JAMA Forum: A New Year’s Wish on Opioids

As overdose deaths mount, leading to a decline in US life expectancy 2 years in a row, my New Year’s wish is for more people to appreciate this statement: Not all well-intentioned approaches to addressing the opioid epidemic are good ideas. Some are based on evidence and experience, others on misunderstanding, blame, fear, or frustration. What’s needed in 2018 is the wisdom—and the courage—to tell the difference.

Addiction Treatment

The use of the opioid agonists methadone and buprenorphine reduces overdose, illicit drug use, crime, and transmission of infectious diseases. A common misconception, however, is that these medications are part of the problem. Even in the field of addiction treatment, many still believe that those who take methadone or buprenorphine are “trading one addiction for another,” “in bondage,” or taking a “cop-out.” The majority of privately funded treatment programs for opioid use disorder do not offer patients the chance to use medications. In addition, Narcotics Anonymous allows chapters to block people who take medications from telling their stories at support meetings. Some judges order patients off medications or allow social services agencies to remove children from parents doing well on medications in treatment.

The consequence of these attitudes and actions? More fatal overdoses. A must-read investigation by journalist Jason Cherkis, a finalist for the Pulitzer Prize, found that the ideology against medications can be so fierce that it leads some to shrug off a greater risk of death.

OpioidsInBlackText

For 2018, I ask for greater understanding that medications can help—not hinder—an individual in taking responsibility for his or her own recovery. Indeed, many patients who take medication explain that it clears their mind of intense cravings and allows them to focus on making amends and rebuilding their lives. Programs such as the Hazelden Betty Ford Foundation that historically promoted “abstinence only” are now incorporating effective medications into their programs. This is not new ground: Medication use and personal responsibility coexist for many other conditions, from diabetes to nicotine addiction.

An expanded appreciation of the role of medications would support the growing bipartisan interest in broadening access to all of the FDA-approved options. Consistent with the approach taken by the Obama Administration, President Trump’s Commission on Combating Drug Addiction and the Opioid Crisis emphatically endorsed treatment that includes medications, and US Food and Drug Administration Commissioner Scott Gottlieb recently testified: “We should not consider people who hold jobs, reengage with their families, and regain control over their lives through treatment that uses medications to be addicted. Rather, we should consider them to be role models in the fight against the opioid epidemic.”

Criminal Justice

It is now recognized by many across the political spectrum—including the Koch brothers—that the arrest and jailing of millions of Americans for their addiction has complicated efforts to address the opioid epidemic. Charging nonviolent individuals for possessing small amounts of drugs strains the courts and jails and tags people with addiction with criminal records that hinder recovery. Yet as overdoses have spiked—in large part due to heroin laced with fentanyl—several states have again increased penalties for possessing small amounts of drugs, and some prosecutors have turned overdoses into crime scenes, charging friends and family with murder. The instinct to “get tough” is understandable, but users rarely know the content of their drugs, and the result is likely to be fewer people calling for help.

There is also the very real danger of overdose after incarceration. In most jails across the country, individuals with an opioid use disorder are forced to endure a painful (and occasionally fatal) withdrawal. While incarcerated, they lose their tolerance to opioids, raising the chance of overdose when opioids become available again. Studies document up to 10-fold elevations of risk of death upon release from detention.

In 2018, I hope for far wider adoption of alternative approaches: fewer arrests for drug use and much greater access to treatment within the corrections system. There are some inspiring examples. Innovative police departments and prosecutors in Massachusetts, New York, Washington, Vermont, and elsewhere are diverting nonviolent users of drugs to treatment instead of detention. Initial results of some of these efforts show substantial declines in recidivism.

Journal-Addiction-Medicine

In addition, states including Rhode Island and Connecticut are beginning to offer access to effective treatment with medications to detainees, with transitions to community care upon release—a promising approach supported by evidence from other countries and consistent with the recommendations of the President’s Advisory Commission.

Health Care System

There is now broad understanding that the overprescribing of opioids has contributed to today’s opioid epidemic. There is much less appreciation, however, that some responses to this insight can make the overdose problem worse. At a time when most insurers still do not provide adequate reimbursement for nonpharmaceutical approaches to pain or treatment for opioid use disorder, overly restrictive prescribing policies risk pushing patients with pain or addiction to illicit drugs, a transition many have made. A few distraught patients have even committed suicide.

The good news is that tools and evidence-based guidelines and coverage policies are available to reduce excessive prescribing of opioids, while preserving the ability to provide individualized care. In 2018, I hope that medical community rapidly adopts a recently released set of quality metrics that was designed to support these thoughtful approaches.

I also hope that in the new year, more health care organizations embrace their responsibility not only to cause less of the opioid problem (by reducing excessive prescribing for pain) but also to contribute more to the solution (by expanding access to addiction treatment). A randomized trial found double the rate of short-term treatment success when emergency departments offered buprenorphine therapy and a warm handoff to ongoing treatment. Similarly, starting treatment with medications on the wards is far better than the oft-provided “detox,” which is associated with a risk of death from overdose.

An inspiring example for the new year? Massachusetts General Hospital, which recently began training emergency department physicians to start treatment on the spot.

Looking to Evidence

On opioids, it can sometimes seem that there are 3 bad ideas for every good one. Public officials have supported limiting the number of naloxone resuscitations and afterwards letting people die, requiring drug testing before enrolling in Medicaid, and launching stigmatizing public relations campaigns that can reduce the chance people will seek treatment. Can we leave such approaches behind in 2017?

Young-man-praying

Worth holding onto are approaches by states like Rhode Island, where the Governor asked a team of local experts to listen to the public, consult the evidence, and provide recommendations for priority strategies. As one Rhode Island expert told an assembled group, “Our goal here is not to make everybody in this room happy. Our goal is to cut down on overdose deaths.” Three years later, after developing a terrific dashboard, investing in access to effective treatment, developing programs to improve prescribing of opioids and benzodiazepines, and setting standards for hospital activities, the state is one of a few actually seeing a decline in overdoses.

The sheer scale of the opioid epidemic is staggering. There needs to be much more work on understanding and addressing the root causes of this problem, as well as greater willingness to try out promising approaches to the emerging threats of fentanyl and related compounds.

To get started on the right foot in 2018, the opioid epidemic demands much more of what works, and much less of what does not—as do our friends, family, and neighbors who are struggling for their very lives.

About the author (pictured below): Joshua M. Sharfstein, MD, is Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is a consultant for Audacious Inquiry, a company that has provided technology services and other support to Maryland’s Health Information Exchange. A pediatrician, he lives with his family in Baltimore.

JoshuaMSharfsteinAuthor

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Link to the original article here: JAMA Forum: A New Year’s Wish on Opioids

What’s Missing from the National Discussion About the Opioid Epidemic

Last Wednesday, less than a week after Donald Trump declared America’s opioid epidemic a national public-health emergency, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final set of policy recommendations. The panel called on Congress and the White House to consider fifty-six proposals, among them streamlining federal funding for addiction treatment, instituting stricter prison sentences for some opioid traffickers, and launching an “aggressive” TV and social-media campaign to dissuade children and teens from taking the drugs. (In his earlier announcement, Trump had promised “really tough, really big, really great advertising, so we get to people before they start.”) The commission also urged the Department of Health and Human Services to develop “a national curriculum and standard of care for opioid prescribers,” to supplement the Centers for Disease Control and Prevention’s existing guide for primary-care physicians.

Patient-on-a-Gurney.jpg
The medical community has long shunned and stigmatized drug users. Can policymakers help doctors keep their compassion alive?

There is no doubt that the epidemic warrants urgent, wide-ranging action. According to a recent C.D.C. report, some twelve and a half million Americans misused prescription opioids in 2015, the latest year for which reliable figures are available, and more than three-quarters of a million used heroin. All told, thirty-three thousand people died of opioid overdoses that year. The situation appears to be worsening; provisional data suggests that the over-all rate of drug-overdose deaths jumped twenty per cent in 2016, with a substantial portion of that likely coming from opioids. Trump has repeatedly acknowledged the scale of the problem, but he has yet to free up the funds to address it. For now, he seems most interested in another round of “just say no” campaigns, which will do nothing to help those already addicted. The idea of creating a curriculum for opioid prescribers is a good one—measures like it have already made the drugs harder to obtain—but the Administration must also work to confront another obstacle within the medical community. The fact is that, for many physicians, caring for drug users is a source of enormous frustration.

This truth became vividly apparent to me early in my training. As an intern at Massachusetts General Hospital in the nineteen-seventies, I was once called to the emergency room to attend to a man in his twenties whom I will call Vinny. He had a fever of a hundred and four, was struggling to breathe, and his blood pressure was falling. On physical examination, I heard a loud heart murmur, indicating that his cardiac valves were malfunctioning. Then I noticed several track marks on his arms. The diagnosis became apparent: Vinny had injected himself with heroin using a dirty needle, and in so doing he had introduced microbes directly into his bloodstream, which had landed inside the heart, causing an infection called bacterial endocarditis.

The medical team moved Vinny to the intensive-care unit and stayed up through the night, working to keep him from going into shock. In addition to antibiotics, he required numerous medications to keep his blood pressure up. By the time the sun rose, his vital signs were stable. I felt heroic, having saved this young man’s life. When I exited the I.C.U. to tell his distraught mother, she burst into tears and kissed my hands.

In the ensuing weeks, as Vinny recovered, I got to know him well. He claimed that he had shot drugs only occasionally and swore on his mother’s life that, after this brush with death, he would never touch heroin again. But, less than a month later, he was back in the E.R., spiking a fever and struggling to breathe. Though a hospital social worker had put him in touch with an addiction clinic, he had continued using drugs. Again the I.C.U. team did its best, and again Vinny survived. But I was filled with anger and resentment: my colleagues and I had been lied to, taken in by his charm, and now it appeared that our time and energy had been for naught. My supervising resident told me that I had been naïve to have any faith in Vinny’s promises; he was, in the parlance of the resident, like all addicts, an S.P.O.S.—a subhuman piece of shit.

The acronym still appalls me, more than four decades later. It was a betrayal of the spirit of compassion that good physicians must bring to the practice of medicine. But I understood then why most doctors I worked with wanted nothing to do with such patients. I later heard that Vinny had died of a drug overdose, but not before infecting his girlfriend with H.I.V. She ended up succumbing to aids. (As it happened, I would devote much of my career to the aids epidemic. Nearly all of my patients in the eighties and nineties were gay men who saw their caregivers as allies.)

As policymakers step up their efforts to check the opioid crisis, how can they best support the physicians on the front line? In August, two infectious-disease specialists at Boston’s Beth Israel Deaconess Medical Center, where I also work, took up that question in the New England Journal of Medicine. “At some point, it became culturally acceptable to treat all conditions in a patient except addiction,” Alison Rapoport and Christopher Rowley write. “It’s a diagnosis still frequently and falsely regarded as untreatable—a convenient assumption driven by the stigma against people with this disease.” The authors tell the story of one of their patients, a Mr. C., who was struggling with opioid-use disorder and bacterial endocarditis. In consultation with Mr. C. and the hospital’s social workers, Rapoport and Rowley devised a successful course of treatment—regular doses of buprenorphine, an opioid that lessens the effects of withdrawal, along with counselling sessions and weekly group meetings. Like Mr. C. himself, they write, “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.” Only then, they add, can physicians begin to mend patients’ “badly damaged sense of trust in a medical system that has long treated them with judgment and neglect.”

It is fitting that this call to action should come from a pair of infectious-disease doctors. As Rapoport and Rowley note, members of their field “have historically been ardent advocates for social justice and public health, championing patients on the margins of society.” One concrete step toward addressing the epidemic, they write, is to expand the use of buprenorphine. Currently, only four per cent of all working doctors in the United States possess the necessary waivers from the Drug Enforcement Administration to prescribe the medication for opioid treatment. Indeed, according to the Trump commission’s final report, nearly half of all counties in the U.S., including almost three-quarters of all rural counties, lack access to buprenorphine. Echoing Rapoport and Rowley, the panel recommends that federally funded health centers mandate that their staff obtain D.E.A. waivers.

Let us hope that the Trump Administration listens. To be sure, many more American doctors will need training in modern methods of treating addiction. That’s actually an easy education. It will be harder to learn how to overcome our disdain for the afflicted, to see the humanity in their plight. Without that change, there is scant hope of success.

The author, Jerome Groopman, has been a staff writer since 1998 and writes primarily about medicine and biology.

Link to the original article here in the New Yorker: What’s Missing from the National Discussion About the Opioid Epidemic

How Science Is Unlocking the Secrets of Addiction

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.

hooked-addiction-gallimberti.adapt.590.1
BREAKING THE CHAIN A serious cocaine addict who’d relapsed several times after treatment, Patrick Perotti finally resorted to an experimental treatment—the application of electromagnetic pulses to his prefrontal cortex— at a clinic in Padua, Italy. It worked. Psychiatrist Luigi Gallimberti has used transcranial magnetic stimulation on other patients with similar success. He and his colleagues are planning a large-scale trial. The technique is now being tested for other types of addiction by researchers around the world.

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.

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.

hooked-addiction-rats.adapt.1190.1
CREATURE OF COMPULSION This rat, in a simulation of a slot machine, is lured by the same types of flashing lights and throbbing sounds that keep humans playing in casinos. With a choice of openings that pay off in sugar pellets, the rat will consistently poke at the one with the biggest payoff but the smallest chance of winning. Using similar studies, Catharine Winstanley, a neuroscientist at the University of British Columbia, has discovered that a medication that blocks a dopamine receptor can reduce risky decision-making linked to compulsive gambling.

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.

hooked-addiction-france-baclofen.adapt.1900.1
CASUAL DRINKING Sylvie Imbert and Yves Brasey credit baclofen, a medication used to treat muscle spasms, with freeing them from their devotion to the bottle. In studies, baclofen has shown promise for treating alcohol dependency. Brasey, having a beer at the Hotel Luxembourg Parc in Paris, now has just a few drinks at a time. Imbert had six to nine drinks almost daily until she started taking baclofen. Now she drinks only occasionally. Imbert and Brasey have become outspoken advocates for the drug.

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.”

hooked-addiction-seattle-police.adapt.1190.1
PATIENTS, NOT PRISONERS The law enforcement officers arresting this man on suspicion of smoking heroin in downtown Seattle chose to refer him to a treatment program for certain low-level drug offenders, rather than take him to jail. The innovative program, under way for more than five years, reflects an increasing awareness that habitual drug abuse stems from addiction and can be treated as a disease, not a crime. The program has reduced recidivism among offenders diverted from the criminal justice system.

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.

Link to article here: How Science Is Unlocking the Secrets of Addiction

ASAM Receives Multimillion Dollar Grant from Ohio Mental Health and Addiction Services

by ASAM Staff | August 31, 2017

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 goals of the project include partnering with Ohio Department of Mental Health & Addiction Services to provide the required education needed to increase the number of physicians with a DATA 2000 waiver 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).

For more information about the course click here.

How My Overdose Saved My Life

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.

That’s today.

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.

Link to article on Huffingtonpost.com here: How My Overdose Saved My Life

 

 

Short Answers to Hard Questions About the Opioid Crisis

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.

-00up-opioids-art1-master1050

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?
 Both.

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.
Sure.

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?
No.

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.

00up-opioids-art2-master1050

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:

Short Answers to Hard Questions About the Opioid Crisis

 

Author: Josh Katz