The problem with opioid use in the U.S. has finally reached epic proportions, and many don’t understand why. We live in a new era full of possibilities and a variety of different treatment methods. Yet, more people are becoming addicted to things like heroin and prescription narcotics than ever before.

Getting to the root of the problem would provide us with more tactics to help those suffering from addiction and allow us to see the problem from the social ground floor. We live in a world with a heightened level of competition and measurable success around every corner.

Our personal standards have changed, and the pressure that we put on ourselves and others to succeed is unreal. All it takes is a trip down memory lane on social media to completely destroy a person’s sense of self-worth and accomplishment.

You may have had expectations for yourself, or others may have had expectations for you that you simply didn’t live up to. This can contribute to depression and anxiety which is a huge factor when it comes to addiction.

 

Opioid use is on the rise

In the last year, more than 64,000 people died from drug overdoses. A person is now more likely to die from an overdose than they are from a car accident or a mishap with a gun. Many people attribute this to the lax prescribing practices surrounding opioid medications.

In part, this is absolutely true. Doctors and pharmacists were entirely aware of the deadly impact that prescription opioids can have on Americans. They underestimated the addictive nature of the drugs and prescribed them in excess.

Some people took narcotics for years at a time in an effort to manage chronic pain or for acute injuries that turned into a full-blown addiction. Becoming addicted to prescription drugs doesn’t take long for a person who’s already predisposed to the disease.

Even after a short prescription intended for acute use, a person may be hopelessly dependent on the drugs. This chemical dependence can lead to withdrawals when they run out of their medication, leading them to seek out illicit drugs.

Some patients end up doctor-shopping or inventing pain in order to convince medical professionals of their need for prescription medications. Fortunately, the U.S. has come up with a narcotic database that allows doctors to be apprised of any and all addictive prescriptions a person is taking.

While this helps to put a stop to the overprescribing of these drugs, it hasn’t done much to derail the existing addiction. When some patients are unable to get their medications directly from their doctor, they may try to convince others to sell their existing prescriptions or turn to things like heroin to compensate.

This is only one part of the problem; the availability of things like heroin and fentanyl on the street has created an entire underground culture of people who depend on the sale of drugs for their income, and to treat addiction in a way that’s both casual and unnerving. I believe that what many people fail to understand is the correlation between our personal expectations and our rising dependence on drugs and alcohol to cope.

Related Content: Financial Preparedness in the Face of Opioid Addiction

The competitive nature of the U.S.

Americans don’t move at the casual pace that they once did. The introduction of technology and real-time communication has pushed people to take on more than ever. We now expect our children to go into competitive educational programs at extremely young ages, and if they fail to keep up they face being ostracized by peers and adults.

We’ve also seen a reduction in the middle class, and the median income. You’re either expected to be a complete success, or you’re considered to be living below the poverty line. It’s easier to compare yourself to a group of your peers than it’s ever been. Social media, web pages, and the constant need to display our accomplishments have put new pressure on people.

If you are unable to match or exceed the accomplishments of others, then you may find yourself dealing with severe anxiety and depression. Everyone is living at a breakneck pace, and this takes its toll on a person’s psyche.

More people experience mental illness and diseases relating to fatigue and immunity disorders than ever before. Part of this has to do with the amount of stress that we place on ourselves, and the way that we push ourselves toward success.

Being unable to achieve what you really wanted to do can leave you grasping for coping skills that you may not have. We spend so much time with tunnel vision and a focus on success that many people don’t understand how to cope with failure.

People expect you to look a certain way, dress a certain way, behave a certain way, and fit into a certain rung of society. Being unable to do this can force you to belong to a demographic that you don’t know how to navigate.

There’s also a serious issue with poverty in many areas of the US. Some people simply don’t know how to live any other way and end up selling drugs because it’s what their parents and grandparents did. That may sound unbelievable, but some communities have generations of dealers and addicts that they just can’t seem to shake.

Whether it’s due to a preconceived notion or simply the subculture of the area, drugs are definitely worse in some places suffering from serious poverty and a lack of gainful employment. Many people simply don’t know how to prevent opioid addiction, and it turns into a vicious cycle.

 

Why people turn to drugs

While many people develop an addiction as a result of a previous prescription, others do it to cope with stress or other problems. They feel so worked up over the events of the day that they need a more concrete way to relax.

This doesn’t always result in healthy behaviors. Many consider drinking to be an acceptable way to deal with a bad day, but others take this a step further. With the availability of opioids and their immediate euphoric effect, they seem like the perfect solution for somebody who feels overwhelmed and can’t seem to climb out of their negative feelings.

Coping with mental illness and trying to stay upright in spite of the weight of the world takes serious dedication and an understanding of different types of coping mechanisms. Some people turn to healthy practices like exercise or meditation, but opioids provide an instant gratification that many people crave.

Some people start out using them as a way to relax and end up physically and psychologically addicted. Once this happens, the focus of their life shifts and they become obsessed with the drugs.

For some, drug use might be the only way to protect themselves from painful memories or past trauma. There’s also a certain stigma that follows people who become addicted to opioids. Many people consider them weak or a failure, and this adds to the overall stress factor.

It’s difficult to seek out help when you feel that you’ll be judged for it.

Related Content: Trump Finally Declares the Opioid Epidemic a National Emergency

Living life at your own pace

If you’re struggling with addiction or you’re struggling with a huge amount of stress, just remember that you need to live life at your own pace. No one’s expectations matter but your own, and you need to put your mental and physical health before the need to succeed.

Take time and de-stress. Value yourself and develop coping mechanisms for every stage of your life. This is the best way to succeed for yourself, which is much more important than the perception of public success.

As the medical marijuana debate rages on, more and more people are beginning to question the legitimacy of the Schedule I controlled substance status that the DEA has classified cannabis under.

Part of the debate is fueled by the fact that cannabis has two main active ingredients that have shown medical potential. The first is tetrahydrocannabinol (THC), the compound responsible for the psychological effects and the “high” associated with ingesting marijuana. The other is cannabidiol (CBD), which doesn’t hold any psychoactive properties but has shown promising medical application of its own. There are multiple benefits associated with using either, according to the experts at Canmedi:

The Benefits of THC:

  • Gives users a relaxing or euphoric sensation
  • Helps in treating pain, both chronic and temporary, such as muscle or joint pain, headaches or PMS
  • Helps treat and prevent nausea, commonly used to help cancer patients with chemotherapy
  • Helps with insomnia and sleep-related issues
  • Increases appetite
  • Helps reduce stress or anxiety (while it is well-known to relax users, be aware that some users can experience increased anxiety)

The Benefits of CBD:

  • Not psychoactive, meaning it can provide benefits and a calming effect without the “high” associated with marijuana
  • Can be used to treat anxiety for people whose symptoms are increased by THC or don’t enjoy the “high”
  • Can also be used to treat and prevent nausea
  • Can help with inflammation and pain, including taking internally or applied externally as a cream or oil
  • Has shown evidence it works as an antioxidant
  • When applied externally, it can help with skin conditions such as eczema and acne
  • Has shown promise in treating medical conditions and mental health issues such as epilepsy, Crohn’s disease, multiple sclerosis, PTSD and depression

To sum it up, research has found that THC, while helpful in reducing stress, anxiety, nausea, and stimulating the appetite, produces strong psychoactive effects that not everybody is prepared for and can be uncomfortable to some. It’s also pretty universally agreed upon that THC is inappropriate for consumption in children. CBD, on the other hand, helps with many of the same conditions without an associated high and has been shown to be potentially effective in reducing seizures and other symptoms of disease — even for children.

Related Content: Cannabidiol Approved to Treat Rare but Severe Forms of Epilepsy

The Fight for CBD and Ties to THC

Because it’s so hard to extract CBD without also extracting trace amounts of THC, federal law still prohibits the manufacture and sale of many of these products. Nevertheless, state and local governments sympathetic to pro-CBD initiatives have allowed the sale of edible or topical products containing said compound with certain caveats attached.

For example, Chris Moore, writing for Merry Jane, explains that “in 2017, Tennessee legislators legalized the sale of hemp-derived CBD edibles or topical products, as long as said products contain less than 0.3 percent THC … But despite this law, Gov. Eric Holcomb ordered state excise police to raid several stores and seize CBD products, and demanded that stores remove any CBD products containing even trace amounts of THC.”

Unfortunately, the demonization of THC is being extended to CBD as well, even though there are often very few facts to back up the claims that THC is indeed more dangerous than it is helpful.

“Despite rhetoric from one side or another, one thing remains an objective reality on the subject: overdosing on marijuana alone is unlikely, if not entirely impossible,” write the experts at The Recovery Village. “Unlike other drugs that are notorious for binding to areas of the brain that control vital functions like breathing, marijuana mostly affects memory and coordination.”

This isn’t to say that loss or impairment of motor function isn’t a serious concern — but even those who point to increased rates of drugged driving in states where recreational marijuana is legal aren’t proving that it’s dangerous. The University of Reno Nevada’s online resources show that, indeed, the first states to pass recreational marijuana initiatives showed similarly strong figures relating to driving under the influence: Self-reporting of past-year driving while under the influence of marijuana was 43.6 percent among respondents, with past month driving being almost 25 percent. However, they also mention this:

“Crucially for public health officials looking to make sense of the data, the perception of danger is at odds with the number of accidents that can be attributed to the drug. According to the American Public Health Association, the NHTSA stated they were unable to find a causality between legal marijuana and fatal traffic accidents — a finding echoed in the aforementioned Washington Drug Policy Alliance report, which showed that traffic accident fatalities remain flat in states with recreational marijuana.”

So even though there is a miniscule amount of THC generally found in CBD concentrates, it’s not enough to cause a psychoactive reaction, and THC hasn’t actually been proven to cause harm to patients using it.

 

What Does the Future Hold for CBD?

It’s hard to say what will come of CBD’s potential, though many are extremely interested. CBS reports that a California couple, Dan and Jennifer Kubisz, had been looking for medication to halt their child’s seizures. The boy, Zack, had tried 12 to 14 different medications, but nothing seemed to work and all produced devastating side effects.

Then, Dan heard about CBD. Zach’s neurologist told the couple that they had nothing to lose, as prescription drugs weren’t alleviating the seizures or the suffering associated.

“Within three weeks, a month – he stopped seizing,” Jennifer told CBS.

“CBD had been our shining light that it really was for us. That miracle that changed his world,” confirmed Dan.

The good news is that stories like Zach’s are driving advocates to action and fueling the fight for change, and could set the precedent for pro-CBD legislation in the future. With the possible benefits that this drug has displayed, it seems absolutely absurd that regulators would hide behind legislation and embody apathy when they could be researching potential solutions to diseases affecting millions. The fight for CBD has just begun, and it would be absurd not to give the children of this country the medication that they deserve.

With drug overdoses now the single largest non-natural killer of young people, the opioid crisis is taking a terrible toll. Unfortunately, West Virginia has been one of the states hit hardest by this epidemic. It is having an impact on most families, hospitals, businesses, and everyone who is an active member of the community in one way or another.

Most people don’t plan on having a loved one fall victim to addiction but the sad reality is that it happens and, in West Virginia, it happens quite regularly. Here’s what families may have to do financially to adapt if their family is impacted by the opioid crisis, based on my experience being a wealth manager in West Virginia, the #1 opioid state.

 

1. Stay liquid and supersize the emergency fund

It’s encouraging to see someone get help for their opioid addiction, but the reality is that most people go through rehabilitation more than once. With the cost of rehab not fully reimbursable by most health insurance plans, the burden of paying for expensive (and often repeated) treatment falls on the family. It can be financially devastating.

While in no way is this an expression of any financial advice geared towards anyone in particular, it is my general experience that families impacted by the opioid crisis with a loved one in rehab will be well served to keep enough cash on hand in liquid vehicles. Rigid, highly structured products tend not to work well if you’re in a situation when you may have wide fluctuations or a need for immediate liquidity. That way, they can access the cash if services are required in a hurry without having to worry about paying penalty fees or losing principal value.

As a parent, it is natural to sacrifice all you have, even your own means, to save your child. If your loved one is a victim of opioid addiction, you never know when you’ll be called upon to support them. It is best to be prepared.

While I typically recommend that families keep 3-6 months of expenses in ready cash in case they lose their job or become unable to work, for an opioid crisis impacted family, I would suggest keeping almost double this amount.

 

2. Know what you can borrow against (but only if you need to)

If you can access cash through a straight withdrawal without the obligation to pay it back, it is usually a better scenario. But what if you can’t? Examples of vehicles that you can borrow against are cash value life insurance (whole life insurance) policies, IRAs and 401ks, and even the equity in your home. These vehicles can be borrowed against but there can be fees that go along with it.

In this scenario, and in general, it’s important to read the fine print and understand all the consequences that go along with financial moves like this. Between minimum account value thresholds, early withdrawal fees, interest fees, any other penalty fees, transaction charges, and the gains or losses you realize from liquidating securities, there can be some pretty significant financial and tax consequences for taking these actions.

 

3. Protect your wealth

Yes, I said it. It’s painful to admit but the truth is that the ravages of addiction can leave no bank account unscathed. The brutal truth is that an addict may devastate a family’s net worth to satisfy their addiction. It is incumbent upon families to protect themselves from this happening, for the good of all the family’s members.

While it is hard to do, families are well served to secure valuable assets, both physically and legally. For many, this involves putting together a sophisticated estate plan to ensure that the proper legal protections are in place for the family. While I’m not an estate planner, I do work with my clients’ attorneys to ensure that they know their options and that they work with the attorney to get the proper documents in place.

According to Kevin Johns writing on WealthManagement.com in 2017, families of addicts may wish to consider disinheritance, leaving the addicted child a smaller inheritance, placing the addicted child’s bequest in the hands of a sibling or otherwise trusted contact, or creating a discretionary trust. Each of these options come with pros and cons, so it is best to consult a legal advisor with questions.

 

4. Don’t sacrifice your own retirement savings for “encore parenting”

As a wealth manager in West Virginia, I’ve seen countless instances of extended families getting involved with raising children. If parents are involved with drugs, often it is the grandparents whose shoulders it falls on to raise their children.

For those thrust into an “encore parenting” role, as I like to call it, the experience can be very different the second time around. Often encore parents are faced with child rearing at a time when they’re not in their working years.

You may be living on a fixed income which, according to your plans, would have been enough to support your basic living needs. But now, you’ve got a child (or even two) to support and that means another mouth to feed, another body to cloth, and another person on your health insurance.

And of course, there’s the urge to provide beyond that for your child. You want them to have a normal life, as healthy and normal as can be despite the unfortunate circumstances. Many grandparents in this situation feel sympathy for the children for the adversities of life they face, through no fault of their own. But the “nice to haves” and “extras” activities can be pricey. What are you going to say when your child asks, “Grandma, can we go to Disney World?” or “Grandpa, I want to go to college.”

How far can you make your retirement dollars stretch? It can only go so far. Here’s where financial planning comes into play. Work with an advisor to understand your assets and future liabilities, set up a budget, and put together a cash flow projection that will help you understand the income and expenses you’ll likely be living with.

 

5. Choose a wealth manager wisely

When it comes to dealing with opioid addiction, not all wealth managers are made the same. You’ll want to work with someone who is extremely vigilant and pays a high degree of personal attention to his or her clients. While this may seem obvious, not all advisors deliver what they say they are going to. Some advisors focus more on meeting their quota and don’t put the needs of the client first.

Your service needs may go deeper than the average client. Here are examples of why:

  • The advisor has to be objective and unemotional and guide you through decisions based on logic rather than emotion.
  • The advisor should be paying enough attention to detect changes in behavior from either the addict or the family, namely people showing too much interest in controlling wealth, trying to intimidate other family members, or using guilt to gain access to family finances. Remember that you are appointing a guardian of your future hopes and dreams and your family’s legacy.
  • You may need the advisor’s expert guidance in making complex decisions about health insurance policies, therapists, rehab centers, etc.

 

Summing it up: A West Virginia wealth manager’s perspective on helping families deal with opioid addiction

While it’s unpleasant to have to discuss these issues in such depth, I do it for the good of those affected. As with any affliction, silence in the enemy and open communication can save lives. If you have any questions about how to help your family financially survive the opioid crisis, please don’t hesitate to get in touch with me.

Opioid Related Content: How the Opioid Crisis Affects Addiction Treatment Centers


 

Disclaimers
Securities offered through Cambridge Investment Research, Inc., a broker-dealer, member FINRA/SIPC. Advisory services offered through Cambridge Investment Research Advisory, a Registered Investment Adviser. Beacon Wealth operates independently of Cambridge.

To drink or not to drink. If you’re an alcoholic like I am, there really is no question—you drink, you always drink. That’s what alcoholics do, we drink, St. Patrick’s Day or not. I’m an alcoholic because when I start drinking alcohol, I do not have the ability to stop on my own and it’s not because I’m Irish.

For an active alcoholic, on holidays like St. Patrick’s Day, we’re not that different. In fact, a lot of us referred to them as ‘Amateur Hour’, where people who can’t hold their liquor get drunk, rowdy, and make fools of themselves. But what happens when you’re newly sober and these holidays arrive? What happens then?

 

A sober St. Patrick’s Day

Sean O'Brien's photoThis year, instead of missing work the day after St. Patrick’s Day, sick and hungover, I’ll be taking St. Patrick’s Day off to celebrate my Irish heritage, sober. I’ll start it off the same way I try to start every day, with gratitude for what my life has become. And then, I’ll take my son to school and prepare to play the bagpipes for the class. Yes, indeed, I play the bagpipes! I’ll wear my Irish heritage kilt and my Prince Charles jacket with vest. I’ll play traditional bagpipe tunes for ten minutes or so and answer questions from the kids about the bagpipes, being Irish, and St. Patrick’s Day. Later that day, I’ll play 3 more gigs—one solo and the other two with my band. I play bagpipes in an Irish rock band, ‘Before the Devil Knows You’re Dead’. Some call it an Irish drinking band, but we aren’t. I don’t drink and neither does James, the singer.

For me, and people like my bandmate, St. Patrick’s Day is a special day where we have the opportunity to celebrate, honor, and share our Irish heritage and culture with others, Irish or not. For some, St. Patrick’s Day represents a day where people go out for a good time, possibly drink too much, wear green t-shirts that say “Kiss me I’m Irish”, and paint shamrocks on their faces.

But for my family and for many whose families originally hailed from Ireland, there’s more to it. For us, St. Patrick’s Day represents courage, hope, faith, spirit, and the pursuit and achievement of our dreams. Equally as important, St. Patrick’s Day also marks the advent of spring, a season of renewal and change.

 

Overcoming obstacles

Recently, I explained to my son who St. Patrick was and why we celebrate. I opened a book called ‘Ordinary People, Extraordinary Lives‘, and interestingly enough, right under St. Patrick’s picture was the caption “Overcoming Obstacles. I was immediately reminded of my alcoholism and that it is a disease of the brain that had terrible effects on me. Many people thought I was bad, a lost cause, and crazy, but, in reality, I was sick. For many of us, alcoholism is one of the biggest obstacles we’ll ever face. Sobriety is not easy, but it is attainable.

Living one day sober for any alcoholic is truly a miracle. As we continue to stay sober, the days turn into weeks, the weeks turn into months, and the months turn into years. But for a lot of us, those first few years can be really tough and grueling. We’re learning a new way to live, doing things for the first time in a long while without the aid of our old crutch, our old friend, alcohol. It is a difficult obstacle to overcome.

Related Content:  10 Ways to Drink Less and Be Merry During the Holidays

Getting sober, staying sober

I got sober, probably for the 100th time on March 8, 2008, ten days before St. Patrick’s Day. For an Irish bagpipe player, I sure have poor timing I thought, ten days before a holiday known for heavy drinking? Why do I continue to make things hard on myself? But getting sober was never the hard part, staying sober was. I knew if I were to stay sober, I would have to do things differently. I’d have to do the things I needed to do and not the things I wanted to do.

“The only difference between the saint and the sinner is that every saint has a past and every sinner has a future.”  –Oscar Wilde

My first St. Patrick’s Day sober was tough—I was outside my comfort zone. An alcoholic without his drink is in an abnormal state. Most of my family and friends would be drinking and I did not want to drink but I also did not want to sit home alone, which would all but guarantee I would drink. I made the choice to go to an AA meeting. And in that meeting, there sat my saints, my St. Patricks were there to support me. I saw guys I hadn’t seen in years, who I thought were either dead or locked up. And there it began, with me finding the strength to do what I needed to do as they helped drive away my snakes when I couldn’t do it by myself. Finally, it was a journey that I was willing to take, my path to recovery with the understanding that there are obstacles to overcome and, for me, knowing that there will always be St. Patrick’s along the way.


First published on March 17, 2016. It has been reviewed and republished on March 16, 2018.

In today’s digital world, we almost can’t help being in front of a screen at all times. Think about how much you rely on your smartphone to complete everyday tasks. From setting an alarm to scheduling an appointment on your calendar to navigating to your next destination, there are many practical reasons to use your phone. Not to mention email, social media, music, and games. We can easily stay plugged-in for most of the day with smartphones, tablets, and laptops facilitating the majority of our information consumption.

Most of us can acknowledge that screen addiction is unhealthy, but we don’t often think about what it’s actually doing to our brains. So, how does being constantly plugged-in affect our mental health?

 

The iGeneration

Teenagers today, or anyone born between 1995 and 2005, have never known life without smartphones. According to Lakeside Behavioral Health System, this “iGeneration” has been informed and shaped by the introduction of digital technology and social media. They are always connected and depend on screen time for daily activity. In fact, a 2015 Pew Research report found that 73% of teens ages 13-17 have a smartphone or access to one. Not only do the majority of teenagers have a smartphone, but more than 50% say they are addicted to their phones and can’t function without them.

Due to this addiction, teenagers are now interacting via faceless communication, where they’d prefer to text or send messages on social media rather than talk to someone in person. This deindividuated approach allows for greater anonymity and isolation and takes away opportunities to practice social skills. The anonymity involved spurs online bullying, as teenagers are less inhibited to say hurtful things to each other when they’re behind their phones.

Sleep deprivation is another side effect of screen addiction among teenagers. Between 2012 and 2015, 22% of teenagers did not get seven hours of sleep per night, primarily due to stimulation from their phone screen lights. That glowing light suppresses melatonin, a hormone that supports sleep. Scrolling through a phone before bed can make it harder to fall asleep, and this lack of sleep can lead to trouble in school, slower reaction times when driving, and mood swings.

Related Content:  Is Technology Good or Bad for Mental Health?

Depression as a side effect

All of these byproducts of screen addiction can contribute to depression among those who are addicted. Cyberbullying negatively impacts individuals’ self-esteem and self-worth, and lack of face-to-face relationships can lead to loneliness. Additionally, sleep deprivation can ultimately be a cause of depression and feelings of lifelessness.

A Monitoring the Futures survey found that teens who spend more time than average on non-screen activities tend to be happier than those who don’t. Stepping away from the screen can be a true lifestyle change with long-term mental benefits.

 

Preventing screen addiction

So, how can you prevent yourself or your children from becoming addicted to your screens? It starts by setting some ground rules for phone use and sticking to them.

Some rules include:

  • Designate specific times for your children to go outside. Set a reminder on your phone if you have to, and when it goes off, put the phone down and send the kids outside. Better yet, set an example by going outside with them.
  • Identify phone-free zones in your house. The kitchen is a good place to start. If your family wants to eat, they need to put their phones down and take time to enjoy meals.
  • Set electronic curfews. This means when the clock strikes nine (or eight or ten), phones are collected and put away for the night. Instead of scrolling through Instagram before bed, encourage your kids to read a book, write in a journal, or draw.

In addition to setting screen rules, it’s important to talk with your children about healthy phone use. This is a way to learn more about their phone interactions and ensure they understand the dangers of cyberbullying and communication with strangers. Establish regular check-ins with your kids to maintain an ongoing conversation about their phone safety.

Ultimately, preventing screen addiction starts with you. Your kids see how often you’re connected to your phone, so be sure to set the right example for them. If you need to, set daily or weekly goals for reducing your own screen time and keep track of your progress in this area. Also, consider deleting any apps that are taking up too much of your time. It may be tough at first, but, in time, you’ll feel a sense of freedom from not always being plugged in.

 

Using caution

Constant online access does provide us many benefits, especially in terms of the speed at which we’re able to gather and distribute information. There’s no doubt that smartphones allow us to move more quickly and efficiently. But, there are many downsides to being plugged-in at all times. When you’re aware of these side effects, you can take the proper steps for you and your family to have a healthy relationship with technology.

Cannabis seems to be growing in popularity across the country, with more and more territories breaking from the federal norm and allowing both recreational and medical cannabis usage within their regions. Despite an increasingly positive reception by the public at large, cannabis is still listed as a Schedule I substance as classified by the DEA, joined by heroin, LSD, ecstasy, methaqualone, and peyote because there is “no currently accepted medical use and a high potential for abuse”.

The National Institute on Drug Use (NIDA) states that “researchers haven’t conducted enough large-scale clinical trials that show that the benefits of the marijuana plant (as opposed to its cannabinoid ingredients) outweigh its risks in patients it’s meant to treat.” However, what little research actually has been done lead to the development of Cesamet and Marinol, which are essentially legally prescribed cannabinoid pills. They are being prescribed to help manage the type of chronic nausea and vomiting brought on by chemotherapy, as well as to stimulate appetite. Unfortunately, the efficacy of these compounds is up for debate, with different individuals reporting varying levels of relief. Some report no relief at all.

I felt no relief, I didn’t feel ill, I felt nothing,” Jeff Elton, a 56-year-old man from Des Moines told CBS correspondent Brian Monopoli. “It might as well be M&M’s.”

Elton claims that switching to actual marijuana, which he inhales via vaporizer, has helped him manage the symptoms of gastroparesis, which includes chronic nausea and vomiting. In fact, he told Monopoli that using cannabis proper has allowed him to keep his food down and regain some of the weight he lost on Marinol.

 

No research for veterans

The good news for people like Elton is that, if Marinol or Cesamet doesn’t prove effective at managing symptoms, more and more states are legalizing marijuana for both recreational and medical use. While this makes it easier for the average citizen to secure cannabis near states where legalization is occurring, some of the people who need treatment the most are stuck in limbo; military veterans are still unable to be referred to state medical marijuana programs by VA physicians due to federal prohibition.

Katie Zezima, writing for The Washington Post, reports that the Department of Veterans Affairs recently released a statement proclaiming that they will not conduct research into whether cannabis can help vets suffering for PTSD and chronic pain. He quotes the Department of Veterans Affairs Secretary David Shulkin’s response to 10 Democrats on the House Veterans’ Affairs Committee:

VA is committed to researching and developing effective ways to help Veterans cope with post-traumatic stress disorder and chronic pain conditions,” Shulkin wrote in a response to the members of Congress. “However, federal law restricts VA’s ability to conduct research involving medical marijuana, or to refer veterans to such projects.”

Zezima then quotes John Hudak, deputy director of the Center for Effective Public Management at the Brookings Institution, who argues that Shulkin’s response is inadequate:

Obviously, it is federally illegal, but there are no restrictions on doing scientific research on it. Universities do this all the time and there’s a process to go through,” he says to Zezima, noting that the National Institute on Drug Abuse funds cannabis research. “It’s really a cop-out for the VA to say, ‘oh, we’re not doing work on this because of federal law’ when actually federal law allows them to do that.”

 

The VA sending mixed signals…

Shulkin’s response letter controversially follows on the heels of a VA policy rolled out at the end of December. Tom Angell, a contributor to Forbes.com, writes that while doctors with the VA still can’t recommend medical marijuana, they are being encouraged to talk more about it with military veterans. This new directive urges VA doctors to “discuss with the Veteran marijuana use, due to its clinical relevance to patient care, and discuss marijuana use with any Veterans requesting information about marijuana,” writes Angell.

The problem is, however, that the VA’s own internal policy toward medical marijuana still prohibits government assistance toward medical marijuana treatment, as evidenced by Shulkin’s quote above. Instead, the VA continues to fund opioid-based pain treatments amidst the worst drug and heroin epidemic in our country’s history. The oxymoronic nature of this type of treatment leaves vets open to the harms of opioid addiction, something that the experts at The Recovery Village claim cannabis could be used to curb:

What some studies are finding is that the use of prescribed marijuana for some medical conditions, especially for pain issues, can help prevent an opioid addiction from developing in the first place,” they write. “Many addicts begin their addiction with a prescription for painkillers, and medical marijuana might be a suitable and safer substitute.

This statement is representative of how the negative public perception of medical cannabis is fading. Experts at the University of Reno Nevada write, for example, that despite increased reports of the hazards of driving under the influence of marijuana, the dangers of cannabis consumption and driving may be putting the cart before the horse.

Crucially for public health officials looking to make sense of the data, the perception of danger is at odds with the number of accidents that can be attributed to the drug,” they write. “According to the American Public Health Association, the NHTSA stated they were unable to find a causality between legal marijuana and fatal traffic accidents—a finding echoed in the aforementioned Washington Drug Policy Alliance report, which showed that traffic accident fatalities remain flat in states with recreational marijuana.”

It’s an unfortunate reality that those looking to demonize marijuana need do no more than point to outdated studies, or like the VA, hide behind unfounded statements and the hazy federal legal status of cannabis.

Veterans like Michael Krawitz are happy about the small steps being made by the VA and federal government, in reference to the recently revised VA policy, but still, think that these small steps aren’t enough. Krawitz is a disabled Air Force veteran who takes oxycodone as well as marijuana to treat injuries he received in Guam in 1984.

Vets are happy that there’s a policy, but they’re unnerved by that prohibition,” he said in an article with Michelle Andrews. Andrews explains that Krawitz, 55, is the executive director of Veterans for Medical Cannabis Access, an advocacy group.

He has always been open with his VA doctors about his medical marijuana use and hasn’t suffered any negative consequences,” she writes. “But Krawitz said he has worked with veterans who have been kicked out of their VA pain management program after a positive drug test and told they couldn’t continue until they stopped using cannabis.”

Andrews adds that while most of these instances are usually misunderstandings that can be corrected, they generally occur due to unclear guidance from the Veterans Health Administration to its staff. It goes without saying, however, that veterans shouldn’t be penalized by the same agency that’s supposed to help them due to a simple mistake on the agency’s part.

Related Content:  Medical Marijuana: What Is CBD and How Is It Different Than THC?

Time will tell…

It’s worth noting that cannabis as a solution is not yet perfect. Medical News Today ran a headline last year titled “Marijuana ‘may be worse than cigarettes for cardiovascular health’” written by Honor Whiteman.

The lead researcher and author, Barbara A. Yankey of the School of Public Health at Georgia State University in Atlanta, found that “compared with subjects who had never used marijuana, the results revealed that marijuana users were 3.42 times more likely to die from high blood pressure. For each year of marijuana use, the risk of death from hypertension increased by 1.04 times.”

The good news is that the rise of new types of marijuana-infused products like tinctures and edibles may circumvent the need to inhale or burn cannabis in the first place. These products are also helping to further a more positive view of cannabis and cannabis-based products and could be instrumental in legitimizing both THC and CBD as a medicine.

Only time will tell whether or not veterans will receive much-needed support from the government and Department of Veterans Affairs beyond flimsy policies that Secretary Shulkin has responded to. Veterans, themselves, are turning to advocacy groups like Krawitz’s Veterans for Medical Cannabis Access and are demanding that the country they’ve served and the government that they answer to does more than give them half-answers and bunk solutions. Despite these obstacles, the future looks bright for proponents of medical marijuana—as the public continues to offer their support, the government will eventually have no choice but to follow suit.

Many policymakers, professionals, and researchers in the substance abuse treatment field believe that Medication Assisted Therapy or MAT is still heavily underutilized. This is particularly relevant considering the continued opioid crisis plaguing our country. There are many barriers in place in implementing MAT.

These barriers include a lack of resources, clinical resistance, and the lack of support in traditional recovery pathways (e.g., 12 step fellowships) for using MAT to name a few.1 Methadone and Suboxone are two commonly used drugs used in MAT. Understanding what methadone and suboxone are, and what they do, is important as we begin to explore the effectiveness of their use in criminal justice settings.

  • Methadone

Methadone blocks the high associated with taking opiates including heroin. When used appropriately, methadone reduces cravings and the withdrawals symptoms of opioid addiction.2 Methadone is most often dispersed in treatment centers and other clinical settings. It is long acting and slow to metabolize in the body. In using methadone, finding the appropriate dose is critical to avoid the “zombie” feelings and effects often associated with its use. Suitable dosing is often elusive to find because clinics often serve so many patients and have so little resources limiting the time and expertise needed to find the appropriate dose.3

  • Suboxone

Suboxone is another drug commonly used to combat the effects of opioid addiction. Suboxone combines two drugs buprenorphine and naloxone. The first drug in Suboxone buprenorphine is a type of opioid medication. Like methadone, buprenorphine is long lasting and slow to metabolize and is seen as a powerful alternative to other opioids more commonly abused (e.g., heroin and Oxycontin). Often used in detox scenarios, it is utilized to reduce the long-term symptom of opioid cravings over time. It is a convenient drug because it can be used in a variety of different settings from treatment centers to home use under the care of a doctor. The second drug in Suboxone is naloxone.3 Naloxone is added to buprenorphine to decrease the probability that patients will abuse buprenorphine. The addition of Naloxone to Suboxone is critical to its safety and effectiveness.4

 

From the criminal justice perspective

Those suffering from the brain disease of addiction are filling our jails and prisons throughout the country. From the National Institute on Drug Abuse:

Opioid use disorders are highly prevalent among criminal justice populations. According to data from the U.S. Department of Justice, approximately half of state and federal prisoners meet criteria for substance use disorder. Even so, there has been reticence in criminal justice settings to using medications (methadone, buprenorphine, naltrexone) to treat opioid use disorders.5

What this means is that sufferers from addiction who find themselves in the criminal justice system most often do not receive the type of treatment that may be most effective for them and may also be the most beneficial to society. The range of treatment options including MAT, which may prove to be effective and even lifesaving, may best be offered within this highly controlled setting. The lack of addiction treatment generally, and MAT specifically, impacts not only a person’s chance of rehabilitation within incarceration but profoundly influences a person’s experience in the post-incarceration environment.

Again, from the National Institute on Drug Abuse:

A former inmate’s risk of death within the first 2 weeks of release is more than 12 times that of other individuals, with the leading cause of death being a fatal overdose. Overdoses are more common when a person relapses to drug use after a period of abstinence due to loss of tolerance to the drug. Untreated opioid use disorders also contribute to a return to criminal activity, reincarceration, and risky behavior contributing to the spread of HIV and hepatitis B and C infections.5

MAT, using methadone and suboxone, in the post-incarceration environment must be highly considered in today’s crisis situation. MAT has the potential to reduce the fatality rate and assist former inmates transition toward becoming productive members of society.

Related Content: Can a Vaccine Cure Heroin Addiction?

What does the research tell us?

Rikers Island operates the longest standing methadone program for incarcerated prisoners in the country. The program named the “Key Extended Entry Program” (KEEP) has shown to be effective in reducing recidivism and relapse rates. KEEP was started in 1986 with the goal of helping inmates with opioid withdrawal symptoms and transitioning them into ongoing methadone maintenance as they reintegrate back into society.

In 2012, researchers Harris, Selling, Luther, et al. published a study which examined 650 opioid-dependent individuals at Rikers Island. Each patient was placed on an evidenced-based, highly monitored dose-adjustment regimen before being released. This was done to improve the post-incarceration reporting and methadone compliance rate. Professionals involved were highly trained to monitor methadone doses and to adjust as necessary. Effective dosing typically occurred after 21 days in treatment within the jail/prison. When effectively dosed before being released, patients reported for their methadone treatment post-incarceration at the best rates. The study indicated that all patients who reached 55 mg/day before they were released reported for ongoing treatment.6 A remarkable finding.

Such high reporting and adherence rates lowers not only recidivism but also relapse rates. This type of program is saving lives. Evidence from the National Institute of Drug Abuse reveals that if incarcerated patients start methadone at least 1 month before they are released, such treatment increased the probability they will remain in treatment and drug-free six months later.7 This is significant and is strong evidence to implement similar protocols and programs in similar environments across the country.

 

A comparative study

Another study conducted on KEEP compared randomly assigned inmates to either buprenorphine or methadone treatment. Results from the study were compelling and were as follows from the authors:

  • “Buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%, p < 0.001).”
  • “Buprenorphine patients stated an intention to continue treatment after release more often than did methadone patients (93% vs. 44%, p < 0.001).”
  • “Buprenorphine patients were also less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%, p < 0.05).”8

Both studies are strong indicators of the effectiveness of using MAT for those incarcerated and also post-incarceration.

It is important to note that MAT should also include other kinds of recovery supports over and above just taking drugs such as methadone or suboxone. MAT is most effective when it combines these replacement drugs with ongoing therapy, recovery fellowships, medical care, community, family, and other types of extended recovery support. The combination of these useful drugs and recovery support is better named Medication Assisted Recovery (MAR).


References
1. Expanding the Use of Medications to Treat Individuals with Substance Use Disorders in Safety-Net Settings (2014) https://www.integration.samhsa.gov/Expanding_the_Use_of_Medications_to_Treat_Individuals_with_SU_Disorders_in_Safety_Net_Settings.pdf
2. WebMD. https://www.webmd.com/mental-health/addiction/methadone
3. Kimball, T.G. (September 2016). Medications to Fight Addiction – Good or Bad? https://thedoctorweighsin.com/medications-to-fight-addiction-good-or-bad/
4. NAABT.Org https://www.naabt.org/faq_answers.cfm?ID=64
5. NIDA. Treatment of Opioid Use Disorder in the Criminal Justice System. https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction/treatment-opioid-use-disorder-in-criminal-justice-system
6. Harris A, Selling D, Luther C, et al. Rate of community methadone treatment reporting at jail reentry following a methadone increased dose quality improvement. Subst Abus 2012;33(1):70-75.
7. Addiction Treatment Forum. httpss://atforum.com/2012/05/prisoners-taking-effective-methadone-doses-report-to-methadone-treatment-programs-after-release/
8. Magura, S., Lee, J. D., Hershberger, J., Joseph, H., Marsch, L., Shropshire, C., & Rosenblum, A. (2009). Buprenorphine and Methadone Maintenance in Jail and Post-Release: A Randomized Clinical Trial. Drug and Alcohol Dependence99(1-3), 222–230. httpss://doi.org/10.1016/j.drugalcdep.2008.08.006

There is a strong connection between those who suffer from chronic pain and the opioid epidemic. Well-meaning doctors, to alleviate the chronic pain suffered by their patients, have prescribed a tremendous amount of opioid pain medication. Although highly effective for acute pain, opioids are not ideal for chronic pain situations.

New research on drugs used for cancer treatment is showing promise as a possible replacement for prescription opioids. These drugs could be one important tactic in curbing the opioid crisis gripping our nation.

 

The chronic pain problem

A hundred million Americans suffer from chronic pain. Different than acute or short-term pain, chronic pain is long-lasting and enduring. According to the American Academy of Pain Medicine, chronic pain is described the following way:

“While acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, chronic pain is different. Chronic pain persists. Pain signals keep firing in the nervous system for weeks, months, even years. There may have been an initial mishap (i.e., sprained back, serious infection) or there may be an ongoing cause of pain (i.e., arthritis, cancer, ear infection), but some people suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults. Common chronic pain complaints include headache, low back pain, cancer pain, arthritis pain, neurogenic pain—pain resulting from damage to the peripheral nerves or to the central nervous system itself.”

If we do not suffer from it ourselves, we all know and love people who suffer from chronic pain.

 

Chronic pain, doctors, and opioids

Those who experience chronic pain benefit from meaningful medical treatment, including responsibly utilizing prescription drugs to improve quality of life and daily functioning. Many of the estimated 100 million people who experience chronic pain reach out for help to their primary care physicians and other family medicine/pain doctors. In an effort to assist their patients, doctors have made use of prescription painkillers, particularly opioid analgesics, to address chronic pain. Unfortunately, there is a connection between the amount of opioid prescription pain medication prescribed and the opioid epidemic we are currently facing.

It is important to note that not all people who utilize pain medication develop a severe substance use disorder. Also, most doctors responsibly prescribe and monitor their patients when it comes to prescription painkillers. However, the use of the powerful pain medication, specifically opioids taken over time, certainly is a factor which increases the probability a person will develop a problem. Chronic pain, coupled with opioids, creates a perfect storm in increasing the probability of abuse and dependency (marked by tolerance and withdrawal), leading to the chronic brain disease of addiction manifesting.

Dr. Nora D. Volkow and Dr. A. Thomas McLellan (2016) recently published an article in The New England Journal of Medicine highlighting the connection between prescription opioid use and the nation’s opioid epidemic. They stated that although prescription opioid medication is excellent for acute pain, the use of such medication for chronic pain is medically questionable. Further, this improper use has led to a “flooding” of opioids in our communities. More specifically they declared:

“Opioid analgesics are widely diverted and improperly used, and the widespread use of the drugs has resulted in a national epidemic of opioid overdose deaths and addictions. More than a third (37%) of the 44,000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids; heroin accounted for an additional 19%.”

It should not be lost on any of us that twice as many overdose deaths are due to pharmaceutical opioids versus the street drug heroin. This is not only astounding but also disconcerting.

What is even more disconcerting is that the vast majority of available opioids on the street are from doctor prescriptions. Because of the powerful potential of opioid abuse, and in the presence of this epidemic, doctors are taking notice. Volkow and McLellan report:

“The major source of diverted opioids is physician prescriptions. For these reasons, physicians and medical associations have begun questioning prescribing practices for opioids, particularly as they relate to the management of chronic pain. Moreover, many physicians admit that they are not confident about how to prescribe opioids safely, how to detect abuse or emerging addiction, or even how to discuss these issues with their patients.”

Assessing the appropriateness of prescribing opioids for chronic pain is important. We, as healthcare and mental health providers, must also become more proficient and willing to find suitable alternatives as well as to detect/assess when prescription pain medications have become a problem. Once detected, meaningful help must be administered in caring and kind ways.

 

Repurposing drugs to fight chronic pain

One group of scientists are seeing promise in using cancer drugs to treat chronic pain in animal subjects. A receptor in the brain, called epidermal growth factor receptor or (EGFR), and its natural ligand epiregulin (EREG) has traditionally been targeted in cancer treatments. More recently, Martin, Smith, Khoutorsky, et al, (2017), have found inhibiting EGFR reduced pain reaction in mice who were experiencing inflammation and chronic pain symptoms.

From the study:

“We show that inhibition of EGFR with clinically available compounds strongly reduced nocifensive (pain reaction) behavior in mouse models of inflammatory and chronic pain. EREG-mediated activation of EGFR enhanced nociception through a mechanism involving the PI3K/AKT/mTOR pathway and matrix metalloproteinase-9. Moreover, EREG application potentiated capsaicin-induced calcium influx in a subset of sensory neurons. Both the EGFR and EREG genes displayed a genetic association with the development of chronic pain in several clinical cohorts of temporomandibular disorder. Thus, EGFR and EREG may be suitable therapeutic targets for persistent pain conditions.”

This is promising research that could have application to people experiencing chronic pain.  I hope they are right. I hope we can find “suitable therapeutic targets”, safer than opioids that will stand the test of human trials. If approved, such pain medication could be safely and effectively utilized to increase the quality of life for those who suffer from chronic pain.

The opioid crisis is real. People are dying every day from this epidemic. Finding effective and safer alternatives to pain management is essential in the fight. It is a preventative measure worth exploring to the fullest. However, it is only one of many areas to be targeted and improved.

In addition to this effort, identifying, assessing, and treating those who suffer and those who love them is also extremely important. These intervention strategies are not used often enough. When identified as having a problem, most people who suffer from opioid addiction do not have access to treatment due to financial, familial, and cultural barriers. We can and must focus our collective efforts and resources into both preventing opioid abuse and intervening when someone suffers from opioid addiction.

The National Academy of Medicine estimates that 100 million Americans now have some form of chronic pain. Just to put this number into perspective, around 25.8 million Americans have diabetes, and another 11.9 million suffer from cancer. Yes, you read that correctly; there are more chronic pain sufferers in the USA than cancer and diabetes patients combined.

Unfortunately, many chronic pain sufferers seek relief through legal and illegal opioids. Medical authorities now believe 90 people die of an opioid-related overdose every day in the USA. These staggering figures prompted President Donald Trump to declare the opioid epidemic a national health emergency.

So, how did this problem start and, more importantly, what can be done to reverse this troubling trend? Most experts believe the roots of the opioid crisis can be traced back to the 1990s. During the 90s, doctors started prescribing opioids more often to chronic pain patients. A study in the 80’s stated that “the development of addiction is rare in medical patients with no history of addiction”. Ever since the 90s, however, the rate of opioid-related deaths has only increased, and more evidence shows that these drugs are indeed habit-forming. We also now know that people who misuse opioids are far more likely to transition to harder drugs like heroin. About 80% of people who try heroin today have first misused prescription opioids.

 

The mind-body alternative: A new prescription for pain?

While there has been a steady flow of new research on the dangers of opioid addiction, there’s also a surge of research being published on effective alternative treatment techniques for chronic pain sufferers that are safe and non-invasive.

One of the most influential doctors in bringing mind-body techniques to pain treatment was Dr. John Sarno. Dr. Sarno, who worked as a doctor at New York University until his death in 2017, is perhaps best known for his book, Healing Back Pain. In this book and others, Dr. Sarno developed the theory of tension myoneural syndrome (TMS) to explain and treat chronic pain conditions. Sarno believed that a majority of chronic pain cases in the USA were psychosomatic in nature and caused primarily by emotional blockages. He went on to develop this theory in works such as The Divided Mind and The Mindbody Prescription.

Since Sarno believed back pain had as much to do with the mind as with the muscles, he told the majority of his patients to become more aware of their thoughts, journal every day, and continue their daily activities despite the physical sensations of pain. Sarno never said the pain his patients experienced wasn’t “real”. Instead, he believed the brain created the pain in another area of the body as a distraction from consciously processing strong emotions.

Perhaps Sarno’s greatest contribution to modern medicine was the re-evaluation of the important role emotions play in our physical well-being. And while Sarno’s ideas were met with some skepticism early on, there are many doctors, such as Srini Pillay, MD, who agree that people with chronic back pain often have psychological issues linked to their pain rather than physical abnormalities. Research published in the Journal of General Internal Medicine also shows that a mind-body approach to chronic pain results in “an immediate decrease in pain level, similar to what one might expect when using opioids.” Again, Sarno’s approach doesn’t mean that nothing is related to biomechanics, but it certainly highlights the importance of the brain’s role in the treatment of chronic pain.

 

Mind-body therapy: The answer to America’s chronic pain problem?

In addition to Sarno’s research, scientific studies have consistently shown the effectiveness of treating chronic pain with “mind-body therapy”, which is the name for a treatment approach that combines cognitive behavioral therapy techniques with education on the science of pain, journal writing, mindfulness meditation, and other “brain training” techniques.

In one study published in The Journal of Pain, Acceptance and Commitment Therapy (ACT), which focuses on behavior change instead of pain reduction, showed positive results and improvements in about 65% of study subjects who suffered from chronic pain. Another study published in Advances in Psychiatric Treatment showed that expressive writing resulted in many beneficial effects in both physical and psychological health.

In chronic pain research conducted with patients at both Cincinnati Children’s Hospital Medical Center and Wake Forest School of Medicine, doctors showed that meditation reduces pain signals sent to the brain without relying on the pathways used by opioids. Interestingly, when doctors gave meditators a drug to block opioid receptors, mindfulness meditation still worked to reduce pain signals in the meditator’s brain, suggesting that there are natural ways of affecting these pain pathways that are still not fully understood.

 

Making mind-body a habit

In light of all this new research, pain management clinics across the nation have started to integrate mind-body therapy into their practice. And while historically, mind-body therapy has been an expensive proposition requiring a specialist and the reading and re-reading of guidebooks, easy to find resources and technology are now making it more accessible than ever.

Keeping a pain journal or writing about your pain, in general, can be beneficial to both your doctor (if you’re being treated by one) and in managing your pain on your own. Check out how to keep a pain journal here. The American Chronic Pain Association has also developed some tools for Cognitive-Behavioral Therapy (CBT) on their website, including free video lessons, which aim to help you change your thoughts and behaviors towards pain, and if you’re interested in meditation, the UCLA Mindful Awareness Research Center offers a number of free guided meditations as well.

Curable, a guided mind-body pain therapy app, combines education, journaling, brain training, and guided meditation into one package, and offers a free guided session on their website.

It’s important to incorporate all aspects of mind-body therapy so it is critical to be educated on all the different exercises chronic pain sufferers can practice. Having a good well-rounded program is essential for the improvement of both physical and psychological symptoms.

 

Join the mindfulness revolution

There’s no denying the healing benefits of mind-body therapy for treating conditions like chronic pain. While opioid medications have their place in the medical establishment, we can now see that overusing and over-prescribing these drugs can have disastrous effects on both individuals and society. Mind-body healing techniques like journaling, talk therapy, and meditation will increasingly become more mainstream as patients seek more affordable and effective alternatives to drug therapy. As more information on mind-body therapy becomes available, public health officials are hopeful that the rates of opioid addiction will begin to decline for good.

On, October 26, 2017, President Trump declared the opioid epidemic a public health emergency. I wanted to know, what does that mean exactly? I was surprised to find little about the implications. In brief, more money will be available, additional personnel can be directed toward the crisis, various insurance requirements can be waived or adjusted, grant deadlines and requirements can be waived or extended, some drugs may become more accessible, and telemedicine can be modified.

Regarding the issuance of a public health emergency, I wonder where the personnel and money will come from and what services will be reduced in exchange. I recently heard a quote, “only the government can cut off 2 inches from the top of a piece of material and sew it onto the bottom and be convinced it makes it longer!” I am extremely happy that solutions are being investigated, but the devil IS in the details.

 

The final commission recommendations

The final commission recommendations were released with 56 specific items. So what has already been addressed and what has not based on the preliminary recommendations? The following occurred prior to the final recommendations:

  • Increased access to treatment at centers with more than 16 beds by allowing a Center for Medicare and Medicaid Services (CMS) waiver (each state Governor must apply)
  • All federally employed prescribers have been directed to receive special training to provide medication-assisted treatment
  • Measures have been implemented to decrease the flow of illicit drugs into the country via the postal service
  • NIH has partnered with pharmaceutical companies to develop non-addictive painkillers and new treatments for addiction and overdose

One would hope that these measures will increase access to treatment, decrease the availability of illicit drugs, and expand efforts to find alternative medications for pain and for treating addiction.

Recommendations that have not yet been followed include:

  • More data sharing among state prescription drug monitoring programs and relaxing patient privacy regulations to allow improved ability to treat patients with substance use disorder (SUD)
  • Full enforcement of Mental Health Parity and Addiction Equity Act to increase benefits for mental health and substance use diagnoses

Both of these actions should have positive effects on the identification and treatment of those with opioid use disorder. Privacy laws sometimes limit important information that a clinician needs to appropriately address the disease and incorporating families and caregivers (who may not be permitted to contribute to a patient’s care with existing regulations) into the plan likely increases success. The Mental Health Parity and Addiction Equity Act (MHPAEA) is crucial in combatting this epidemic. Addiction is a disease and should be afforded the same financial provisions of other diseases, like heart disease and cancer. Financial barriers fuel the denial of someone with SUD, often preventing them from seeking treatment.

In general, the focus of the final recommendations can be divided into several sections. I won’t comment on every recommendation, just some that I find interesting and worthy of attention.

Related articles: Here is a link to Dr. Dye’s two previous commentaries on the preliminary recommendations from Trump’s opioid commission.

 

 

Federal funding and programs

To improve the delivery of federal funding to states, the commission urged Congress and the administration to block grant federal funding for opioid- and SUD- related activities to the states. Block granting allows a large sum of money from the federal government to be spent with limited provisions on how. Evidence-based programs would be funded through these grants. The commission also acknowledges the need for better data analysis and accountability to ensure that the dollars are spent on the most effective solutions. One of the big problems with government spending is that so much money goes into the bureaucracy and not enough makes it to the heart of the problem. Maybe, in this case, it will be different.

 

Opioid addiction prevention

Many don’t know that prescribing opioids is often the cheapest way to “address” acute and chronic pain. The commission identified a disturbing trend in federal healthcare reimbursement policies that incentivize the prescribing of opioids and limit access to non-addictive treatments for pain.

Unfortunately, opioids are relatively inexpensive, so insurance companies are often happy to cover them. In some cases, non-addictive pain management, addiction treatment, and medication-assisted treatment are bundled into federal reimbursement policies so that hospitals and doctors are essentially discouraged from providing alternatives to opioids and from offering treatment for opioid use disorder. Physical therapy and non-opioid medication should be easily accessible and affordable and addiction treatment should be encouraged. This is something the government can affect—it may help turn the tide on the crisis while providing adequate relief for those in pain.

Thankfully, the commission recognizes the unintended consequences of the infamous pain scale and making pain the “fifth vital sign”! One would think that requiring hospitals and doctors to identify and treat pain quickly could only be a good thing. However, many medical professionals, including me, believe this is a core cause of the culture of overprescribing that contributed to the crisis.

The U.S. Department of Health and Human Services (HHS) previously included pain question responses from discharged patients in calculations to determine incentive payment. In other words, if patients didn’t get the pain treatment they thought they deserved, (which often was a prescription for opioids), the payment to hospitals and doctors was reduced! Addressing a possible SUD takes a great deal of time and specialized expertise, which many doctors do not have. It is much easier to just prescribe an opioid and “satisfy” patients and not risk a reduction in pay. The commission recommends that CMS remove pain questions entirely from patient satisfaction surveys so providers are not encouraged to prescribe opioids to make patients happy. This is long overdue.

Among the recommendations of the commission, there is also a focus on prescribing guidelines, regulation, and education. There are several detailed suggestions, including education of prescribers, residents, and medical students. But what about others in the hospital, like nurses and allied health, who tend to spend more time with the patients? If all personnel are educated in the recognition of SUD, the diagnosis will be more frequently considered and treatment may be extended to more people. Thankfully, more educational resources are becoming available not only to physicians on the front lines but also for the general public. In fact, Elsevier launched its free Opioid Epidemic Resource Center which provides continually updated resources from healthcare experts on multiple topics related to opioid use and addiction.

Related Content: E-Prescribing: A Powerful Tool in the War Against Opioid Abuse

Opioid addiction treatment, overdose reversal, and recovery

HHS/CMS, the Indian Health Service, Tricare, and the VA still have reimbursement barriers to substance abuse treatment, including limiting access to certain FDA-approved medication-assisted treatment, counseling, and inpatient/residential treatment. It’s imperative that federal treatment providers lead the way by treating addiction as a disease and removing these barriers. Primary care providers employed by these federal health systems should screen for SUDs and, directly or through referral, provide treatment within 24-48 hours. Each physician employee should be able to prescribe buprenorphine (if that is the most appropriate treatment for the patient) in primary care settings. For individuals with a SUD, ensuring life-saving access to affordable healthcare benefits is an essential tool in fighting the opioid epidemic.

Relaxation of telemedicine regulations can also aid in access to treatment and is addressed in the commission’s report. Many areas, rural and non-rural, in the U.S. have no provider available who is certified to prescribe medication-assisted treatment. If telemedicine allows qualified providers to treat patients without having to be physically present, access to treatment can increase significantly. Patients who are willing to pursue medication-assisted treatment will no longer have to sometimes travel long distances for monthly visits when they can do virtual visits.

 

Drug courts

The commission also recommends that drug courts be established in all 93 federal district courts and that they embrace the use of medication-assisted treatment. Drug court offers the option of treatment and probation rather than incarceration. Eligibility requires very strict criteria be met before this option is offered. Not only does this increase the chances that many will receive appropriate treatment, it may decrease the prison population. There is data to support that drug courts are more effective than incarceration, yet 44% of U.S. counties do not offer it. Medication-assisted treatment can lead to lasting recovery when abstinence-only may not.

The issue of opposition to the concept of drug court brings up a very important aspect of addiction. The untrue belief that acknowledging SUD as a disease means that those affected should not have consequences for their behavior, is a huge barrier to progress and contributes to the stigma of addiction. While SUD is a disease, it is not an excuse. Offering strict treatment through drug court to a very specific group does not let them off the hook. Once a person acknowledges they have the disease, it is that person’s responsibility to treat it and not use it as a crutch. Drug court may offer the only opportunity for someone to finally recognize what “is wrong with them”. The additional education and treatment may be the only hope for long-term sobriety and an end to a lifetime of crime to obtain more drugs.

Unfortunately, my local county in Ohio, reports that many of those offered drug court reject it because going to jail for a few months is easier than the strict 18-month treatment pathway. Perhaps, we should start treating patients in the prison system. Their room and board are already provided and they are a captive audience. Why not provide treatment without having to build a new structure?

 

The bottom line

The commission’s final report is very extensive and has many recommendations. It is not surprising that the major themes are prevention and increasing access to treatment. Education is such a huge part of the solution and is addressed in the report. Those with opioid use disorder continue to use because they don’t believe they have a choice. For someone without the disease, it is very difficult to conceive.

In the grip of the disease, an addict’s brain is wired to seek drugs, like he or she seeks food when hungry, just to feel “normal”. It is no longer about getting high; it is about survival.

Fortunately, there are solutions. Even if the success rate is low, most of us believe that saving lives is important. We don’t give up on a cure for a rare, fatal cancer. Opioid addiction is the cancer of our generation—it is progressive and often rapidly fatal. Why should we give up on it?

The opioid epidemic has been a growing problem in the U.S. for over a decade. However, recent allegations by whistleblower and former head of the DEA’s Office of Diversion Control, Joe Rannazzisi, paint an even more sinister picture, complete with backroom deals and conspiracies. He says that Congress and lobbyists alike have knowingly derailed DEA efforts to get the problem under control. According to a story about the Washington Post/60 Minutes investigation,

“[Rannazzisi’s] greatest ire is reserved for the distributors, some of them multi-billion dollar Fortune 500 companies. They are the middle-men that ship pain pills from manufacturers, like Purdue Pharma and Johnson & Johnson, to drug stores all over the country,” explains 60 Minutes correspondent Bill Whitaker. “Rannazzisi accuses the distributors of fueling the opioid epidemic by turning a blind eye to pain pills being diverted to illicit use.”

Rannazzisi claims that the pharmaceutical industry allowed the distribution of millions of drugs to doctors and pharmacies that had no legitimate need for them. These distribution companies are required by law to look into suspicious shipments but turned a blind eye in the name of profit.

You know the implication of what you’re saying, that these big companies knew that they were pumping drugs into American communities that were killing people?” asks 60 Minutes’ Bill Whitaker.

That’s not an implication,” responds Rannazzisi, “that’s a fact. That’s exactly what they did.”

The cost of the opioid epidemic and search for solution

In response to Rannazzisi’s interview on 60 Minutes, President Trump vowed to declare a national emergency to combat the opioid epidemic. He made the same declaration in August, but unfortunately, he never followed through with it. But a report from the New York Times shows that he is set to declare a public health emergency of the situation. Julie Hirschfeld Davis reports:

“The move falls short of Mr. Trump’s sweeping promise to declare a national emergency on opioids, which would have triggered the rapid allocation of federal funding to address the issue, and does not on its own release any money to deal with the drug abuse that claimed more than 59,000 lives in 2016… But it would allow some grant money to be used for a broad array of efforts to combat opioid abuse, and would ease certain laws and regulations to address it.”

As the battle against opioids rages on, the search for a solution continues as well. Patient education has long been deployed as one solution, as well as alternative treatment options. Regis College’s Online MSN Program lists at least 10 types of alternative pain treatment and rates of prescription:

  • Natural Products (17.7%)
  • Deep Breathing (10.9%)
  • Yoga/Tai Chi/Qi Gong (10.1%)
  • Chiropractic Techniques (8.4%)
  • Meditation (8%)
  • Massage (6.9%)
  • Special Diets (3%)
  • Homeopathy (2.2%)
  • Progressive Relaxation (2.1%)
  • Guided Imagery (1.7%)

While these are great alternatives for pain management, the proof is in the pudding. Rates of opioid addiction and abuse have been steadily rising for the past decade. Nevertheless, there are those who think that the most commonly prescribed alternative pain management technique, “natural products”, could change the game, were it not for its hazy federal legal status.

Is medical marijuana a solution?

Between 1999 and 2010, only about 13 states had medical marijuana laws in place. Interestingly, researchers began to see a correlation between medical marijuana states and rates of fatal opioid overdoses. In 2010 alone, medical marijuana states showed fewer opiate-related deaths than states without said laws.

We found there was about a 25 percent lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law,” lead study author Dr. Marcus Bachhuber says in an article via DrugAbuse.com.

Even treatment centers are beginning to look into the merit of cannabis-based treatment. The Recovery Village, based in Umatilla, FL, has a post on their website titled “Can Marijuana Be Used as a Treatment in Drug Addiction Recovery?” in which they acknowledge the potentially addictive nature of cannabis but also take a look at its benefits. From their blog,

“What some studies are finding is that the use of prescribed marijuana for some medical conditions, especially for pain issues, can help prevent an opioid addiction from developing in the first place. Many addicts begin their addiction with a prescription for painkillers, and medical marijuana might be a suitable and safer substitute… It bears noting, however, that there are no scientific or long-term studies to back up these methods.”

The need for more studies

The biggest problem that the legitimacy of medical marijuana suffers is indeed the same problem that recreational marijuana faces: A lack of well-designed scientific studies, either for or against. Public perception against marijuana can be strong at times, flying in the face of the actual numbers that support an opposing viewpoint. For example, the University of Reno Nevada (UNR), writing on cannabis’ relation to drugged driving, points out that approximately 44% of self-reporting respondents to a survey claimed they’d driven under the influence of marijuana in states that have legalized it, many of them unaware that they’d been breaking specific ordinances. This sounds bad because our gut reaction tells us: “Driving under the influence is bad.” However, the same article from UNR states that “the perception of danger is at odds with the number of accidents that can be attributed to the drug.”

UNR cites the American Public Health Association website that proclaims that they were unable to find causality between legal marijuana and fatal traffic accidents. The Washington Drug Policy Alliance issued a similar report with similar findings, echoing that traffic accident fatalities have not increased, but have, in fact, remained flat in states with recreational marijuana. This indicates that even when we think we know quite a bit on a topic, there’s usually still more to learn. Hopefully, this type of work will foreshadow a time when we are able to overcome the stigmas and stereotypes attached to marijuana use.

As time goes on, we’ll no doubt see more studies that lend credence to the use of medical marijuana as a tool for harm reduction in the opioid crisis. The Recovery Village post even mentions that the National Institute on Drug Abuse (NIDA) is currently funding several projects to investigate the use of synthetic THC for the treatment of addiction. For now, we’ll have to wait, but the future looks bright.

Today, 90% of non-controlled substance medications are e-prescribed, while only 14% of controlled substance medications, including prescription opioids, are e-prescribed. This means that 86% of controlled substance prescriptions are still hand-written on a piece of paper and handed to a patient.

This is a problem.

Between 3% and 9% of drugs that are diverted for abuse are tied to fraud and/or forgery of paper prescriptions. This is a blind spot we can no longer live with.

 

The rise of a full-scale epidemic

More people than ever are dying of opioid overdose and the latest figures show that opioid addiction rates continue to rise, even among older Americans. Since 1999, deaths from prescription painkiller overdose have quadrupled. And in 2015 alone, opioid overdoses killed more than 33,000 Americans. Beyond the devastating loss of life, prescription opioid abuse costs the United States $55 billion in health and social costs each year, according to a 2011 study by Birnbaum, et al.

The crisis was recently declared a public health emergency by President Trump to provide additional resources to combat it with greater urgency.

 

Taking paper out of the game

Paper prescriptions are not only prone to inaccuracy and quality issues, they’re also vulnerable to theft and forgery. One way to make certain the right person is getting the right medication is to replace paper prescriptions with electronic ones.

E-Prescribing of Controlled Substances (EPCS) provides both security and convenience from the point of prescribing to the pharmacy dispensing medications to the patient. Keeping paper prescriptions and doctors’ credentials out of the hands of dealers and people suffering from addiction will save lives.

In addition to e-prescribing, other digital tools can help address fraud and abuse by providing clinicians with a more complete and timely picture of their patients’ clinical and medication histories. The technology exists today to

  • Give healthcare providers a patient’s prescription and visit history to identify potential doctor shopping.
  • Ensure that only those who are authorized to prescribe controlled substances are able to do so.
  • Help patients receive and adhere to their medications, and
  • Inform providers if a patient was recently treated for a drug overdose.

We do not have a technology issue. We have a utilization issue.

 

Change is coming

The Surescripts network is taking action to fight the opioid epidemic, resulting in increased EPCS and Medication History utilization and enablement.

In 2016, there were 1.08 billion requests from providers for their patients’ medication history data and there were more than 45 million EPCS transactions (a 256% increase over 2015). EPCS enablement among prescribers nearly tripled from 5.7% in 2015 to 14.1%, and pharmacy enablement increased nearly 10% from 80.6% in 2015 to 90.3% in 2016.

 

Mandates are helping

Policymakers are taking action to drive nationwide adoption of EPCS and to stop opioids from ending up in the wrong hands. Several states, including New York, Maine, Virginia, Connecticut, North Carolina, and Rhode Island, have passed legislation to mandate EPCS. Now, these states have a much more secure process either in place or in the works.

State regulations, like New York’s i-STOP law, made an immediate and significant impact on driving adoption and utilization among prescribers. In 2016, the year the legislation was enacted,

  • Prescriber enablement in the state increased by 45.5% (with 72% of prescribers enabled).
  • Pharmacy enablement in the state increased 7% (with 98% of pharmacies enabled).

The portion of controlled substances prescribed electronically increased 54.2% (with 91% prescribed electronically) according to Surescripts 2016 National Progress Report, a summary of the network and the industry’s progress in using health IT to improve healthcare.

And at the federal level, the Every Prescription Conveyed Securely (EPCS) Act was recently introduced in the House of Representatives that would require that all controlled substances under Medicare Part D be prescribed electronically by 2020.

 

Where we (all can) come in

With the right technologies at our disposal today, we have the opportunity and the responsibility to fight the opioid epidemic. These tools deliver the right data to the right place at the right time and empower both clinicians and pharmacists to make informed decisions and deliver safe, affordable, and high-quality care.

But to truly unlock the full potential of these tools, we have to appreciate the “network effect”, which means that only as allies coming together from every facet of the healthcare system will we be able to affect positive change when it comes to opioid abuse.

For our part, we’re using the network alliance we built 17 years ago to replace paper prescriptions with electronic ones in order to answer some of the most pressing questions that healthcare professionals ask when making care decisions about their patients, like:

  • What medication is my patient taking?
  • What is my patient’s clinical history?
  • Is my patient adhering to their medication therapies or taking a medication inappropriately?
  • Has my patient received care or medications from other providers?

The answers to these everyday questions are relevant to the opioids conversation because the information conveyed is critical to preventing fraud, addiction, overdose, and death. It’s not the singular solution to the whole problem of opioid abuse in the U.S., but it puts the technology solutions we have in our hands today on the front lines, where they can do the most good.