Despite current treatment guidelines, fewer than 10 percent of adults with co-occurring mental health and substance use disorders receive treatment for both disorders, and more than 50 percent do not receive treatment for either disorder. The findings highlight a large gap between the prevalence of co-occurring disorders and treatment rates among U.S. adults and the need to identify effective approaches to increasing treatment for those with these conditions. An analysis of data from U.S. adults with both a mental health disorder and a substance use disorder indicates that only 9.1 percent of those adults received both types of care over the past year, and 52.5 percent received neither mental health care nor substance use treatment.
The study, based on data collected from the 2008-2014 National Survey on Drug Use and Health, reports that 3.3 percent of the adult U.S. population, or some 7.7 million individuals, suffers from both a mental health and substance use disorder. Those adults with co-occurring disorders who did receive both types of treatment tend to have more serious psychiatric problems and accompanying physical ailments and were more likely to be involved with the criminal justice system compared to individuals who did not receive both types of care. The primary reasons for not seeking care were inability to afford treatment, lack of knowledge about where to get care, and a low perceived need among those with both disorders.
Why do they do it? This is a question that friends and families often ask of those who are addicted.
It’s difficult to explain how drug addiction develops over time. To many, it looks like the constant search for pleasure. But the pleasure derived from opioids like heroin or stimulants like cocaine declines with repeated use. What’s more, some addictive drugs, like nicotine, fail to produce any noticeable euphoria in regular users.
So what does explain the persistence of addiction? As an addiction researcher for the past 15 years, I look to the brain to understand how recreational use becomes compulsive, prompting people like you and me to make bad choices.
Myths about addiction
There are two popular explanations for addiction, neither of which holds up to scrutiny.
The first is that compulsive drug taking is a bad habit – one that addicts just need to “kick.”
However, to the brain, a habit is nothing more than our ability to carry out repetitive tasks – like tying our shoelaces or brushing our teeth – more and more efficiently. People don’t typically get caught up in an endless and compulsive cycle of shoelace tying.
Another theory claims that overcoming withdrawal is too tough for many addicts. Withdrawal, the highly unpleasant feeling that occurs when the drug leaves your body, can include sweats, chills, anxiety and heart palpitations.
For certain drugs, such as alcohol, withdrawal comes with a risk of death if not properly managed.
The painful symptoms of withdrawal are frequently cited as the reason addiction seems inescapable. However, even for heroin, withdrawal symptoms mostly subside after about two weeks. Plus, many addictive drugs produce varying and sometimes only mild withdrawal symptoms.
This is not to say that pleasure, habits or withdrawal are not involved in addiction. But we must ask whether they are necessary components of addiction – or whether addiction would persist even in their absence.
Pleasure versus desire
In the 1980s, researchers made a surprising discovery. Food, sex and drugs all appeared to cause dopamine to be released in certain areas of the brain, such as the nucleus accumbens.
This suggested to many in the scientific community that these areas were the brain’s pleasure centres and that dopamine was our own internal pleasure neurotransmitter. However, this idea has since been debunked. The brain does have pleasure centres, but they are not modulated by dopamine.
So what’s going on? It turns out that, in the brain, “liking” something and “wanting” something are two separate psychological experiences.
“Liking” refers to the spontaneous delight one might experience eating a chocolate chip cookie. “Wanting” is our grumbling desire when we eye the plate of cookies in the centre of the table during a meeting.
Dopamine is responsible for “wanting” – not for “liking.” For example, in one study, researchers observed rats that could not produce dopamine in their brains. These rats lost the urge to eat but still had pleasurable facial reactions when food was placed in their mouths.
All drugs of abuse trigger a surge of dopamine – a rush of “wanting” – in the brain. This makes us crave more drugs. With repeated drug use, the “wanting” grows, while our “liking” of the drug appears to stagnate or even decrease, a phenomenon known as tolerance.
In my own research, we looked at a small subregion of the amygdala, an almond-shaped brain structure best known for its role in fear and emotion.
We found that activating this area makes rats more likely to show addictive-like behaviors: narrowing their focus, rapidly escalating their cocaine intake and even compulsively nibbling at a cocaine port. This subregion may be involved in excessive “wanting,” in humans, too, influencing us to make risky choices.
The recent opioid epidemic has produced what we might call “involuntary” addicts. Opioids – such as oxycodone, percocet, vicodin or fentanyl – are very effective at managing otherwise intractable pain. Yet they also produce surges in dopamine release.
Most individuals begin taking prescription opioids not for pleasure but rather from a need to manage their pain, often on the recommendation of a doctor. Any pleasure they may experience is rooted in the relief from pain.
However, over time, users tend to develop a tolerance. The drug becomes less and less effective, and they need larger doses of the drug to control pain. This exposes people to large surges of dopamine in the brain. As the pain subsides, they find themselves inexplicably hooked on a drug and compelled to take more.
The result of this regular intake of large amounts of drug is a hyperreactive “wanting” system. A sensitised “wanting” system triggers intense bouts of craving whenever in the presence of the drug or exposed to drug cues.
These cues can include drug paraphernalia, negative emotions such as stress or even specific people and places. Drug cues are one of an addict’s biggest challenges.
These changes in the brain can be long-lasting, if not permanent. Some individuals seem to be more likely to undergo these changes.
Research suggests that genetic factors may predispose certain individuals, which explains why a family history of addiction leads to increased risk. Early life stressors, such as childhood adversity or physical abuse, also seem to put people at more risk.
Addiction and choice
Many of us regularly indulge in drugs of abuse, such as alcohol or nicotine. We may even occasionally overindulge. But, in most cases, this doesn’t qualify as addiction. This is, in part, because we manage to regain balance and choose alternative rewards like spending time with family or enjoyable drug-free hobbies.
However, for those susceptible to excessive “wanting,” it may be difficult to maintain that balance. Once researchers figure out what makes an individual susceptible to developing a hyper reactive “wanting” system, we can help doctors better manage the risk of exposing a patient to drugs with such potent addictive potential.
In the meantime, many of us should reframe how we think about addiction. Our lack of understanding of what predicts the risk of addiction means that it could just as easily have affected you or me.
In many cases, the individual suffering from addiction doesn’t lack the willpower to quit drugs. They know and see the pain and suffering that it creates around them. Addiction simply creates a craving that’s often stronger than any one person could overcome alone.
That’s why people battling addiction deserve our support and compassion, rather than the distrust and exclusion that our society too often provides.
Article written by: Mike Robinson, Assistant Professor of Psychology, Wesleyan University.
We’re learning more about the craving that fuels self-defeating habits—and how new discoveries can help us kick the habit.
Addiction hijacks the brain’s neural pathways. Scientists are challenging the view that it’s a moral failing and researching treatments that could offer an exit from the cycle of desire, bingeing, and withdrawal that traps tens of millions of people.
Patrick Perotti scoffed when his mother told him about a doctor who uses electromagnetic waves to treat drug addiction. “I thought he was a swindler,” Perotti says.
Perotti, who is 38 and lives in Genoa, Italy, began snorting cocaine at 17, a rich kid who loved to party. His indulgence gradually turned into a daily habit and then an all-consuming compulsion. He fell in love, had a son, and opened a restaurant. Under the weight of his addiction, his family and business eventually collapsed.
He did a three-month stint in rehab and relapsed 36 hours after he left. He spent eight months in another program, but the day he returned home, he saw his dealer and got high. “I began to use cocaine with rage,” he says. “I became paranoid, obsessed, crazy. I could not see any way to stop.”
When his mother pressed him to call the doctor, Perotti gave in. He learned he would just have to sit in a chair like a dentist’s and let the doctor, Luigi Gallimberti, hold a device near the left side of his head, on the theory it would suppress his hunger for cocaine. “It was either the cliff or Dr. Gallimberti,” he recalls.
Gallimberti, a gray-haired, bespectacled psychiatrist and toxicologist who has treated addiction for 30 years, runs a clinic in Padua. His decision to try the technique, called transcranial magnetic stimulation (TMS), stemmed from dramatic advances in the science of addiction—and from his frustration with traditional treatments. Medications can help people quit drinking, smoking, or using heroin, but relapse is common, and there’s no effective medical remedy for addiction to stimulants like cocaine. “It’s very, very difficult to treat these patients,” he says.
More than 200,000 people worldwide die every year from drug overdoses and drug-related illnesses, such as HIV, according to the United Nations Office on Drugs and Crime, and far more die from smoking and drinking. More than a billion people smoke, and tobacco is implicated in the top five causes of death: heart disease, stroke, respiratory infections, chronic obstructive pulmonary disease, and lung cancer. Nearly one of every 20 adults worldwide is addicted to alcohol. No one has yet counted people hooked on gambling and other compulsive activities gaining recognition as addictions.
In the United States an epidemic of opioid addiction continues to get worse. The Centers for Disease Control and Prevention reported a record 33,091 overdose deaths in 2015 from opioids, including prescription painkillers and heroin—16 percent more than the previous record, set just the year before. In response to the crisis, the first ever U.S. surgeon general’s report on addiction was released in November 2016. It concluded that 21 million Americans have a drug or alcohol addiction, making the disorder more common than cancer.
After spending decades probing the brains of drug-loving lab animals and scanning the brains of human volunteers, scientists have developed a detailed picture of how addiction disrupts pathways and processes that underlie desire, habit formation, pleasure, learning, emotional regulation, and cognition. Addiction causes hundreds of changes in brain anatomy, chemistry, and cell-to-cell signaling, including in the gaps between neurons called synapses, which are the molecular machinery for learning. By taking advantage of the brain’s marvelous plasticity, addiction remolds neural circuits to assign supreme value to cocaine or heroin or gin, at the expense of other interests such as health, work, family, or life itself.
“In a sense, addiction is a pathological form of learning,” says Antonello Bonci, a neurologist at the National Institute on Drug Abuse.
Gallimberti was fascinated when he read a newspaper article about experiments by Bonci and his colleagues at NIDA and the University of California, San Francisco. They had measured electrical activity in neurons in cocaine-seeking rats and discovered that a region of the brain involved in inhibiting behavior was abnormally quiet. Using optogenetics, which combines fiber optics and genetic engineering to manipulate animal brains with once unimaginable speed and precision, the researchers activated these listless cells in the rats. “Their interest in cocaine basically vanished,” Bonci says. The researchers suggested that stimulating the region of the human brain responsible for inhibiting behavior, in the prefrontal cortex, might quell an addict’s insatiable urge to get high.
Gallimberti thought TMS might offer a practical way to do that. Our brains run on electrical impulses that zip among neurons with every thought and movement. Brain stimulation, which has been used for years to treat depression and migraines, taps that circuitry. The device is nothing but a coiled wire inside a wand. When electric current runs through it, the wand creates a magnetic pulse that alters electrical activity in the brain. Gallimberti thought repeated pulses might activate drug-damaged neural pathways, like a reboot on a frozen computer.
He and his partner, neurocognitive psychologist Alberto Terraneo, teamed up with Bonci to test the technique. They recruited a group of cocaine addicts: Sixteen underwent one month of brain stimulation while 13 received standard care, including medication for anxiety and depression. By the end of the trial, 11 people in the stimulation group, but only three in the other group, were drug free.
The investigators published their findings in the January 2016 issue of the journal European Neuropsychopharmacology. That prompted a flurry of publicity, which drew hundreds of cocaine users to the clinic. Perotti came in edgy and agitated. After his first session, he says, he felt calm. Soon he lost the desire for cocaine. It was still gone six months later. “It has been a complete change,” he says. “I feel a vitality and desire to live that I had not felt for a long time.”
It will take large, placebo-controlled trials to prove that the treatment works and the benefits last. The team plans to conduct further studies, and researchers around the world are testing brain stimulation to help people stop smoking, drinking, gambling, binge eating, and misusing opioids. “It’s so promising,” Bonci says. “Patients tell me, ‘Cocaine used to be part of who I am. Now it’s a distant thing that no longer controls me.’”
Not long ago the idea of repairing the brain’s wiring to fight addiction would have seemed far-fetched. But advances in neuroscience have upended conventional notions about addiction—what it is, what can trigger it, and why quitting is so tough. If you’d opened a medical textbook 30 years ago, you would have read that addiction means dependence on a substance with increasing tolerance, requiring more and more to feel the effects and producing a nasty withdrawal when use stops. That explained alcohol, nicotine, and heroin reasonably well. But it did not account for marijuana and cocaine, which typically don’t cause the shakes, nausea, and vomiting of heroin withdrawal.
The old model also didn’t explain perhaps the most insidious aspect of addiction: relapse. Why do people long for the burn of whiskey in the throat or the warm bliss of heroin after the body is no longer physically dependent?
The surgeon general’s report reaffirms what the scientific establishment has been saying for years: Addiction is a disease, not a moral failing. It’s characterized not necessarily by physical dependence or withdrawal but by compulsive repetition of an activity despite life-damaging consequences. This view has led many scientists to accept the once heretical idea that addiction is possible without drugs.
The most recent revision of the Diagnostic and Statistical Manual of Mental Disorders, the handbook of American psychiatry, for the first time recognizes a behavioral addiction: gambling. Some scientists believe that many allures of modern life—junk food, shopping, smartphones—are potentially addictive because of their powerful effects on the brain’s reward system, the circuitry underlying craving.
“We are all exquisite reward detectors,” says Anna Rose Childress, a clinical neuroscientist at the University of Pennsylvania’s Center for Studies of Addiction. “It’s our evolutionary legacy.”
For years Childress and other scientists have tried to unravel the mysteries of addiction by studying the reward system. Much of Childress’s research involves sliding people addicted to drugs into the tube of a magnetic resonance imaging (MRI) machine, which tracks blood flow in the brain as a way to analyze neural activity. Through complex algorithms and color-coding, brain scans are converted into images that pinpoint the circuits that kick into high gear when the brain lusts.
Childress, who has flaming red hair and a big laugh, sits at her computer, scrolling through a picture gallery of brains—gray ovals with bursts of color as vivid as a Disney movie. “It sounds nerdy, but I could look at these images for hours, and I do,” she says. “They are little gifts. To think you can actually visualize a brain state that’s so powerful and at the same time so dangerous. It’s like reading tea leaves. All we see is spots that the computer turns into fuchsia and purple and green. But what are they trying to tell us?”
The reward system, a primitive part of the brain that isn’t much different in rats, exists to ensure we seek what we need, and it alerts us to the sights, sounds, and scents that point us there. It operates in the realm of instinct and reflex, built for when survival depended on the ability to obtain food and sex before the competition got to them. But the system can trip us up in a world with 24/7 opportunities to fulfill our desires.
Desire depends on a complex cascade of brain actions, but scientists believe that the trigger for this is likely to be a spike in the neurotransmitter dopamine. A chemical messenger that carries signals across synapses, dopamine plays wide-ranging roles in the brain. Most relevant to addiction, the flow of dopamine heightens what scientists call salience, or the motivational pull of a stimulus—cocaine, for instance, or reminders of it, such as a glimpse of white powder. Each drug that’s abused affects brain chemistry in a distinct way, but they all send dopamine levels soaring far beyond the natural range. Wolfram Schultz, a University of Cambridge neuroscientist, calls the cells that make dopamine “the little devils in our brain,” so powerfully does the chemical drive desire.
How powerfully? Consider the strange side effect of medications that mimic natural dopamine and are used to treat Parkinson’s. The disease destroys dopamine-producing cells, primarily affecting movement. Dopamine-replacement drugs relieve the symptoms, but about 14 percent of Parkinson’s patients who take these medications develop addictions to gambling, shopping, pornography, eating, or the medication itself. A report in the journal Movement Disorders describes three patients who became consumed by “reckless generosity,” hooked on giving cash to strangers and friends they thought needed it.
Through learning, the signals or reminder cues for rewards come to provoke surges of dopamine. That’s why the aroma of snickerdoodles baking in the oven, the ping of a text alert, or chatter spilling out the open door of a bar can yank a person’s attention and trigger craving. Childress has shown that people who are addicted don’t have to consciously register a cue for it to arouse their reward system. In a study published in PLoS One she scanned the brains of 22 recovering cocaine addicts while photos of crack pipes and other drug paraphernalia flashed before their eyes for 33 milliseconds, one-tenth the time it takes to blink. The men didn’t consciously “see” anything, but the images activated the same parts of the reward circuitry that visible drug cues excite.
In Childress’s view the findings support stories she has heard from cocaine patients who relapsed yet couldn’t explain what prompted it. “They were walking around in environments where most of the time one thing or another had been signals for cocaine,” she says. “They were basically getting primed, having that ancient reward system tingled. By the time they became conscious of it, it was like a snowball rolling downhill.”
The brain, of course, is more than an organ of reward. It houses evolution’s most sophisticated machinery for thinking, considering risks, and controlling runaway desire. Why do craving and habits overpower reason, good intentions, and awareness of the toll of addiction?
“There’s a strong-ass demon that messes you up,” says a burly man with a booming voice who smokes crack regularly.
He sits in a black swivel chair in a small windowless room at the Icahn School of Medicine at Mount Sinai in Manhattan, waiting for his MRI. He’s taking part in a study in the lab of Rita Z. Goldstein, a professor of psychiatry and neuroscience, about the role of the brain’s executive control center, the prefrontal cortex. While the scanner records his brain activity, he’ll view pictures of cocaine with instructions to imagine either the pleasures or the perils that each image evokes. Goldstein and her team are testing whether neurofeedback, which allows people to observe their brains in action, can help addicts take more control over compulsive habits.
“I keep thinking, I can’t believe I’ve wasted all that damn money on the drug,” the man says as he’s led to the MRI machine. “It never balances out, what you gain versus what you lose.”
Goldstein’s neuroimaging studies helped expand understanding of the brain’s reward system by exploring how addiction is associated with the prefrontal cortex and other cortical regions. Changes in this part of the brain affect judgment, self-control, and other cognitive functions tied to addiction. “Reward is important in the beginning of the addiction cycle, but the response to reward is reduced as the disorder continues,” she says. People with addiction often persist in using drugs to relieve the misery they feel when they stop.
In 2002, working with Nora Volkow, now the director of NIDA, Goldstein published what has become an influential model of addiction, called iRISA, or impaired response inhibition and salience attribution. That’s a mouthful of a name for a fairly simple idea. As drug cues gain prominence, the field of attention narrows, like a camera zooming in on one object and pushing everything else out of view. Meanwhile the brain’s ability to control behavior in the face of those cues diminishes.
Goldstein has shown that as a group, cocaine addicts have reduced gray matter volume in the prefrontal cortex, a structural deficiency associated with poorer executive function, and they perform differently from people who aren’t addicted on psychological tests of memory, attention, decision-making, and the processing of nondrug rewards such as money. They generally perform worse, but not always. It depends on the context.
For example, on a standard task that measures fluency—how many farm animals can you name in a minute?—people with addiction may lag. But when Goldstein asks them to list words related to drugs, they tend to outperform everyone else. Chronic drug users are often great at planning and executing tasks that involve using drugs, but this bias may compromise other cognitive processes, including knowing how and when to stop. The behavioral and brain impairments are sometimes more subtle than in other brain disorders, and they’re more heavily influenced by the situation.
“We think that is one of the reasons why addiction has been and still is one of the last disorders to be recognized as a disorder of the brain,” she says.
Goldstein’s studies don’t answer the chicken-and-egg question: Does addiction cause these impairments, or do brain vulnerabilities due to genetics, trauma, stress, or other factors increase the risk of becoming addicted? But Goldstein’s lab has discovered tantalizing evidence that frontal brain regions begin to heal when people stop using drugs. A 2016 study tracked 19 cocaine addicts who had abstained or severely cut back for six months. They showed significant increases in gray matter volume in two regions involved in inhibiting behavior and evaluating rewards.
Marc Potenza strides through the cavernous Venetian casino in Las Vegas. Electronic games—slot machines, roulette, blackjack, poker—beep and clang and trill. Potenza, an affable and energetic psychiatrist at Yale University and director of the school’s Program for Research on Impulsivity and Impulse Control Disorders, hardly seems to notice. “I’m not a gambler,” he says with a slight shrug and a grin. Out of the pleasure palazzo, he heads down an escalator and through a long concourse to a sedate meeting room in the Sands Expo Convention Center, where he will present his research on gambling addiction to about a hundred scientists and clinicians.
The meeting is organized by the National Center for Responsible Gaming, an industry-supported group that has funded gambling research by Potenza and others. It takes place on the eve of the industry’s mega convention, the Global Gaming Expo. Potenza stands at the podium, talking about white matter integrity and cortical blood flow in gamblers. Just beyond the room, expo exhibitors are setting up displays touting innovations engineered to get dopamine flowing in millennials. E-sports betting. Casino games modeled on Xbox. More than 27,000 game manufacturers, designers, and casino operators will attend.
Potenza and other scientists pushed the psychiatric establishment to accept the idea of behavioral addiction. In 2013 the American Psychiatric Association moved problem gambling out of a chapter called “Impulse Control Disorder Not Elsewhere Classified” in the Diagnostic and Statistical Manual and into the chapter called “Substance-Related and Addictive Disorders.” This was no mere technicality. “It breaks the dam for considering other behaviors as addiction,” says Judson Brewer, director of research at the Center for Mindfulness at the University of Massachusetts Medical School.
The association considered the matter for more than a decade while research accumulated on how gambling resembles drug addiction. Insatiable desire, preoccupation, and uncontrollable urges. The fast thrill and the need to keep upping the ante to feel the fireworks. An inability to stop, despite promises and resolve. Potenza did some of the first brain-imaging studies of gamblers and discovered that they looked similar to scans of drug addicts, with sluggish activity in the parts of the brain responsible for impulse control.
Now that the psychiatric establishment accepts the idea that addiction is possible without drugs, researchers are trying to determine what types of behaviors qualify as addictions. Are all pleasurable activities potentially addictive? Or are we medicalizing every habit, from the minute-to-minute glance at email to the late-afternoon candy break?
In the United States the Diagnostic and Statistical Manual now lists Internet gaming disorder as a condition worthy of more study, along with chronic, debilitating grief and caffeine-use disorder. Internet addiction didn’t make it.
But it makes psychiatrist Jon Grant’s list of addictions. So do compulsive shopping and sex, food addiction, and kleptomania. “Anything that’s overly rewarding, anything that induces euphoria or is calming, can be addictive,” says Grant, who runs the Addictive, Compulsive and Impulsive Disorders Clinic at the University of Chicago. Whether it will be addictive depends on a person’s vulnerability, which is affected by genetics, trauma, and depression, among other factors. “We don’t all get addicted,” he says.
Perhaps the most controversial of the “new” addictions are food and sex. Can a primal desire be addictive? The World Health Organization has recommended including compulsive sex as an impulse control disorder in its next edition of the International Classification of Diseases, due out by 2018. But the American Psychiatric Association rejected compulsive sex for its latest diagnostic manual, after serious debate about whether the problem is real. The association didn’t consider food addiction.
Nicole Avena, a neuroscientist at Mount Sinai St. Luke’s Hospital in New York, has shown that rats will keep gobbling sugar if you let them, and they develop tolerance, craving, and withdrawal, just as they do when they get hooked on cocaine. She says high-fat foods and highly processed foods such as refined flour may be as problematic as sugar. Avena and researchers at the University of Michigan recently surveyed 384 adults: Ninety-two percent reported a persistent desire to eat certain foods and repeated unsuccessful attempts to stop, two hallmarks of addiction. The respondents ranked pizza—typically made with a white-flour crust and topped with sugar-laden tomato sauce—as the most addictive food, with chips and chocolate tied for second place. Avena has no doubt food addiction is real. “That’s a major reason why people struggle with obesity.”
Science has been more successful in charting what goes awry in the addicted brain than in devising ways to fix it. A few medications can help people overcome certain addictions. For example, naltrexone was developed to treat opioid misuse, but it’s also prescribed to help cut down or stop drinking, binge eating, and gambling.
Buprenorphine activates opioid receptors in the brain but to a much lesser degree than heroin does. The medication suppresses the awful symptoms of craving and withdrawal so people can break addictive patterns. “It’s a miracle,” says Justin Nathanson, a filmmaker and gallery owner in Charleston, South Carolina. He used heroin for years and tried rehab twice but relapsed. Then a doctor prescribed buprenorphine. “In five minutes I felt completely normal,” he says. He hasn’t used heroin for 13 years.
Most medications used to treat addiction have been around for years. The latest advances in neuroscience have yet to produce a breakthrough cure. Researchers have tested dozens of compounds, but while many show promise in the lab, results in clinical trials have been mixed at best. Brain stimulation for addiction treatment, an outgrowth of recent neuroscience discoveries, is still experimental.
Although 12-step programs, cognitive therapy, and other psychotherapeutic approaches are transformative for many people, they don’t work for everyone, and relapse rates are high.
In the world of addiction treatment, there are two camps. One believes that a cure lies in fixing the faulty chemistry or wiring of the addicted brain through medication or techniques like TMS, with psychosocial support as an adjunct. The other sees medication as the adjunct, a way to reduce craving and the agony of withdrawal while allowing people to do the psychological work essential to addiction recovery. Both camps agree on one thing: Current treatment falls short. “Meanwhile my patients are suffering,” says Brewer, the mindfulness researcher in Massachusetts.
Brewer is a student of Buddhist psychology. He’s also a psychiatrist who specializes in addiction. He believes the best hope for treating addiction lies in melding modern science and ancient contemplative practice. He’s an evangelist for mindfulness, which uses meditation and other techniques to bring awareness to what we’re doing and feeling, especially to habits that drive self-defeating behavior.
In Buddhist philosophy, craving is viewed as the root of all suffering. The Buddha wasn’t talking about heroin or ice cream or some of the other compulsions that bring people to Brewer’s groups. But there’s growing evidence that mindfulness can counter the dopamine flood of contemporary life. Researchers at the University of Washington showed that a program based on mindfulness was more effective in preventing drug-addiction relapse than 12-step programs. In a head-to-head comparison, Brewer showed that mindfulness training was twice as effective as the gold-standard behavioral antismoking program.
Mindfulness trains people to pay attention to cravings without reacting to them. The idea is to ride out the wave of intense desire. Mindfulness also encourages people to notice why they feel pulled to indulge. Brewer and others have shown that meditation quiets the posterior cingulate cortex, the neural space involved in the kind of rumination that can lead to a loop of obsession.
Brewer speaks in the soothing tones you’d want in your therapist. His sentences toggle between scientific terms—hippocampus, insula—and Pali, a language of Buddhist texts. On a recent evening he stands in front of 23 stress eaters, who sit in a semicircle in beige molded plastic chairs, red round cushions nestling their stockinged feet.
Donnamarie Larievy, a marketing consultant and executive coach, joined the weekly mindfulness group to break her ice cream and chocolate habit. Four months in, she eats healthier food and enjoys an occasional scoop of double fudge but rarely yearns for it. “It has been a life changer,” she says. “Bottom line, my cravings have decreased.”
Nathan Abels has decided to stop drinking—several times. In July 2016 he ended up in the emergency room at the Medical University of South Carolina in Charleston, hallucinating after a three-day, gin-fueled bender. While undergoing treatment, he volunteered for a TMS study by neuroscientist Colleen A. Hanlon.
For Abels, 28, a craftsman and lighting design technician who understands how circuitry works, the insights of neuroscience provide a sense of relief. He doesn’t feel trapped by biology or stripped of responsibility for his drinking. Instead he feels less shame. “I forever thought of drinking as a weakness,” he says. “There’s so much power in understanding it’s a disease.”
He’s throwing everything that the medical center offers at his recovery—medication, psychotherapy, support groups, and electromagnetic zaps to the head. “The brain can rebuild itself,” he says. “That’s the most amazing thing.”
About the author: Fran Smith is a writer and editor. This is her first article for National Geographic. Max Aguilera-Hellweg is a photographer who also trained as a medical doctor. His last assignment for the magazine was “Beyond Reasonable Doubt,” in the July 2016 issue.
The American Society of Addiction Medicine (ASAM) is proud to announce the acquisition of a $2.2 million grant from the state of Ohio to help combat the prescription opioid and heroin crisis. Ohio has been awarded over $26 million through the 21st Century Cures Act from the Substance Abuse and Mental Health Services Administration (SAMHSA) to strengthen their healthcare system. ASAM is grateful to be a part of building a strong healthcare system, particularly for patients with addiction, in Ohio. The grant-funded project is beginning immediately and is projected to continue through April 2018.
“ASAM is ready to help Ohio take on this project,” said Ohio State Chapter President Dr. Shawn Ryan, “this will make a difference locally for the physicians who treat addiction and save lives in Ohio.”
The objectives of the project include conducting 42 live 8-hour waiver-qualifying CME trainings, providing access to ASAM’s online waiver-qualifying CME for up to 2,000 physician learners, and providing financial compensation to those physicians who meet training and waiver requirements. All goals and objectives will be completed within the funding period (from July 1, 2017 – April 30, 2018).
I’m a mom and a wife. I’m a Chemical Dependency Counselor Assistant and Peer Recovery Support Specialist for BrightView Health in Cincinnati, Ohio, supporting those struggling with substance use disorder.
And I’ve been in recovery from heroin addiction for five years.
Five years ago, I was sprawled on the pavement getting a dose of naloxone. I had overdosed on heroin. It was a near-death end to a reckless existence that had started without warning.
Naloxone didn’t just bring me back to life, it gave me a second chance at life. But more than that – naloxone was the bridge that got me from the brink of death to treatment and recovery.
When I was young, I had several knee surgeries. I was prescribed pain medication on a regular basis, whether or not I needed it. And at no point was naloxone part of any medical conversation.
If it were, maybe I would have been more aware of the high risks and addictive properties of prescription opioids.
Suddenly, I was hooked. By 15, I was diagnosed as an addict and the cycle of addiction consumed the next decade of my life. I doctor shopped for pills, took opioids, used cocaine, methamphetamine and ecstasy to get my fix. I dropped out of high school, gave up the rights to my first child, and married an abusive man whose drug use was like my own.
What started as a prescription from my doctor spiraled into a deadly mission of finding the next, stronger high – eventually leading me to heroin.
I committed felonies for drug money and couldn’t hold a steady job. My young life was decaying. I became associated with members of a Mexican drug cartel and eventually became a drug mule, buying and selling black tar heroin.
I was so far gone, until thankfully, I overdosed. I say thankfully because had it not happened then, I may not be here to share my story.
Addiction is no joke. It’s not a choice. Yes, I chose heroin, but I didn’t choose to be an addict. Naloxone gave me the chance to correct my wrong choice. It didn’t enable me to keep using, like some may think.
The only thing naloxone enables is breathing.
When I overdosed, my body was pushed out of a car and onto the pavement of a parking lot. I was revived by naloxone, I woke up to strangers around me. I refused treatment and within minutes, I stood up and walked away from where my body laid, moments from death. Six weeks later, I entered into treatment, March 9, 2012.
For ten days, I slowly purged my body of the deadly drugs that brought me to that place. I left clean and with a conviction to stay that way.
Quitting heroin was the easy part, rebuilding my life was hard. But it is possible.
I cleared my criminal record, I mended relationships with my family – my daughter that I had walked away from so long ago. I remarried and gave birth to another beautiful baby girl.
As I rebuilt my life, I decided to focus my energy on helping those that were in the same nightmare I had just escaped. I went through a certification course to become a Chemical Dependency Counselor Assistant. I have worked incredibly hard to build my credibility as someone working in the field to show other addicts that recovery is possible.
So today, on International Overdose Awareness Day, what I want everyone to know is that if it weren’t for naloxone, I’d be one of the mourned, not one of the recovered.
The second chance I got is only possible with the ability to enter treatment. If an addict is still alive, there is still hope.
When a person is revived with naloxone, that is the crucial time when we as a society must offer love and compassion to them. That is the moment to look at the patient and say, “You’ve been through a lot, I want to help you find treatment and change your life.” Because no matter how far a person has gone in their life to support their addiction, as long as they are alive, hope is never gone.
I carry naloxone with me everywhere I go. It is the world we are living in today, that I need to be prepared to reverse an overdose at any time. The only way we are going to change this epidemic is if we as members of society and fellow human beings call upon each other to show compassion and love. Not one person is immune to addiction. Addiction has no prejudice and does not care who you are or how much money you have or what you look like. I am living and breathing proof why naloxone needs to be in everyone’s possession. My life is beautiful today, because of naloxone.
Amy Parker is a Chemical Dependency Counselor Assistant and Peer Recovery Support Specialist for BrightView Health in Cincinnati, Ohio. She is a member of the WCPO 9 News Heroin Advisory Board and a Motivational Speaker. Amy has been in recovery from heroin addiction for more than five years.
On our infectious diseases (ID) consult service, we recently cared for Mr. C., a young man with Staphylococcus aureus tricuspid valve endocarditis, septic arthritis, and empyema that were consequences of his opioid use disorder (OUD). Several years earlier, he had started taking oxycodone at parties, and eventually, when the cost of pills became prohibitive, he’d progressed to injecting heroin. His days were consumed by the logistics of obtaining heroin to stave off the exhausting cycle of opioid withdrawal. Despite his deep desire to stop using, he was initially ambivalent when we offered to start treatment with buprenorphine, which is commonly coformulated with naloxone as Suboxone (Reckitt Benckiser). “Doc,” he said, “you gotta understand that as an addict, the scariest thing right now is the idea of putting another opioid in my body, even if it’s going to help me.”
Although Mr. C. had done well on buprenorphine in the past, accumulating several months of recovery, he felt overwhelmed by the prospect of starting the process again. In the days after his clinical status stabilized and the ID service defined his antibiotic course, we kept visiting Mr. C. on the ward. We confronted the dual imperatives to treat his infection and his OUD to reduce his near-term chance of dying from an overdose or relapsed infection. During our visits, we discussed his resolving empyema, but also his cravings, withdrawal symptoms, and readiness to start buprenorphine treatment. On the day before his discharge, as he faced impending relapse, Mr. C. decided he was ready. That afternoon, we completed an observed buprenorphine induction and made an appointment to see him the following week in the ID clinic for ongoing buprenorphine and antibiotic treatment.
As the opioid use and overdose epidemic ravages the United States, bearing witness to the physical and psychosocial consequences of addiction has become part of many physicians’ daily work. Despite our position on the epidemic’s front lines, the remarkable reality is that we remain systematically undertrained and underengaged in addiction-treatment efforts. Though we have taken steps toward recognizing our profession’s complicity in the epidemic’s roots, most physicians feel paralyzed when it comes to effecting change for individual patients.
The history of medicine is, in part, the history of physicians stretching the scope of their practice to answer the pressing needs of their times. In the face of OUD, a treatable illness with a striking capacity to rapidly and definitively alter the lives of our patients, their families, and the communities we serve, we have been late and ineffective in our response. In recent years, the number of hospitalizations for the medical consequences of OUD has escalated, and in 2015 alone, more than 33,000 people died in the United States from opioid-related overdose.2 Yet rates of active physician engagement in addiction treatment remain embarrassingly low.
At some point, it became culturally acceptable to treat all conditions in a patient except addiction. It’s a diagnosis still frequently and falsely regarded as untreatable — a convenient assumption driven by the stigma against people with this disease. ID specialists have historically been ardent advocates for social justice and public health, championing patients on the margins of society who have stigmatizing illnesses. In the age of the opioid epidemic, treatment of life-threatening infections arising from injection drug use accounts for an increasing proportion of our practice. Far too often, however, infections that we treat resolve while underlying substance use disorders are left to fester.
Under the federal Drug Addiction Treatment Act of 2000, physicians who register with the Drug Enforcement Administration, regardless of their subspecialty, can receive a waiver to prescribe buprenorphine for OUD treatment after undergoing 8 hours of training. According to the Substance Abuse and Mental Health Services Administration, the federal body that oversees the buprenorphine waiver program, there are currently 37,448 physicians with such waivers, representing only approximately 4% of all professionally active U.S. physicians. Nationally, the distribution of physicians with waivers is grossly uneven, and many suffering communities are left with little to no capacity for buprenorphine treatment. Obtaining a waiver is one concrete action that all physicians can take to help stem the tide of this epidemic. Physicians practicing in clinical contexts in which long-term prescribing is not possible can prescribe a short course of buprenorphine therapy as a bridge to long-term treatment managed by one of a growing number of primary care physicians and psychiatrists.
As a small group of ID fellows and faculty practicing at Beth Israel Deaconess Medical Center, a large tertiary care hospital in Boston, we have pursued this strategy. We offer buprenorphine in conjunction with antibiotics to patients who are hospitalized with infectious complications of injection drug use. We ask patients about injection practices, counsel them about harm reduction, and prescribe intranasal naloxone for overdose reversal, recognizing that OUD is marked by both recovery and relapse. We partner with colleagues in social work to build viable treatment plans to facilitate recovery and eventually transfer addiction care to long-term programs. As we have waited for institutional capacity to increase, we have also started to offer inpatient buprenorphine induction for patients without concurrent infection.
We anticipated some resistance on both the institutional and the provider levels, but in practice, we have largely encountered appreciation, and our work has served as one impetus for a larger hospital initiative to address the opioid crisis. This pilot program was born in our ID division, but we believe it is replicable by any physician group — for example, surgical teams discharging patients admitted with OUD-related complications or psychiatry teams discharging patients with both substance use disorder and mental illness. For all physicians, it is vital to recognize that medication treatment for OUD is a cornerstone of recovery for most patients, and when it’s omitted, high rates of relapse are consistently observed.
We are wading into the turbulent waters of our patients’ lives to see them through to a time when they are clear of their infection and on the continuum of recovery. Though our efforts are still relatively new, we have been changed by the experience. Some of our patients have had relapses or haven’t returned for care. But we’ve also seen remarkable successes — patients who presented in the depths of addiction and illness who have subsequently reconnected with their families, have started to work again, and now use opioids less or not at all. By providing the bridge to long-term addiction treatment, we have observed patients remain in care at higher rates and start to mend their badly damaged sense of trust in a medical system that has long treated them with judgment and neglect.
We are providing this care outside the realm of traditional ID consultation because the crisis demands it. Today in the United States, another 91 people will die from an opioid overdose.5 Under the watchful eyes of physicians, many people survive their acute illnesses only to die in public restrooms, in private homes, or on the street. There are many inspiring examples of physicians and health care communities that have similarly stretched the scope of their practice, and lives have been saved as a result. We believe it’s time for more of us to join the movement.
Two months after being discharged, Mr. C. continues to receive buprenorphine treatment. He gets his prescriptions through a program close to his home, where he attends weekly group meetings and individual counseling sessions. He wholly understands the gravity of his infection; his heart valve has been left severely damaged, and he still feels weak. But he has reconnected with friends and family and is making plans to return to work. He is in early recovery from his OUD and from the chaos, social isolation, and depression that come with it. As we see it, the medical community is also in early recovery — moving past implicit biases, stigma, and fear to connect with our patients and respond to a defining crisis of our time.
Alison B. Rapoport, M.D., and Christopher F. Rowley, M.D.
Following the recent recommendation of the White House’s opioid commission, President Trump announced today that the Administration is moving to declare a national emergency on opioid abuse.
Jessica Nickel, President and CEO of the Addiction Policy Forum, released this statement in response to the announcement:
“We applaud President Trump for taking this important step today to declare a national emergency on this crisis. This declaration can help communities with flexibility and resources to help implement a comprehensive response to the opioid epidemic. Every day we are losing 144 people to drug overdoses — 144 daughters, sons, mothers, sisters and fathers. We can do better for our families and communities.”
This week, President Trump’s commission on combating the opioid crisis, led by Gov. Chris Christie of New Jersey, recommended that the president declare a national emergency.
The problem has become significantly worse recently, so you might feel that you could use a little catching up. Here are 11 things you need to know.
1. How bad is it?
It’s the deadliest drug crisis in American history.
2. What is an “opioid”?
Something that acts on opioid receptors in the nervous system.
That’s not really a helpful answer.
The first such drug, and the one from which the opioid receptors get their name, was opium. Opium, a narcotic obtained from a kind of poppy, has been used in human societies for thousands of years. From opium people derived a whole host of other drugs with similar properties: first morphine, then heroin, then prescription painkillers like Vicodin, Percocet and OxyContin. Opium along with all of these derivatives are collectively known as opiates.
Then there are a handful of compounds that act just like opiates but aren’t made from the plant. Opiates along with these synthetic drugs — chiefly methadone and fentanyl — are grouped together into the category of substances called opioids.
Opioid receptors regulate pain and the reward system in the human body. That makes opioids powerful painkillers, but also debilitatingly addictive.
3. So is this crisis about prescription painkillers or heroin?
The crisis has its roots in the overprescription of opioid painkillers, but since 2011 overdose deaths from prescription opioids have leveled off. Deaths from heroin and fentanyl, on the other hand, are rising fast. In several states where the drug crisis is particularly severe, including Rhode Island, Pennsylvania and Massachusetts, fentanyl is now involved in over half of all overdose fatalities.
While heroin and fentanyl are the primary killers now, experts agree that the epidemic will not stop without halting the flow of prescription opioids that got people hooked in the first place.
4. Show me one way the epidemic has changed.
The latest iteration of the opioid epidemic has been especially deadly among adults in their 20s and early 30s.
In 2000, the most common age for drug deaths, including those not involving opioids, was around 40. This was the generation that first grew addicted to prescription opioids in large numbers — white people especially so. Now there’s evidence that the opioid epidemic is dividing into two waves, with a new group of younger drug users growing addicted to, and dying from, heroin or fentanyl rather than prescription pills.
5. Where is the worst of the problem?
The Midwest, Appalachia and New England. For now.
There’s a lot of geographic variation in the rate of drug deaths, with the highest overdose rates clustered in Appalachia, the Rust Belt and New England.
Teasing out the reasons for the geographical differences is not easy. In certain places, the ways in which people use drugs could be more dangerous (you’re more likely to die from injecting heroin than you are from smoking it, for example).
But it’s clear that a significant portion of the variation in deaths, if not necessarily in use, is being driven by the appearance of fentanyl in the drug supply. Fentanyl, a highly potent opioid, affects heroin users and pill users both, the latter often falling victim to counterfeit pills that look like prescription painkillers.
So far, the white population has been hardest hit, but this is beginning to change. Several critics have been quick to point out that the country’s response was not nearly as public-health-oriented during the crack cocaine epidemic in the 1980s, which disproportionately affected African-Americans.
6. Why has this problem gotten so much worse in recent years?
Decades of opioid overprescription, an influx of cheap heroin and the emergence of fentanyl. Addiction to opioids goes back centuries, but the current crisis really starts in the 1980s. A handful of highly influential journal articles relaxed long-standing fears among doctors about prescribing opioids for chronic pain. The pharmaceutical industry took note, and in the mid-1990s began aggressively marketing drugs like OxyContin. This aggressive and at times fraudulent marketing, combined with a new focus on patient satisfaction and the elimination of pain, sharply increased the availability of pharmaceutical narcotics.
Pill mills began popping up around the country as communities were flooded with prescription opioids. Over the next decade, a growing number of people grew addicted to the drugs, whether from prescriptions or from taking them recreationally. For many, what started with pills evolved into a heroin addiction.
At the same time, the heroin market was changing. The price plummeted. Newly decentralized drug distribution networks pushed heroin and counterfeit pharmaceuticals into suburban and rural areas where they had never been. Everywhere the suppliers went, they found a ready and willing customer base, primed for addiction by decades of prescription opiate use.
Then in 2014, fentanyl began entering the drug supply in large amounts.
7. What is fentanyl and why is it killing people?
It’s a synthetic opioid 50 times more potent than heroin.
Heroin is derived from opium, a plant. That means its growers need fields and labor to harvest the crop. They are tied to land, weather and time.
Fentanyl is purely synthetic. Think chemistry, not agriculture. It’s commonly used for surgical anesthesia and is prescribed to treat pain, but almost all of the fentanyl on the streets is illicitly manufactured. According to the Drug Enforcement Administration, the majority of illicit fentanyl in the United States is manufactured either in China or in Mexico using precursors bought from China. And at least some portion of it comes to the United States in the mail, ordered from dark web sources like the recently shuttered AlphaBay. But we don’t know how much.
Fentanyl is a fine-grained powder, meaning that it’s easy to mix into other drugs. This is how most people are exposed to illicit fentanyl: It will be mixed into, or made to look like, powdered heroin or it will be used to produce counterfeit prescription pills.
It’s super potent, meaning you’re dealing with very small quantities. That makes it almost impossible to control supply. Though most of the fentanyl in America is thought to originate in China, the fact that it’s synthetic means it’s much harder to know where the drugs are coming from. With heroin, investigators could rely on regionally specific chemical markers to indicate where the drugs had been produced. With drugs synthesized in a lab, it’s harder to tell.
8. Why would people take fentanyl? It does not sound fun.
Many aren’t intending to.
From a dealer’s perspective, fentanyl is easier to get and more profitable to sell. Some law enforcement officials argue that drug users will seek out batches of drugs that contain fentanyl or that are known to have killed people, as that demonstrates the drugs’ potency.
While that is certainly true for some number of drug users, research suggests that they are a minority. Most are exposed to fentanyl inadvertently — it’s difficult to know just what is in the drugs they are buying (many dealers don’t know themselves), one more risk in a dangerous pursuit of a high.
For long-time drug users, their continued use underlines the grip of addiction and the agony of withdrawal: They know it could kill them but do it anyway. Casual drug users are also at risk of fentanyl poisoning, particularly with increased reports of fentanyl-adulterated cocaine.
9. So shouldn’t we just stop prescribing opioids?
Opioids are a vital component of modern medicine that have measurably improved the quality of life for millions of people, particularly cancer patients and those with acute pain. But their efficacy in treating chronic pain is less clear, especially when weighed against the risks of overdose and addiction.
Though prescription opioid consumption has been decreasing in the United States since 2010 or 2011, it remains high. According to the International Narcotics Control Board, if the amount of opioids prescribed per year were averaged out over each person living in America, everyone would get about a two-week supply. (Or a three-week supply, according to the C.D.C. Different ways of measuring what counts as a daily opioid dose give different values.) Either way you count, it’s higher than anywhere else in the world.
At the same time, some chronicpainpatientsnow struggle to fill their prescriptions. Solving the opioid problem requires controlling prescription opioid distribution while maintaining access for patients with legitimate medical needs. Suddenly removing access to opioids from those who are dependent on them to function could easily push people to illicit opioid sources, like heroin or counterfeit pills.
10. What can be done?
There’s no silver bullet.
Experts agree fixing the opioid epidemic will take a combination of solutions. But it’s a question of priorities: Which approaches will be most effective and most efficient? What is the best use of resources?
Officials want to use state prescription drug monitoring programsto reduce the supply of prescription opioids that end up being used recreationally while maintaining adequate access for current chronic pain patients. More broadly, experts say we need to improve the way our medical system manages pain. Remember the 12 million people we said took prescription painkillers outside of medical use? Roughly two-thirds of those did so to relieve physical pain. A more holistic approach to pain treatment would lessen the need for opioids.
On the treatment side, experts stress the importance of having treatment readily available for those who are already addicted. Often that means going to where the people are, not waiting for them to seek out treatment themselves. And addiction treatment doesn’t just mean counseling or an inpatient clinic. Studies show the most effective treatment for opioid addiction often requires opioid medications like methadone or buprenorphine.
In the meantime, widespread distribution of naloxone — an overdose antidote — will save lives in acute cases.
There isn’t agreement about other possible measures that could help. Public health experts advocate things like safe injection sites, where people could use drugs under medical supervision, and drug checking services that people could use to test drugs for fentanyl, but many in law enforcement remain reluctant to adopt such measures.
11. Will the commission’s recommendations help?
Maybe, but only if they’re adopted. The commission laid out a series of recommendations in its interim report, with a final report expected in October.
Some of the recommendations — like enhancing prescription drug monitoring programs and mandatory physician education on the dangers of opioids — are aimed at prevention. Some — expanding access to and funding development of medication-assisted treatment, eliminating Medicaid barriers to in-patient addiction treatment and enforcing laws that prevent health insurance companies from limiting mental health coverage — are aimed at treatment. The commission’s report also called upon the president to mandate that naloxone be carried by every American law enforcement officer.
Of course, these are only recommendations. It’s up to the president and the various executive agencies to implement them. Experts know how to attack the problem. It’s just a matter of having the will to put those policies into practice.
Link to the original article with an accompanying interactive graph and charts here:
The National Academies report includes recommendations for federal agencies, states and medical personnel.
When the U.S. Food and Drug Administration screens new opioid drugs it should better anticipate how people might abuse them in the real world, the National Academies of Sciences, Engineering and Medicine warns in a major report issued Thursday on the country’s opioid crisis, which kills 91 people a day—often via overdoses on prescription drugs. The FDA needs to move beyond its traditional focus on clinical studies about drug effectiveness and side effects, and to seek public health data on potential abuse, the Academies advises in its 400-page proposal for targeting the deadly issue.
The FDA had asked for the report, and its release comes as several states are suing pharmaceutical companies over allegations that they downplayed the addictive nature of certain prescription painkillers and helped fuel the current crisis. “The focus of the request from the FDA was for advice on what they could do to evaluate [opioids] more completely before approving them for use,” says Stanford University anesthesiology professor David Clark, a member of the Academies committee that drafted the report. A key recommendation, Clark says, is for “the FDA to move beyond its standard matrix of considerations for drug safety and—at least for opioids—move into a more public health–centered matrix of considerations which could help us predict what might happen for people beyond the intended recipient of the drug.”
The 18-member committee, which worked on the report for more than a year, identified specific steps that states, federal agencies and medical providers should take to stem the tide of abuse of substances including heroin, fentanyl and prescription drugs—even as they ensure pain patients have access to legal relief. Any policy that aims to restrict lawful access to prescription opioids would drive some people toward the illegal market, the report warns. Instead it urges states, regulators and public health agencies to work toward universal access to evidence-based interventions for substance abuse, including treatment programs and full coverage of medications approved to fight addiction. The report calls for expanding access to the overdose antidote naloxone to laypeople, and also says jurisdictions should explicitly authorize syringe exchange as well as their sale or distribution. “Reducing the scope of the epidemic of opioid addiction is my highest immediate priority as commissioner,” the FDA’s Scott Gottlieb said in an e-mailed statement. “I was encouraged to see that many of [the Academies’] recommendations for the FDA are in areas where we’ve made new commitments.”
The Academies’ report also recommends increasing the FDA’s formal reevaluations of opioid approval decisions, in order to ensure that the drugs’ benefits still outweigh the risks. It advises the FDA and other federal health agencies to improve their data tracking on pain and opioid use, and to invest more money in research for a clearer picture of the opioid epidemic—and for potential ways to combat it, such as programs that track prescribing and dispensing information.
Officials battling the crisis on the ground applauded some of the Academies’ findings. “The report is in line with the work we are already doing in Baltimore City,” says Leana Wen, the city’s public health commissioner. “We have had needle exchange programs for over 20 years, and we also have a very aggressive naloxone program.” The report focuses on improving research and regulatory actions before a prescription drug hits the market, Wen notes. “All these are important, but I continue to emphasize what I see on the frontlines—a need for increased access to treatment that is evidence-based and well established.” With naloxone’s price rising and a shortage of substance abuse treatment beds, these are crucial needs, she says.
The report also says states should take specific actions, such as creating more year-round programs in which pharmacies or other establishments take back unused prescription painkillers—so they do not sit around patients’ houses, where they might be abused or stolen. (According to the National Institute on Drug Abuse, nearly half of young people who inject heroin abused prescription opioids first.) “The concerns on this point are more impetus rather than obstacle,” Clark says. “It is not uncommon to have drug take-back programs through churches, pharmacies, universities, and public interest groups and community organizations. But none of those organizations are set up to do that kind of thing on an ongoing basis.” Some pharmacies have already moved in this direction by setting up drop boxes to dispose of old drugs when someone comes in to fill a new prescription, he adds.
The President’s Commission on Combating Drug Addiction and the Opioid Crisis, chaired by New Jersey Gov. Chris Christie, also aims to come up with concrete recommendations. It was scheduled to release an interim report last month but has not done so, and now expects to put the report out at the end of this month, around its next meeting. “The Commission is continuing to look at how the administration can best address this unprecedented crisis and will be releasing its [final] report in October,” Richard Baum, acting director of the Office of National Drug Control Policy, told Scientific American in an e-mailed statement. “The Trump administration is committed to addressing the opioid epidemic,” Baum wrote, and in just six months it has “sent nearly $500 million to the states to address the epidemic locally, begun work on the president’s first National Drug Control Strategy and established the President’s Commission on Combating Drug Addiction and the Opioid Crisis.” (The latest version of the Senate health care bill, released Thursday, also would include $45 billion to help support substance abuse treatment.)
Addressing the opioid epidemic requires action in the medical and patient community as well, the Academies’ committee says. It advises states to create better pain education materials for medical schools, medical licensing boards and the public. States and the federal government should also work in concert to help boost access to medication for addiction—and to make sure patients can afford it, the report says. Managing the opioid crisis is a balancing act requiring trade-offs when it comes to restricting the lawful opioid supply, influencing prescriber practices, cutting demand and reducing harm, the committee members wrote. Yet they add that their proposal should, “leave adequate space for responsible prescribing and reasonable access for patients and physicians who believe an opioid is medically necessary.”
Sending more people to prison for drug offenses won’t have an effect on drug use and deaths, according to a new analysis released this week.
Researchers from the Pew Charitable Trusts crunched state-by-state data on drug imprisonment, drug use, overdoses and drug arrests and found no evidence that they affected one another.
That lack of a pattern shows the flaw in a central philosophy in the war on drugs: That doling out harsh penalties makes people less inclined to use drugs or join the drug trade, said Adam Gelb, director of Pew’s public safety performance project, which works to reform state-level drug policies.
“There seems to be this assumption that tougher penalties will send a stronger message and deter people from involvement with drugs. This is not borne out by the data,” Gelb said.
He included the entire analysis in a letter Monday to Chris Christie, who is both governor of New Jersey and head of President Donald Trump’s Commission on Combating Drug Addiction and the Opioid Crisis.
The commission held its first public meeting on Friday. It is responsible for coming up with a plan to help the federal government tackle an addiction crisis that killed more than 50,000 people last year. The growing number of overdoses is being driven by runaway rates of addiction to prescription painkillers and heroin, researchers say.
Meanwhile at the Justice Department, Attorney General Jeff Sessions is carving out his own approach — focused on punishment. He issued a memo to federal prosecutors in May ordering them to seek the maximum punishment for drug offenses, a return to harsh policies that predate former President Barack Obama.
Pew’s study was relatively simple: gather data from each state in four categories: incarceration of drug offenders, overdose deaths, drug arrests and drug use. The latest year for which all the data was available was 2014.
The theory, Gelb said, was that if deterrence worked, the states with the highest incarceration rates would have lower rates of drug use.
But that’s not what they found.
For example, Louisiana, the state with the highest incarceration rate, was in the middle of the pack on overdoses, drug arrests and drug use. Massachusetts, with the lowest incarceration rate, was toward the bottom in arrests and use, but near the top in overdoses. West Virginia, with the highest overdose rate, was 21st in incarcerations. And Colorado, with the highest rate of drug use, was 37th in incarcerations.
Gelb said he hoped the commission and other policy makers would use it to chart their course forward.
“This is fresh data that should inform the important conversation happening in Washington and around the country about what the most effective strategies are for combatting the rise in opioid addiction and other substance abuse,” Gelb said.