3 Suggestions to Boost Your Mood and Improve Your Performance
This past year I have noticed how my vocabulary impacts my attitude. Words have power. They impact others, of course, but they can also have an impact on us.
I was once headed out of town for a speaking engagement. A friend called and asked me where I was going. I said, “Oh, I’m headed to San Jose. I have to speak at a convention.” I said it with a little resignation in my voice.
The moment I hung up, it hit me. I don’t have to speak. I get to speak. That instantly changed my attitude.
How many people would gladly do this for free—or even pay for the opportunity? Yet I was getting paid to do it.
Small Shift, Big Difference
The first expression (i.e., I have to do it) is the language of duty. Nothing wrong with that. I am all for responsibility.
But too often we say it with a sigh, like it’s a sentence—or we’re a victim. It can easily become pessimistic, and nothing will kill your creativity, job performance, or relationships like going negative.
The second expression (i.e., I get to do it) is the language of privilege. It’s as if we have been given a gift, and we are relishing the opportunity.
This subtle shift may seem small, but it has had a big impact on my attitude. I am choosing the language of privilege every chance I get.
I don’t have to workout this morning; I get to workout. What a privilege to be healthy and be able to care for my body.
I don’t have to write a new blog post. I get to write one. What a privilege to have readers that actually care what I have to say.
I don’t have to meet with the guys in my mentoring group; I get to. What a privilege to meet with eight young men who want to learn and grow.
I don’t have to go to church today; I get to go to church. What a privilege to belong to a church where I can worship God and where I have such good friends.
I don’t have to stop by the grocery store on my way home; I get to stop by the grocery store. What a privilege to live in a place and at a time where we don’t have to forage for food.
You get the idea.
3 Suggestions to Make the Shift Yourself
You can make this shift, too. Here are three suggestions:
Become aware of your vocabulary. This is a little like my post on the difference between try and do. The first step is to actually become aware of the words you’re using. Sometimes it feels like the mouth has a mind of its own. We just say things out of habit.
Start using get to rather than have to. Habits can be hard to break. This might require some practice and a little persistence. You don’t need to become compulsive about it, but start intentionally using the language of privilege rather than duty.
Notice the difference it makes in your attitude. For starters, it can suddenly make you grateful. Rather than dreading or resenting an activity, you can be thankful for it. And the more gratitude we express, the better we feel and perform. It will give you several distinct advantages, especially at work.
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.
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:
More and more people in the US are able to identify a friend, relative or neighbor who has succumbed to opioid addiction as it increasingly damages the nation.
It’s a frightening reality, but there are options available for people hoping to gain control of their condition and live a life that isn’t dictated by these potent drugs.
What are the routes to recovery from addiction? The Guardian explored that question and more as part of a series of pieces this week looking at survivors of addiction and how to tackle it.
Can opioid addiction be cured?
There is no cure for addiction, but the disease can be managed just like other chronic medical conditions including diabetes and high blood pressure.
That’s one of the reasons people who are no longer addicted to drugs or alcohol might describe themselves as being “in recovery”. Recovery means different things to different people but generally describes someone who is able to live life without it being disrupted by addiction.
How do you get to be in recovery from opioid addiction?
There are many routes for addiction treatment but the one with the most scientific support combines medication, counseling and recovery meetings.
“If people do those three things together, their chances of getting onto a path of recovery are significantly better than if they try to detoxify off the heroin or the pills they are taking and try to go immediately go to an abstinence-oriented program, where they are not taking any medication to help them during the early stage of their recovery,” said Samuel Ball, president and CEO at the National Center on Addiction and Substance Abuse.
How does medication help treat drug addiction?
Medication is used to stabilize people when they quit using opioids. These drugs include opioids like methadone and buprenorphine, which can reduce the painful effects of withdrawal by lowering the amount of opioids people are taking. They can also help people who want to quit using stave off overwhelming cravings.
A third medication treatment, naltrexone, is different in that it blocks the effect of opioids and it has been studied less closely than the other two drugs.
Isn’t using these drugs just substituting one type of opioid drug for another?
No, though the US health secretary Tom Price said it was last month. Price’s comment sparked a furor among health professionals – nearly 700 researchers and practitioners sent a letter urging Price to “set the record straight”.
“The perception that persons receiving long-term therapy with medications – especially with buprenorphine and methadone – are not actually in recovery is widespread but grossly inaccurate,” the letter said.
The Department of Health and Human Services then clarified that expanding access to medication-assisted treatments is a key element of the federal government’s plans to curb opioid addiction.
That said, these drugs aren’t perfect. Buprenorphine and methadone can and have been abused by opiate users, which is why it is recommended these drugs be taken alongside other therapies.
What happens if people quit using opioids without medication?
For people who abruptly quit, a cluster of unpleasant symptoms can occur as part of withdrawal: anxiety, body aches, nausea, vomiting, diarrhea, agitation.
There is a school of thought that the sheer unpleasantness of withdrawal will push someone out of addiction for good, and that certainly works for some people, but Ball warned it is not something worth betting on.
“I think If you asked me 10 years ago, I might have said detoxing and trying an abstinence-oriented approach, maybe that’s worth a try one time,” said Ball. “And then if that doesn’t work try one of the medications.”
These days, however, Ball said the addiction crisis has “become so life and death” that he thinks medication should be incorporated from the beginning of addiction treatment.
Why can’t people just decide to quit?
There is a narrative, often perpetuated by the media, of people becoming stubborn and quitting on their own once and for all – whether it’s because of a revelation triggered by an emotional low point or, in the case of one person the Guardian spoke with, spending some time in jail where they were forced to withdraw without any support.
“It’s miraculous, and great stories to hear, but I think for many people with opioid addiction, it’s not a realistic thing to plan for, if that kind of epiphany happens for you, it’s wonderful, but you can’t make it happen,” Ball said.
He said the “chances of you staying alive for a longer period of time” are much higher if you access other forms of treatment, particularly medication.
How effective is rehab at treating addiction?
If pop culture is your guide, the answer to addiction can be found at a swanky beach house rehab center in Malibu, California, or sunny Florida.
These centers – just like residential centers in less idyllic locations across the US – can certainly be effective, but they aren’t required to provide evidence-based treatment, so the efficacy varies wildly.
Some centers don’t have a trained physician or psychiatrist on staff around the clock or only offer a couple hours of therapy each week – an insufficient amount for someone who has deemed their problem so severe they aren’t safe at home.
Also, there is a potentially enormous cost tied to rehab that do not always reflect the quality of service. Insurers don’t always cover these programs, and if they do, they limit how long they will cover the service for.
That is a huge problem because addiction experts agree that addiction can’t be resolved in a short period of time.
How long does it take to recover?
This is obviously different from everyone, and must be considered alongside the fact that relapse is common.
Though it would seem like taking up drugs again is a failure, the US National Institute of Drug Abuse (Nida) said relapse is a sign that treatment needs to be adjusted or started again and is certainly not an indication that someone has irreparably harmed their chances of living a life free from addiction.
Relapse is common for 40% to 60% of patients being treated for addiction and 50% to 70% of people with asthma and hypertension, according to the Nida. The agency notes those disease also have physiological and behavioral components people must manage, particularly when experiencing a relapse.
The latest government numbers on opioid-related hospitalizations paint a picture of a country in a drug-related crisis. Between 2005 to 2014, emergency room visits stemming from opioid use rose 99 percent and inpatient stays jumped 64 percent, according to the Agency for Healthcare Research and Quality.
In 2014 alone, opioid-related hospitalizations totaled 1.27 million.
The spike in hospital visits was driven largely by people ages 25 to 44. The report by the Rockville, Maryland-based agency also noted gender differences in the way men and women used hospital services.
Women were more likely to have inpatient stays, while men were more likely to visit the ER in 2014. “Our data tell us what is going on. They tell us what the facts are. But they don’t give us the underlying reasons for what we’re seeing here,” Anne Elixhauser, co-author of the report and senior research scientist at AHRQ, told the Washington Post.
“It is no surprise that opioid-related hospitalizations rose significantly during that time period,” Dr. Peter Friedmann, associate dean for research at the University of Massachusetts Medical School and chief research officer at the nonprofit Baystate Health, told HuffPost.
“The surge of opioid use disorder and opioid-related overdose deaths that started in the late ’90s continues unabated in most of the U.S. Overdose deaths are the tip of the iceberg,” Friedmann said.
A U.S. Centers for Disease Control and Prevention report published in June found that between 2010 to 2015, North Carolina hospitals saw a 12-fold increase in patients suffering from endocarditis, an infection of the heart, that was linked to drug dependence.
“As the U.S. opioid epidemic continues to grow, hospitalizations for infectious complications associated with injection drug use are likely to increase,” the report said.
The AHRQ report follows a New York Times Upshot analysis of data from health agencies around the country that estimated drug overdose deaths will top 59,000 in 2016. That’s up from 52,404 overdose deaths in 2015, a 19 percent increase that would be the largest such jump in U.S. history.
According to the Times, the numbers are expected to rise again in 2017.
New data compiled from hundreds of health agencies reveals the extent of the drug overdose epidemic last year.
AKRON, Ohio — Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States, according to preliminary data compiled by The New York Times.
The death count is the latest consequence of an escalating public health crisis: opioid addiction, now made more deadly by an influx of illicitly manufactured fentanyl and similar drugs. Drug overdoses are now the leading cause of death among Americans under 50.
Although the data is preliminary, the Times’s best estimate is that deaths rose 19 percent over the 52,404 recorded in 2015. And all evidence suggests the problem has continued to worsen in 2017.
Because drug deaths take a long time to certify, the Centers for Disease Control and Prevention will not be able to calculate final numbers until December. The Times compiled estimates for 2016 from hundreds of state health departments and county coroners and medical examiners. Together they represent data from states and counties that accounted for 76 percent of overdose deaths in 2015. They are a first look at the extent of the drug overdose epidemic last year, a detailed accounting of a modern plague.
The initial data points to large increases in drug overdose deaths in states along the East Coast, particularly Maryland, Florida, Pennsylvania and Maine. In Ohio, which filed a lawsuit last week accusing five drug companies of abetting the opioid epidemic, we estimate overdose deaths increased by more than 25 percent in 2016.
“Heroin is the devil’s drug, man. It is,” Cliff Parker said, sitting on a bench in Grace Park in Akron. Mr. Parker, 24, graduated from high school not too far from here, in nearby Copley, where he was a multisport athlete. In his senior year, he was a varsity wrestler and earned a scholarship to the University of Akron. Like his friends and teammates, he started using prescription painkillers at parties. It was fun, he said. By the time it stopped being fun, it was too late. Pills soon turned to heroin, and his life began slipping away from him.
Mr. Parker’s story is familiar in the Akron area. From a distance, it would be easy to paint Akron — “Rubber Capital of the World” — as a stereotypical example of Rust Belt decay. But that’s far from a complete picture. While manufacturing jobs have declined and the recovery from the 2008 recession has been slow, unemployment in Summit County, where Akron sits, is roughly in line with the United States as a whole. The Goodyear factories have been retooled into technology centers for research and polymer science. The city has begun to rebuild. But deaths from drug overdose here have skyrocketed.
In 2016, Summit County had 312 drug deaths, according to Gary Guenther, the county medical examiner’s chief investigator — a 46 percent increase from 2015 and more than triple the 99 cases that went through the medical examiner’s office just two years before. There were so many last year, Mr. Guenther said, that on three separate occasions the county had to request refrigerated trailers to store the bodies because they’d run out of space in the morgue.It’s not unique to Akron. Coroners’ offices throughout the state are being overwhelmed.
Drug overdose deaths in six Ohio counties, 2010 to 2017
Totals for 2017 assume that overdose deaths continue at the same rate through the remainder of the year.Source: Butler County Coroner’s Office; Cuyahoga County Medical Examiner’s Office; Hamilton County Coroner; Montgomery County Alcohol, Drug Addiction & Mental Health Service; Montgomery County Sheriff’s Office; Summit County Department of the Medical Examiner
In some Ohio counties, deaths from heroin have virtually disappeared. Instead, the culprit is fentanyl or one of its many analogues. In Montgomery County, home to Dayton, of the 100 drug overdose deaths recorded in January and February, only three people tested positive for heroin; 99 tested positive for fentanyl or an analogues.
Fentanyl isn’t new. But over the past three years, it has been popping up in drug seizures across the country.
Most of the time, it’s sold on the street as heroin, or drug traffickers use it to make cheap counterfeit prescription opioids. Fentanyls are showing up in cocaine as well, contributing to an increase in cocaine-related overdoses.
The most deadly of the fentanyl analogues is carfentanil, an elephant tranquilizer 5,000 times stronger than heroin. An amount smaller than a few grains of salt can be a lethal dose.
“July 5th, 2016 — that’s the day carfentanil hit the streets of Akron,” said Capt. Michael Shearer, the commander of the Narcotics Unit for the Akron Police Department. On that day, 17 people overdosed and one person died in a span of nine hours. Over the next six months, the county medical examiner recorded 140 overdose deaths of people testing positive for carfentanil. Just three years earlier, there were fewer than a hundred drug overdose deaths of any kind for the entire year.
This exponential growth in overdose deaths in 2016 didn’t extend to all parts of the country. In some states in the western half of the U.S., our data suggests deaths may have leveled off or even declined. According to Dr. Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco, and an expert in heroin use in the United States, this geographic variation may reflect a historical divide in the nation’s heroin market between the powdered heroin generally found east of the Mississippi River and the Mexican black tar heroin found to the west.
This divide may have kept deaths down in the West for now, but according to Dr. Ciccarone, there is little evidence of differences in the severity of opioid addiction or heroin use. If drug traffickers begin to shift production and distribution in the West from black tar to powdered heroin in large quantities, fentanyl will most likely come along with it, and deaths will rise.
First responders are finding that, with fentanyl and carfentanil, the overdoses can be so severe that multiple doses of naloxone — the anti-overdose medication that often goes by the brand name Narcan — are needed to pull people out. In Warren County in Ohio, Doyle Burke, the chief investigator at the county coroner’s office, has been watching the number of drug deaths rise as the effectiveness of Narcan falls. “E.M.S. crews are hitting them with 12, 13, 14 hits of Narcan with no effect,” said Mr. Burke, likening a shot of Narcan to “a squirt gun in a house fire.”
Early data from 2017 suggests that drug overdose deaths will continue to rise this year. It’s the only aspect of American health, said Dr. Tom Frieden, the former director of the C.D.C., that is getting significantly worse. Over two million Americans are estimated to be dependent on opioids, and an additional 95 million used prescription painkillers in the past year — more than used tobacco. “This epidemic, it’s got no face,” said Chris Eisele, the president of the Warren County Fire Chiefs’ Association and fire chief of Deerfield Township. The Narcotics Anonymous meetings here are populated by lawyers, accountants, young adults and teenagers who described comfortable middle-class upbringings.
Back in Akron, Mr. Parker has been clean for seven months, though he is still living on the streets. The ground of the park is littered with discarded needles, and many among the homeless here are current or former heroin users. Like most recovering from addiction, Mr. Parker needed several tries to get clean — six, by his count. The severity of opioid withdrawal means users rarely get clean unless they are determined and have treatment readily available. “No one wants their family to find them face down with a needle in their arm,” Mr. Parker said. “But no one stops until they’re ready.”
About the data
Our count of drug overdoses for 2016 is an estimate. A precise number of drug overdose deaths will not be available until December.
As the chief of the Mortality Statistics Branch of the National Center for Health Statistics at the C.D.C., Robert Anderson oversees the collection and codification of the nation’s mortality data. He noted that toxicology results, which are necessary to assign a cause of death, can take three to six months or longer. “It’s frustrating, because we really do want to track this stuff,” he said, describing how timely data on cause of death would let public health workers allocate resources in the right places.
To come up with our count, we contacted state health departments in all 50 states, in addition to the District of Columbia, asking for their statistics on drug overdose deaths among residents. In states that didn’t have numbers available, we turned to county medical examiners and coroners’ offices. In some cases, partial results were extrapolated through the end of the year to get estimates for 2016.
While noting the difficulty of making predictions, Mr. Anderson reviewed The Times’s estimates and said they seemed reasonable. The overdose death rate reported by the N.C.H.S. provisional estimates for the first half of 2016 would imply a total of 59,779 overdose deaths, if the death rate remains flat through the second half of the year. Based on our reporting, we believe this rate increased.
While the process in each state varies slightly, death certificates are usually first filled out by a coroner, medical examiner or attending physician. These death certificates are then collected by state health departments and sent to the N.C.H.S., which assigns what’s called an ICD-10 code to each death. This code specifies the underlying cause of death, and it’s what determines whether a death is classified as a drug overdose.
Sometimes, the cases are straightforward; other times, it’s not so easy. The people in charge of coding each death — called nosologists — have to differentiate between deaths due to drug overdose and those due to the long-term effects of drug abuse, which get a different code. (There were 2,573 such deaths in 2015.) When alcohol and drugs are both present, they must specify which of the two was the underlying cause. If it’s alcohol, it’s not a “drug overdose” under the commonly used definition. Ideally, every medical examiner, coroner and attending physician would fill out death certificates with perfect consistency, but there are often variations from jurisdiction to jurisdiction that can introduce inconsistencies to the data.
These inconsistencies are part of the reason there is a delay in drug death reporting, and among the reasons we can still only estimate the number of drug overdoses in 2016. Since we compiled our data from state health departments and county coroners and medical examiners directly, the deaths have not yet been assigned ICD-10 codes by the N.C.H.S. — that is, the official underlying cause of death has not yet been categorized. In addition, the mortality data in official statistics focuses on deaths among residents. But county coroners typically count up whichever deaths come through their office, regardless of residency. When there were large discrepancies between the 2015 counts from the C.D.C. and the state or county, we used the percent change from 2015 to calculate our 2016 estimate.
We can say with confidence that drug deaths rose a great deal in 2016, but it is hard to say precisely how many died or in which places drug deaths rose most steeply. Because of the delay associated with toxicology reports and inconsistencies in the reported data, our exact estimate — 62,497 total drug overdose deaths — could vary from the true number by several thousand.
OHSAM President Dr. Shawn Ryan is co-author of this striking contribution about the potential newly proposed health care bill and how families and individuals suffering from opioid addiction will be among the hardest hit.
Of the many emotions evoked by House passage of the American Health Care Act, the Republican bill to repeal and replace the Affordable Care Act (aka Obamacare), sadness and fear were among the most pervasive. While the legislation reduces the benefits and increases the coverage costs for almost every demographic of our country, families and individuals suffering from opioid addiction will be among the hardest hit. In places like Ohio that are being ravaged by addiction, that is unacceptable.
In 2015, 52,000 Americans died from overdoses; that’s 144 a day. The opioid and prescription drug epidemic is clearly a national crisis. Entire communities are collapsing because of a lack of resources to push back against the rising tide.
Last year, Congress took some concrete steps towards fighting back. Last July, the Comprehensive Addiction and Recovery Act was signed into law, creating a comprehensive framework to address substance use disorder and key resources for communities. Congress also passed the 21st Century CURES Act, which included $1 billion for states to help with the local response to this ongoing epidemic. While these programs are positive efforts to confront this crisis, the Affordable Care Act has played a central role in getting people the treatment they need.
The Affordable Care Act made it possible for Americans suffering from substance use disorder to get access to quality treatment – many for the first time in their lives. Through the inclusion of substance use disorder treatment as an essential health benefit, the extension of the parity law to the small group and individual market, and the expansion of Medicaid, millions of Americans were able to gain the coverage they desperately needed to treat addiction. The House Republican health care bill, on the other hand, would not only roll back these advancements, but it could rip health coverage away from the 2.8 million Americans still struggling with addiction.
Our country is suffering. We should be moving forward, not backward. We fully recognize that passage of this legislation might make political sense to some, but doing so is leaving behind millions of Americans most in need. This epidemic is costing our nation $700 billion in health, crime and lost productivity, but that is nothing compared to the toll it is taking on our communities. These men and women are not strangers – they are our friends and neighbors, our brothers and sisters. There is a reason over 435 addiction and mental health groups nationwide have spoken out against this House Republican health care bill: it’s because it would leave people in need without coverage or access to care.
This legislation still needs to pass the Senate before it can be signed into law by President Trump. We urge the Senate to do the right thing and toss out this bill. It is dangerous and short-sighted, and it would be devastating for our nation’s struggle to end the opioid and prescription drug epidemic that is ravaging every corner of the United States of America.
Opioid misuse and addiction is an ongoing and rapidly evolving public health crisis, requiring innovative scientific solutions. In response, and because no existing medication is ideal for every patient, the National Institutes of Health (NIH) is joining with private partners to launch an initiative in three scientific areas: developing better overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery; finding new, innovative medications and technologies to treat opioid addiction; and finding safe, effective, nonaddictive interventions to manage chronic pain. Each of these areas requires a range of short-, intermediate-, and long-term research strategies.
Every day more than 90 Americans die from opioid overdoses. Overdoses result from an opioid’s agonist effects at the mu-opioid receptor (MOR), located on brainstem neurons that control breathing. The MOR antagonist naloxone can reverse an overdose, if it is administered shortly after the overdose occurs. Although naloxone has saved tens of thousands of lives, overdoses frequently occur when no one else is around, and often no one arrives in time to administer it.
Overdose fatalities have also been fueled by the increased availability of very potent synthetic opioids such as fentanyl and carfentanil (50 and 5000 times as potent as heroin, respectively). Misuse of or accidental exposure to these drugs (e.g., laced in heroin) is associated with very high overdose risk, and naloxone doses that could reverse prescription-opioid or heroin overdoses may be ineffective. New and improved approaches are needed to prevent, detect, and reverse overdoses.
Through a successful partnership, the National Institute on Drug Abuse (NIDA) and industry developed a user-friendly intranasal naloxone formulation (Narcan Nasal Spray) that results in blood naloxone levels equivalent to those achieved with parenteral administration; it was approved by the Food and Drug Administration (FDA) in 2015. The NIH will now work with private partners to develop stronger, longer-acting formulations of antagonists, including naloxone, to counteract the very-high-potency synthetic opioids that are now claiming thousands of lives each year.
In the intermediate and longer term, alternative interventions against opioid-induced respiratory depression, such as 5-hydroxytryptamine type 1A (5-HT1A) agonists, ampakines, and phrenic-nerve-stimulation devices, could protect persons at particularly high risk for overdose. Research is also under way to characterize the physiological signals that can predict an impending overdose, which would allow wearable devices to detect an overdose when it is occurring and signal for help, automatically inject naloxone, or both.
TREATMENTS FOR OPIOID ADDICTION
This partnership will also focus on opioid addiction (the most severe form of opioid use disorder [OUD]), which is a chronic, relapsing illness. Abundant research has shown that sustained treatment over years or even a lifetime is often necessary to achieve and maintain long-term recovery. Currently, there are only three medications approved for treating OUD: methadone, buprenorphine, and extended-release naltrexone. These medications coupled with psychosocial support are the current standard of care for reducing illicit opioid use, relapse risk, and overdoses, while improving social function. However, limited access to providers and programs can create barriers to treatment.
The NIH has successfully partnered with industry to help develop new formulations of existing medications to improve compliance and reduce the potential for diversion. To facilitate compliance with buprenorphine treatment, NIDA worked with Titan and Braeburn Pharmaceuticals to produce a long-lasting (6-month) implant, Probuphine, which the FDA approved in 2016. Initial clinical trials testing the safety, efficacy, and pharmacokinetics of buprenorphine formulations that deliver therapeutic doses over 1-week or 1-month periods have also been completed; such formulations may be particularly valuable for patients in emergency departments after nonfatal opioid overdoses, to facilitate engagement in long-term treatment.
There is a clear need to develop new treatment strategies for opioid-use disorders. New pharmacologic approaches aim to modulate activity of the reward circuit through antagonists of the neurokinin-1 receptor and counteract the aversive state of withdrawal through antagonists of kappa-opioid receptors. The selective 5-HT2C-receptor agonist lorcaserin, an FDA-approved diet drug, was found to reduce opioid seeking in a rodent model. NIDA has also helped fund clinical trials of lofexidine, an α2A-adrenergic-receptor agonist not currently approved in the United States. Lofexidine was originally developed as an antihypertensive drug and is currently used in the United Kingdom for opioid detoxification, since it controls withdrawal symptoms (although not cravings).
Vaccines against prescription opioids, heroin, and fentanyl, which induce antibodies to opioids in the bloodstream to keep them from entering the brain, have shown great promise in preclinical studies. Similarly, long-lasting monoclonal antibodies against very potent synthetic opioids (e.g., fentanyl and its analogues) have the potential to prevent overdoses and relapses.
NONADDICTIVE TREATMENTS FOR CHRONIC PAIN
The third area of focus is chronic pain treatment: overprescription of opioid medications reflects in part the limited number of alternative medications for chronic pain. Thus, we cannot hope to prevent opioid misuse and overdose without addressing the treatment needs of people with moderate-to-severe chronic pain. Though more cautious opioid prescribing is an important first step, there is a clear need for safer, more effective treatments.
One short-term goal is the development of formulations of opioid analgesics with abuse-deterrent properties that are more difficult to manipulate for snorting or injecting, the routes of administration most frequently associated with misuse because of their rewarding effects. Such formulations, however, can still be misused orally and still lead to addiction. Thus, a more promising longer-term avenue to advancing pain treatment is developing a new generation of powerful, nonaddicting opioid analgesics. Recent x-ray crystallography studies of the MOR have provided insight into two separate intracellular signaling pathways: a pathway originating with the Gi protein is believed to underlie analgesia, while a separate pathway involving β-arrestin is believed to underlie the rewarding and respiratory-depressing effects of opioid agonists. One MOR-biased agonist (TRV130) has successfully completed phase 2 clinical testing. If the trials show that TRV130 is not associated with rewarding or respiratory effects, it could energize industry to accelerate development of other MOR-biased agonists.
Ongoing research is also exploring compounds that target other opioid receptors. Through the NIH Blueprint Neurotherapeutics Program, a team of researchers is working to optimize a recently discovered series of selective and orally available kappa-opioid antagonists as nonaddictive medications for stress-induced pain disorders, such as headache and fibromyalgia. Antagonists of the kappa-opioid system are also therapeutic targets for OUD. Encouraging pharmacokinetic studies suggest that these compounds have the potential to be safe and effective drugs for pain, and perhaps also for opioid addiction.
Compounds that target nonopioid pain pathways, such as the endocannabinoid system, are also being evaluated for chronic pain management. There is strong evidence of the efficacy of cannabinoids, including tetrahydrocannabinol (THC), in treating pain. Medications that target the endocannabinoid system without producing the cognitive impairment and rewarding effects of marijuana could provide a powerful new tool. Other targets being investigated include a dopamine D3 antagonist, which was shown to reduce morphine tolerance and dependence without inhibiting analgesia when administered in conjunction with morphine, making this a potentially promising approach to enhancing the safety of existing opioids.Genetic mutations in the sodium channel Nav1.7 in humans modulate pain; loss-of-function mutations result in congenital insensitivity to pain, and gain-of-function mutations cause pain syndromes. Several Nav1.7 antagonists are being explored as analgesics.
Therapeutics that antagonize inflammatory signals involved in pain have led to FDA-approved treatments for specific pain conditions, such as tumor necrosis factor inhibitors for rheumatoid arthritis and monoclonal antibodies to nerve growth factor for osteoarthritis; researchers are exploring their value in other pain conditions. In parallel, clinical trials are testing the efficacy of antibodies to calcitonin gene–related peptide for treating migraine.
Nonpharmacologic approaches including brain-stimulation technologies such as high-frequency repetitive transcranial magnetic stimulation (rTMS, already FDA-approved for depression) have shown efficacy in multiple chronic pain conditions. At a more preliminary stage are viral-based gene therapies and transplantation of progenitor cells to treat pain. NIH researchers are investigating the use of gene therapy to deliver a potent antiinflammatory protein to painful sites. Preclinical studies show powerful and long-lasting effects in reducing pain without side effects such as numbness, sedation, addiction, or tolerance.
Development of new pain treatments builds on a foundation of basic research on the complex pathophysiology of chronic pain and the mechanisms underlying the transition from acute to chronic pain. The NIH is committed to working with industry partners to advance basic research in this area and to identify and validate biomarkers for pain and pain relief. Biomarkers can move the field away from reliance on subjective pain assessments, and will facilitate medication development and individualized clinical management. Precision-medicine research is expected to help identify the pain-management interventions likely to be most effective for specific patients.
Recent NIH–industry partnerships, such as the Accelerating Medicines Partnership, demonstrate the power of public–private collaboration in speeding the development of new medications. Ending the opioid crisis will require this kind of collaboration. In April 2017, the NIH began discussions with pharmaceutical companies to accelerate progress on identifying and developing new treatments that can end the opioid crisis. Some advances may occur rapidly, such as improved formulations of existing medications, opioids with abuse-deterrent properties, longer-acting overdose-reversal drugs, and repurposing of treatments approved for other conditions. Others may take longer, such as MOR-biased agonists, opioid vaccines, and novel overdose-reversal medications. For all three areas, our goal is to cut in half the time typically required to develop new safe and effective therapeutics.
As we have seen repeatedly in the history of medicine, science is one of the strongest allies in resolving public health crises. Ending the opioid epidemic will not be any different. In the past few decades, we have made remarkable strides in our understanding of the biologic mechanisms that underlie pain and addiction. But intensified and better-coordinated research is needed to accelerate the development of medications and technologies to prevent and treat these disorders. The scope of the tragedy of addiction and overdose deaths plaguing our country is daunting. With our partners, the NIH will take an “all hands on deck” approach to developing and delivering the scientific tools that will help end this crisis and prevent it from reemerging in the future.
This article was published on May 31, 2017, at NEJM.org.
From the National Institute on Drug Abuse (N.D.V.), and the Office of the Director (F.S.C.), National Institutes of Health, Bethesda, MD.