navigate the system, and the persistence to pursue all avenues, this individual was able to initiate treatment. Many are not this fortunate.
#10 How to have a conversation with your medical provider about prescription opioids.
With all the discussion and media attention about opioids, many people are concerned about taking prescription pain relief, even when prescribed by their medical provider. Although opioids can be addictive and have serious side effects, they are safest and most effective when taken short-term for moderate to severe effective pain management.
The purpose of this article is not to give medical advice, but to help individuals prepare for conversations with their provider to determine whether opioids are the best course of treatment for their specific needs. We suggest questions to ask and background information about each question. Your health care provider will help you find the most appropriate treatment for your condition.
Are there other treatment options I could try first? Recent studies have shown that prescription opioids may not be the best first step in dealing with pain. Sometimes physical therapy, exercise, ice, rest, chiropractic treatment, massage, yoga, acupuncture, and other alternative treatments can be just as beneficial as a prescription pain killer. Some people find relief alternating over-the-counter acetaminophen with non-steroidal anti-inflammatory drugs such as ibuprofen, aspirin or naproxen. Again, be sure to check with your medical provider first and follow all dosing instructions on the package.
What are the side effects and risks of taking opioid pain killers? Side effects may include constipation, drowsiness, dizziness, impaired judgment and nausea or vomiting. The biggest potential risk is becoming dependent or addicted. For some people, three to five days of an opioid prescription are enough to develop dependence. Ask your care giver about signs of dependence and what to do if you suspect you are developing tolerance or dependence. Another opioid risk is that their long-term use can mask the symptoms of other diseases.
How will opioids interact with the medications I am already taking? Be sure to discuss any other prescriptions and over-the-counter medications you are taking as well. Opioids should not be mixed with alcohol, illegal drugs, and many other medications, so be sure to share a complete list with your doctor. Don’t forget to include any meds prescribed by psychiatrists, dentists, specialists, herbalists and other treatment providers.
How can I safely store and then dispose unused medications? Medications should be stored in safe places that are unavailable to anyone who visits your home. There are safe disposal boxes at the White County Sheriff’s office as well as the Monticello Police Department.
Will the opioids cause me to experience more pain? Because of the way opioids interact with the pain receptors in our brains, long term use may suppress natural pain inhibitors causing pain to be felt more acutely.
Your doctor will want to know if there is a history of addiction or alcoholism in your family or in your past.
Remember, this article is NOT intended to offer medical advice. Rather these suggestions are offered to help you partner with your doctor to be informed and engaged in determining the most appropriate treatment plan to address your specific medical needs.
Lynn Saylor is an AmeriCorps member serving in the United Against Opioid Abuse Initiative through the White County United Way. She can be contacted at firstname.lastname@example.org.
#9: Drug Take-backs
As I continue to learn about the opioid crisis, one of the most interesting aspects is where people obtain illicit prescription opioids.
I find it fascinating that over half of people who misuse prescription drugs get them from friends and family members. Many were given the prescription opioid by a friend or family member for free, while others took them from a friend or family member without asking.
Which brings us to the point of this article: You may unknowingly be providing drugs to someone. If you are storing your medications on a counter top or medicine cabinet, anyone who has access to those areas of your home could be taking your medication.
I have heard stories of grandparents who have had their prescriptions stolen by family members, of people who had workers in their homes and their prescriptions “disappeared,” of people having an open house to sell their home and returned to find their medications were gone.
Many of us have pain medications leftover from surgeries, tooth extractions, and injuries. We hang on to them for the “just in case.” Just in case, the old injury flares up. Just in case, we get hurt again. Just in case, we might need them in the future. But in doing so, we may be putting ourselves and our loved ones at risk.
Instead of keeping those prescriptions around, the best course of action is to get rid of them. In the past, we have been told to flush them down the toilet. Now we know this contributes to the pollution to our ground water.
The good news is there are several options. The best way to dispose of medications is to simply take your unused or expired pills to a drug take-back location. The good news is that we have two places to do that in White County. Both the White County Sheriff’s Department and the Monticello City Police Department have drug take-back containers in their lobbies. You don’t have to show ID. You don’t have to talk to anyone. You just walk in, drop in your prescription bottles and walk out. No questions asked.
Be aware that they do not take liquids, inhalers or sharps, including needles. In addition, they suggest you remove all labels from the containers or use a black permanent marker to cover any identifying information.
And what is done with these medications? They are taken to a specially designed incinerator and destroyed.
If you are uncomfortable going to the police or sheriff’s office, you can mix your prescriptions with water in the original container, shake the container until the pills are dissolved, then add dirt, coffee grounds or cat litter to make the medication unusable. Remove labels or black out identifying information and dispose of the closed bottle in the trash.
Many communities have Drug Take-Back days. We will notify the public of any such local events.
Correctly disposing of unused medications is a simple step that anyone can take to help combat the opioid epidemic.
#8 Dreamland: Book Review
One of the most interesting and informative books I have read about the origins of the opioid crisis in the United States is Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones.
Sam Quinones is an experienced investigative reporter from the LA Times. Dreamland is the name of the community pool in Portsmouth Ohio where from 1929 to 1993, the community gathered. There, rites of passage occurred, children grew, and generations swam with their families. Quinones uses the Dreamland pool to center his narrative about how the opioid epidemic came to dominate the United States.
Quinones weaves together story from the vantage points of the history of Oxycontin, the story of black tar heroin, and the factors of economic downturn. He details the rise of Purdue Pharm and the resulting over-prescription of opioid pain-killers. He explains the influx of heroin brought to the United States by the Mexican Jalisco boys. Quinones also investigates poverty in the Rust Belt of Ohio and coal mining areas of West Virginia.
We are first taken back to the 1980s, when Purdue Pharm developed and patented the new drug Oxycontin as a “miracle pain pill.” Quinones explains that Purdue Pharm falsely claimed its non-addictive qualities, and aggressively marketed Oxycontin to physicians in the economically depressed Appalachian Mountains of West Virginia. Quinones emphasizes the young, attractive sales force that knew how to sell, plying physicians with free merchandise, meals and trips. OxyContin sales grew from $48 million in 1996 to almost $1.1 billion in 2000. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/)
Black tar heroin is in many ways the opposite of Oxycontin. Black tar heroin gets its name because of its dark, sticky appearance, looking much like roofing tar. It is crudely manufactured in the mountains of Mexico, containing many impurities that, when injected, can cause life-threatening infections and vein disease. It is more potent than white powder heroin. (White powder heroin is cut many times by various levels of dealers before it reaches users.)
Black tar heroin gained a foothold in the southwestern United States through its delivery system. The Jalisco boys revolutionized drug dealing by delivering their product to customers, much like a pizza delivery. Customers call a phone number; a delivery place is determined. Drivers and customers meet at the designated location to make the sale. Deliveries were followed up by phone calls checking the customer satisfaction.
Once hooked on opioid pills, customers found it cheaper and easier to obtain the more potent black tar heroin. Many users made the switch from white powder, facilitated by the service-oriented Jalisco delivery system. Quiniones tells how law enforcement agencies cooperated beyond state lines to piece together the puzzle of how the Jalisco network worked across the nation. Quinones describes of the doctors and researchers who noticed the increase of overdose death and investigated them looking for patterns. He reveals pill mills that distribute thousands of opioid pain pills a day. And yes, we read about the lives of the addicted and the devastation to themselves and their families.
Dreamland tells a well-researched and well-written story of the multifaceted events that came together to create the opioid crisis we know today.
#7 Saving Jake
Recently, I have been reading books related to the opioid crisis. I will be sharing some of them with you here.
Saving Jake: When Addiction Hits Home by D’Ann Burwell* is our focus for today. D’Ann recounts the story of discovering her son, Jake’s, addiction to heroin, the roller coaster of their family’s struggle and five stints with rehab to achieve recovery. Jake started experimenting with alcohol and marijuana in college, then Oxycontin which led to heroin. D’Ann shares how her middle class, smart, athletic son lost three years of his life to addiction and how this impacted their family. She offers three suggestions for other families who are involved in this battle.
Saving Jake is a recommended read for those struggling to support loved ones or wishing to know more about addiction. Addiction is a lifelong disease. Recovery is a lifelong process. D’Ann Burwell presents families with an honest picture of addiction. She demonstrates that with perseverance, resources, and support, recovery is possible. Check your local library for copies.
Lynn Saylor is an AmeriCorps member serving in the United Against Opioid Abuse Initiative through the White County United Way. She can be contacted at email@example.com. Previous articles may be found on whitecountyunitedway.org/opioids.html.
*Burwell,D’Ann. Saving Jake: When Addiction Hits Home. Los Altos, CA: FocusUp Books, 2015. Print.
#6 Stories of Addiction
In past articles we have discussed opioids definitions, addiction, dependence, tolerance and signs of addiction. This time we look at a story of someone involved in addiction.
From her mid-forties, Karen struggled with mystery illnesses that defied diagnosis. Trips to her family doctor, specialists and even Mayo Clinic did not bring definitive answers. Finally, she was diagnosed with fibromyalgia, bursitis, arthritis and eventually Crohns, all chronic pain producing conditions that couldn’t be fixed. Doctors began prescribing pain medication to help. It started as one prescription. A different doctor added another, then another: prednisone, pain medications and pain patches in increasing doses. At one point she was taking 60 medications a day. Karen and her husband pursued any medical advice offering hope of relieving her suffering. Physical therapy and an electro-stimulator didn’t work and only caused more pain.Over the years this loving, generous, godly woman was slowly consumed with her pain and prescriptions. Her world became smaller and more self-absorbed as time went on. When confronted with her overuse of prescription drugs, her comment was “You just don’t understand my pain management needs.” But in reality, she was addicted to prescription drugs.
Prescribing laws changed, doctors became more reluctant to prescribe opioid pain killers cutting back on the strength of her prescriptions and number of pills. Karen’s health continued to deteriorate, and she began taking her opioids more frequently and in greater amounts than prescribed. Her husband drove from pharmacy to pharmacy in the middle of the night trying to find some way to get refills for already filled prescriptions. In his desperation, he was willing to buy them on the street if he could not find them legally. Her family intervened and Karen was able to receive palliative care in a nursing facility. Within three months, she died of a cancer that was diagnosed too late, unnoticed because of her chronic health issues and reliance on opioids.
Karen never intended to become addicted to opioids. No one ever imagined that her true problem was addiction. Looking back, it seems obvious that many of her symptoms were related to addiction and cycles of withdrawal. Over the years as opioids decreased her body’s ability to deal with pain, she required more and more opioids to function. Eventually, even the opioids became ineffective, and she continued to suffer in spite of the massive quantities she took.
Although the details of their stories may be different, many others have suffered the same plight, starting opioid use because of legitimate pain issues and becoming addicted without any understanding of what was happening to them. Sadly, this is more common than we might think. If you or a family member finds yourself in this situation, talk to your medical provider about treatment alternatives such as physical therapy, chiropractic treatment, massage, injections, nerve blocks, acupuncture, exercise, yoga, an anti-inflammatory diet, cognitive based therapy or non-opioid medications. This should not be considered as diagnostic or treatment advice, but a place to begin a conversation with your provider.
Lynn Saylor is an AmeriCorps member serving in the United Against Opioid Abuse Initiative through the White County United Way. She can be contacted at firstname.lastname@example.org. Previous articles may be found on whitecountyunitedway.org/opioids.html.
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.