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.[1]
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.[2] More than 72,000 Americans died of drug overdose in 2017, two thirds of these deaths involved opioids.[3] The average American life expectancy decreased in 2016 and 2017 due to increased drug overdose and suicide.[4] American’s are now more likely to die of a drug overdose than a car accident.[5]    
In spite of these dire statistics, the pendulum is beginning to swing back again.  

[1] Beth Macy,   Dopesick: Dealers, Doctors and the Drug Company that Addicted America, (New York, Little, Brown and Company, 2018), page 29.

[2] https://www.politifact.com/missouri/statements/2017/may/10/claire-mccaskill/mccaskill-cites-long-disproven-figure-opioid-use/

[3] https://www.nytimes.com/2018/08/15/upshot/opioids-overdose-deaths-rising-fentanyl.html

[4] https://www.washingtonpost.com/national/health-science/us-life-expectancy-declines-again-a-dismal-trend-not-seen-since-world-war-i/2018/11/28/ae58bc8c-f28c-11e8-bc79-68604ed88993_story.html?utm_term=.5d2dd28a8f10

[5] https://www.usatoday.com/story/news/nation/2019/01/14/odds-dying-opioid-overdose-higher-than-car-crash-analysis-finds/2567996002/
 

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.[1]  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.[2]
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.[3] 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.”[4]
Next time we will continue our discussion of how a variety of factors brought us to the opioid crisis of today.

[1] https://www.narconon.org/drug-information/heroin-history-1900s.html

[2] https://www.statnews.com/2017/10/29/opioid-epidemic-shares-chilling-similarities-with-past-drug-crises/ 

[3] http://www.druglibrary.org/schaffer/library/studies/cu/cu8.html 

[4] https://www.vox.com/science-and-health/2017/12/18/16635910/opioid-epidemic-lessons

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.