Because a recovering addict has become accustomed to the constant intake of drugs and alcohol that have chemically altered their brain, body, and nervous systems, the sudden deprivation of illicit substances will cause them to experience post-acute-withdrawal syndrome (PAWS), a withdrawal period that can last between a few weeks to two years. During this time, one of the symptoms faced is insomnia.

Insomnia puts a recovering addict at risk for relapse since they once relied on the sedative properties of drugs and alcohol to function, and can be tempted to use those same substances to aid their aggravating lack of sleep. In order to prevent the possibility of a relapse, recovering addicts can turn to non-pharmaceutical options to combat both their addiction and insomnia.

Strategies proven to improve sleep quality during addiction recovery

1. Cognitive behavioral therapy

The psychological intervention of cognitive behavioral therapy (CBT) tackles both the mental and physical obstacles of insomnia, such as stress sources and the reactions that occur because of them. CBT focuses on rewiring how the brain perceives sleep in order to identify and understand the factors that impact sleep and change an individual’s behaviors towards those factors mentioned above.

CBT has several alleviating strategies:

  • Controlling external elements and the environment of a bedroom

    The bedroom should only be limited to two things: sleep and sex. Anything else will cause the body to associate a bedroom with stressful stimuli, such as completing work, which is one of the last things one need when they are trying to fall asleep. Therefore, a recovering addict should focus on controlling the most influential external elements in a bedroom: exposure to light, temperature, and noise.

    If light exposure—whether that’s in the form of fluorescent light or technology’s blue and white light—is not limited one to two hours before sleep, the body will suppress the production of melatonin, the “sleep hormone”. Additionally, the room should be kept at a cool temperature, between 60°F to 67°F (roughly between 15°C to 19°C). Insomnia prevents one’s body temperature from cooling down in the evening which hinders their ability to fall or stay asleep. Furthermore, the body is prone to cultivate even more heat due to this stress.

    Lastly, outside noise should be minimized as much as possible. It has the ability to increase adrenaline as one is falling asleep or suddenly disrupt a sleep pattern in the middle of the night. While traffic, cars, and honking cars cannot be controlled, a person can settle for playing white noise in the bedrooms background or using earbuds to cancel out sound altogether.

  • Restricting sleep

    Sleep restriction is a technique where the individual establishes a strict schedule of time allowed to spend in bed and a regular awakening time. The time needed to stay awake each day is calculated by adding the allowed bedtime to the awakening time. For example, if the allowed bedtime is 6 hours and the awakening time is 6 am, the individual must stay awake from 6 am until midnight. As sleep improves, the time in bed can be advanced in 15-minute increments until a healthy sleep/wake cycle of refreshing sleep is reestablished. It is important to get at least 30 minutes of bright light exposure upon awakening either via direct sunlight or a light box and to avoid napping. The goal of this behavioral therapy is to consolidate sleep time by restricting the amount of time spent in bed. By doing that, it is hoped that the individual will eventually acclimatize to specific times of day when they are active and alert and others allowed to sleep.

    Another important factor to consider is to avoid using weekends as an excuse to “catch-up” on sleep by sleeping in. Contrary to popular belief, no one can ever compensate for the lack of sleep they have experienced throughout a week. In fact, setting aside even two days that do not adhere to a weekday sleep schedule can throw off one’s desired sleep schedule all-together.

  • Follow a nightly ritual

    A nightly ritual should include practicing good sleep hygiene, such as avoiding naps that last for hours during the day and avoiding stimulating elements, such as technology, sugar, and caffeine, before bed. This is also an excuse to indulge in a series of relaxing activities, such as a taking a warm bath, doing yoga, and taking time to meditate. The body will eventually turn the nightly ritual into an everyday and necessary sleeping habit.

  • Implement the use of biofeedback

    Under the instruction of a doctor, one can track and recognize the physiological and physical responses that prevent them from adequately sleeping. The main elements that are observed in bio-feedback are heart and muscle tension. Biofeedback utilizes electrodes (sensors) which record the biological signals that occur before and during sleep (i.e., an accelerating heartbeat or tightening muscles). Upon becoming aware of their physical symptoms and reactions during insomnia, an individual can then find ways to combat them, especially with relaxation therapy.

2. Paying mind to diet and exercise

Instead of turning to addicting sleeping pills, an individual can simply be meticulous about their daily meals. Maintaining a healthy diet will always be a valuable contribution to improving sleep, in addition to keeping the mind and body functioning at their optimum levels. This is especially significant considering that some foods naturally produce melatonin, the “sleeping hormone” that automatically kick-starts the body to rise or drift off to sleep.

High-intensity and low-intensity exercise, in conjunction with a healthy diet, also increases serotonin production which maintains the chemical levels necessary for a proper sleep-wake cycle. Additionally, vigorous physical activity always leads to the body undergoing a necessary recovery period where it significantly drops in temperature that encourages a state of rest.

3. Natural forms of relaxation

Herbal remedies

The use of herbs is a safe, non-addictive remedy. They have naturally sedating properties that affect brain receptors directly connected to the central nervous system to induce relaxation and drowsiness. The most popular herbs include chamomile, passion flower, and lavender, which are recommended to be consumed either as a tea, a supplement, or used in aromatherapy. However, an individual should first consult with their doctor about herbal remedies to find what herbs work best for them to determine a proper and measured intake that accommodates to their sleep needs.

Tune out the world with music

Playing soft music relaxes the central nervous system by diminishing the presence of stress and anxiety. According to a study, music was found to improve sleep quality by inducing its listener in a deep REM sleep, the most vital part of sleep that encourages the restoration of the body’s psychological well-being. It is necessary for the body to recover during sleep because, without that restorative process, one will suffer fatigue, possible depression, anxiety symptoms, and poor memory function.

Massage therapy

Massage therapy not only reduces anxiety and promotes relaxation, but it also helps the body produce more serotonin. Without a proper influx of serotonin levels, an individual is more likely at risk for not only triggering insomnia but depression and fatigue as well. Fortunately, the technical movements of massage therapy stimulate the production of dopamine and endorphins, which increases blood flow, diminishes inflammation, and reduces muscle tension. Some examples of massage therapy techniques that provide the benefits mentioned above are kneading, the pull-and-squeeze motion of muscle tissue, and myofascial release, which is the gradual pressure on fascias (the fibrous tissue that encloses muscles and other organs) that had previously restricted blood flow.

Acupuncture

A unique method that impacts the quality of sleep is acupuncture. Since acupuncture’s purpose is to stimulate nerves and muscles in the autonomic nervous system—which controls the involuntary bodily functions such as digestion, the beating of the heart, and breathing—the technique regulates the cortisol “stress” hormone imbalance that commonly occurs in insomnia. Too much stress is also associated with increased levels of epinephrine (adrenaline) that can keep a person wide awake at night.

On a final note, all efforts taken in addiction recovery are valuable steps forward

By following the strategies above, a recovering addict can overcome the inevitable insomnia stage during their journey to sobriety, and be assured that they are not restricted to medication to help them sleep and can instead use non-pharmaceutical options that will work just as well, and sometimes, even better.

Anytime there is an increased need or demand for services, businesses and industries are created and also expanded to meet that need. This is the American way. The treatment and recovery field is no exception to this rule. However, the need for services far outweighs the demand as many people who meet the critical for severe substance use disorder meet financial barriers to access treatment.

 

The opioid epidemic is getting worse

The terrifying power of the opioid epidemic is one factor that has increased the need for treatment- and recovery-related services. The opioid epidemic is not getting better but is actually getting worse over time. There are more and more people impacted by the epidemic through death, overdose, addiction, and abuse.1

 

Multiple pathways of recovery

Another factor increasing the demand and need for more treatment is the treatment and recovery field embracing more pathways of recovery. Individuals and their families who suffer from the chronic brain disease of addiction are seeing an ever-increasing variety of pathways to choose from and those pathways are becoming more and more accepted within recovery environments.

As evidenced of the increase, and the acceptance, of multiple pathways of recovery, in 2010, the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as the Center for Substance Abuse Treatment (CSAT), conducted a qualitative study with 33 participants with a history of alcohol and other drug problems.2 Within the focus groups, the participants reported utilizing both traditional and non-traditional pathways to facilitate the development of recovery capital and wellness.

Broadly stated, recovery capital is the internal and external resources that people draw upon to not only begin the recovery journey but sustain it over time. The building of recovery capital is naturally attached to a strength-based approach and the pursuit of resiliency and recovery protection.3

The participants in the study above described the variety of different pathways of recovery they utilized. They included the following:

  • Natural recovery
  • Mutual aid groups – 12-step based programs including Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)
  • Mutual aid groups – non-12-step based programs such as Women for Sobriety and SMART Recovery
  • Faith-based recovery
  • Cultural recovery including traditional Native American sweat lodges
  • Criminal justice including incarceration and drug court
  • Outpatient treatment
  • Inpatient treatment
  • Bodywork including yoga, traditional Chinese medicine, and Addiction Energy Healing
  • Other therapies including art or music therapy

Most of the participants stressed that they utilized not just one of the pathways listed above, but instead utilized two or more pathways on the journey to find recovery and wellness. They also indicated that their journey to find the right pathway for them took several years to discover.

Related Content: Opioid Addiction is the Cancer of Our Generation

Barrier to services

Even with the demand for services increasing and providers attempting the meet the demand for these services, participants of the study identified the barriers to finding adequate services. The barriers discussed included the lack of services provided and support options available. We also know that cost of services for many is a significant barrier to meaningful help.

 

Medicated-assisted treatment

One of the pathways of recovery in ever-increasing demand due to the opioid crisis is medication-assisted treatment or MAT. From SAMSHA:

Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies>, to provide a “whole-patient” approach to the treatment of substance use disorders. Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling with addiction, MAT can help sustain recovery.

MAT is primarily used for the treatment of addiction to opioids such as heroin and prescription pain relievers that contain opiates. The prescribed medication operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.4

 

Opioid-related services are in ever-increasing demand

One example of the increase in demand for opioid-related services can be found in Hartford, Connecticut. In an article published at HartfordBusiness.com, the authors reported that nearly 15,000 people sought help from their opioid addiction in the area last year. The number of people seeking services for opioid addiction has increased 25% since 2012. The article reports that the recovery pathway in most demand and the fastest growing is MAT.5 MAT, as described above, is often argued as a less intrusive pathway than other pathways of recovery. By reducing cravings, MAT potentially allows more people to embrace less intrusive pathways, such as an outpatient environment versus inpatient. Being able to embrace a less intrusive pathway immediately or more quickly may provide the option for individuals to maintain their employment and/or continue with their education.

The authors of the article further point out that most of the treatment in Hartford is being conducted by non-profit agencies including state-run facilities. However, when there is demand for services, then for-profit organizations will always come into play. For-profit businesses are a natural player within the treatment and recovery field and have been for a long time.

It is a misnomer to believe that all for-profits do not offer good services or have improper motivations when providing addiction treatment. Yes, for-profits are in the business of making money but must to do so by providing good quality treatment at reasonable costs based on demand.

A big concern is that the demand for service within this opioid epidemic far outweighs the ability for non-profits, state-run agencies, and even cost-effective for-profit organizations to provide.

Such is the case in Arizona, where an article published earlier this year reported a huge increase of treatment providers offering services as the opioid epidemic is in full swing in the state. When there is an increase of demand, for-profits naturally increase the price. For example, the article reports that in Arizona:6

  • A non-profit sober living environment costs around $400.00 a month.
  • A non-profit inpatient environment around $15,000 a month.
  • A for-profit inpatient environment around $40,000 a month.
  • A for-profit inpatient opioid treatment can cost as much as $80,000 a month.

Someone is making a lot of money on the current opioid epidemic.

 

Supply and demand in the opioid crisis

It seems clear that there will continue to be an increase of demand for treatment- and recovery-related services. The opioid crisis we are currently seeing is a huge factor in fueling this demand. We must find ways to increase access to multiple pathways of recovery for individuals and families who suffer. We cannot tackle addiction and the current opioid epidemic in acute ways as we have done in the past. If we do so then the current epidemic will continue to spiral. A continued exploration of the impact of providing long-term recovery support through more cost-effective mechanisms (e.g., recovery peers) and utilizing adaptive engagement mechanism of support (e.g., technology-based engagement) is vital to this continued effort.


References
1. USA Today (October, 2017). Opioid Epidemic getting worse instead of better, public health warninghttps://www.usatoday.com/story/news/politics/2017/10/05/opioid-epidemic-getting-worse-instead-better-public-health-officials-warn/732192001/
2. The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT) (201). Pathways to Healing and Recovery: Perspectives from Individuals with Histories of Alcohol and Other Drug Problems. httpss://www.naadac.org/assets/1959/pathways_to_healing_and_recovery.pdf
3. White, W., Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27. httpss://www.naadac.org/assets/1959/whitewlcloudw2008_recovery_capital_a_primer.pdf
4. SAMHSA. https://www.samhsa.gov/medication-assisted-treatment/treatment
5. Hartfordbusiness.com (August, 2017). Opioid Addiction Treatment Industry Grows as Epidemic Spreads. httpss://www.hartfordbusiness.com/article/20170828/PRINTEDITION/308249903/1043
6. Columbus, C. (January, 2017). Substance-Abuse Treatment Industry Grow to Keep Up With the Demand. Cronkite News. https://cronkitenews.azpbs.org/hookedrx/opioid-drug-abuse-treatment-rehab-industry-growth-az/

The problem of opioid abuse in this country has been growing for the past few decades, with the number of opioid-related deaths sharply increasing in the last four years. From 2014 to 2015, deaths caused by heroin overdose increased by 23% and synthetic opioids, other than methadone, increased by 73%. Some states are more affected than others. In Ohio, for example, there were 1,800 opioid-induced deaths just in the last year. This is more than any other state has ever seen before.

The CDC also reports that between 2000 and 2015, more than half million people died of an overdose in this country. Six out of ten overdoses of those overdoses are due to opioids. That means that about 300,000 people died of an opioid overdose. These numbers cannot be ignored.

While many attribute opioid overdoses to heroin, this is no longer the only pressing issue. The abuse of opioid prescription pharmaceuticals, such as oxycodone and hydrocodone, is a big part of the problem as well. Sadly, little is being done to solve this part of the equation.

Big Pharma has bought influence with the billions in profit from opioid sales, making it very difficult for government agencies like the Drug Enforcement Administration (DEA) to fight the epidemic.

 

Big pharma and prescription medications feed the epidemic

According to the Centers for Disease Control and Prevention, prescriptions for opioid medications almost quadrupled between the years of 1999 and 2010. The number of deaths caused by prescription opioids also more than quadrupled in that same period.

Previously, opioid therapy was reserved for rare occasions of severe pain, as practitioners feared the danger of addiction associated with these drugs. Now, opioids are commonly prescribed for fairly minor painful conditions.

Advertising, drug detailing, and lobbying, funded largely by the pharmaceutical industry, aggressively pushed to relax prescribers’ caution about writing prescriptions for opioids with the false argument that “less than 1% become addicted from opioid therapy.” Sadly, this statistic—gleaned from a note to the editor in New England Journal of Medicine—was misused. It was not peer-reviewed and was based exclusively on hospitalized patients who received controlled short-term treatment.

Big pharma pushed dangerous drugs with insufficient research and evidence of their safety because it was profitable to do so. Consider Purdue Pharma, which raked in 3.1 billion in 2010 from OxyContin sales alone. Endo Pharmaceuticals made approximately 380 million in 2011 in Opana sales. Insys has made 147.2 million in Subsys (a.k.a. fentanyl) in only the first six months of 2015, and the list goes on.

 

Pain prescriptions create heroin addictions

Prescription opioids interact with the brain and body in the same ways as heroin. In fact, a person with a legitimate prescription for Percocet could take it daily for only a couple of weeks and develop an addiction. And, unfortunately, prescriptions often include many more pills than needed to manage pain after procedures, such as minor surgery.

Someone addicted to a prescription opioid soon realizes that it is very expensive to acquire these drugs regularly. This is the point at which many people turn to heroin, a much cheaper option. While this jump may seem unfathomable to many, it is actually a very common narrative.

When addiction is formed, a reward loop associated with the drug develops in the brain which causes the brain to prioritize the drug above all else. A person’s judgment and logic are compromised which is how the previously absurd possibility of using heroin becomes a viable option for so many.

 

People drop like flies from fentanyl and carfentanyl

Fentanyl is an opioid that is 50 to 100 times stronger than morphine. Recently, many analogs of fentanyl have been manufactured in illegal labs in Mexico and distributed for illicit sale. Meanwhile, shady pharmacies and pain clinics in the U.S. are hemorrhaging opioid drugs, including fentanyl, as drugs obtained with illegitimate prescriptions wind up being sold on the streets.

Because of its high potency, fentanyl’s street presence has resulted in many more deaths than seen before in some areas. Dealers commonly sell fentanyl as heroin, while the users have no idea that it’s dangerously stronger than heroin.

Carfentanyl, an elephant tranquilizer that is 5,000 times stronger than heroin, has also made it onto the streets of some cities. This happened in Akron, Ohio, contributing to the state’s recent spike in opioid deaths. An amount equivalent to a few grains of salt can be lethal; that is how strong this drug is.

The DEA has issued a statement and warning about fentanyl, announcing that the drug is a threat to public health safety. Yet, it is legal to prescribe and distribute it in the U.S.

 

Big pharma fights opioid regulation & pushes pills

The state of Ohio is suing big pharma companies for “fraudulent marketing”. The accused are Purdue Pharma, Endo Health Solutions, Teva Pharmaceutical Industries and subsidiary Cephalon, Johnson & Johnson and subsidiary Jansen Pharmaceuticals, and Allergan. Ohio isn’t alone, though. Many states and cities are taking similar actions, outraged that companies pack in the cash while millions of Americans die from their products.

Pharmaceutical companies continue to market opioids dishonestly, as safe with little risk of addiction. They also inappropriately bribe and pressure doctors to prescribe opioids more often and for less severe conditions. They gift doctors with huge sums of money, disguised as payment for “speaking opportunities”, as well as with food and other items.

Now, there is a reason to believe that many big pharma companies have turned a blind eye to suspiciously big drug orders and paid to pass legislation that keeps the DEA out of these transactions. It’s time for big pharma to stop pushing their own profit incentives into medical practice.

 

Pharmaceutical distributors supplying opioids for illegal sale

Former DEA agent, Joe Rannazzisi, exposed some dark realities about the DEA, Congress, and big pharma during his recent appearance on a 60 Minutes segment. As the Washington Post reported“Rogue doctors wrote fraudulent prescriptions for enormous numbers of pills, and complicit pharmacists filled them without question, often for cash.” They also reported that internet pharmacies were also giving massive amounts of prescriptions without even requiring doctor visits.

These prescription medications have been getting onto the streets and sold illegally for years now. It seems that distribution is the primary weak point in prescription drug circulation which drug dealers could take advantage of and that is exactly what has been happening.

For years, the DEA could prosecute these companies for not reporting such suspicious orders, fining them for millions of dollars and suspending their shipments. This hasn’t happened in about two years though, due to legislative changes.

As reported by 60 Minutes and the Washington Post, Rannazzissi claims that big pharmaceutical distributors—AmerisourceBergen, Cardinal Health, and Mckesson to name a few—used money and influence to persuade lawyers and DEA officials to lessen these penalties.

By hiring flip-flop lawyers who had previously worked for the DEA, pharmaceutical companies were able to challenge these tactics. Linden Barber, for example, who ran the DEA’s Diversion Control litigation office, was one of these lawyers. He quit the DEA and began selling his services to pharmaceutical companies who needed defense against the DEA’s charges.

 

Pharma influences law and government agencies

Near the end of April in 2015, a bill called the “Ensuring Patient Access and Effective Drug Enforcement Act,” written by Linden Barbur himself, was passed. This bill purported to grant patients more access to pain management, when over-prescription of opioid medications was already prevalent.

The bill deprived the DEA of its ability to freeze suspicious shipments and made it virtually impossible for the DEA to go after the corrupt companies making these shipments. The attorney general at the time cautioned that this law would make it more challenging to keep American people safe from opioid abuse.

The bill was considered and edited for two years, during which time “the drug industry spent $102 million lobbying Congress on the bill and other legislation,” according to the Washington Post. The Post also claims that Congressman Tom Marino, who sponsored the bill and firmly pushed it through, received $100,000 that came from the drug industry. They also say that Orin Hatch, who helped pushed the bill, received $177,000. It was passed with zero objections.

 

Treating opioid abuse as a dire health crisis

Now that President Trump has officially categorized the opioid crisis as a “public health emergency,” some grant money might be put towards addressing the epidemic. One effort being made is for first responders like police officers to have the life-saving drug, Naloxone (brand name Narcan), at their immediate disposal. Naloxone stops the effects of opioids, halting an overdose for long enough to save a person’s life.

Most of all, though, people need to contact senators and government officials about their dissatisfaction with the current legislation and call for new laws. We need laws that restrict opioid prescriptions more and that do not cripple the DEA from enforcing regulations. We need laws that keep big pharma manufacturers and distributors in check and the American people protected from these dangerous drugs.

“Our body is our temple.”

This is a saying you’ve probably heard before, as had I many a time. But the real meaning of the phrase didn’t hit me like a ton of bricks until I began my recovery from drugs and alcohol. During the dark days of my disease, I didn’t care much about my body; abusing drugs and alcohol, I certainly did considerable damage to it. When I finally got clean, got my act together, and began to think about improving my overall health, I didn’t really know how.

Below are five essentials tips to live a healthy life distilled from my own road to recovery. These tips not only helped me heal my damaged body and mind in my early recovery, but they also keep giving me the physical and mental strength I need to stay alcohol and drug-free every day of my life. My hope is that they will serve you well, too.

1. Refuel: Eat better

The food you eat fuels you and your entire engine—not just body but mind and soul, too. Aside from the more obvious physical ramifications to our bodies, research has also proven the impact of different foods on mood and overall wellness time and again. Thankfully though, eating well isn’t rocket science and oddly enough, the computer science acronym GIGO [Garbage In Garbage Out] comes to mind as a simple rule of thumb.

Here’s the simple formula: Increase the good, cut out the bad, and avoid food triggers that trip you up personally.

Eat the rainbow! This means a diet consisting mostly of different colored fruits, vegetables, whole grains, and legumes that provide your body with the diverse nutrients it needs. Dark green and orange vegetables are said to be some of the healthiest—think spinach, kale, broccoli, and carrots.

Significantly reduce (or cut out altogether) the bad stuff: processed foods, saturated fat, alcohol (and drugs, of course), and sugar.

Find ways to avoid foods that lead you to binge eat. Usually things like chocolate bars, chips, cookies, and fast food. In my case, trigger foods were strongly linked to my alcohol consumption. So, as you can imagine, healthy was not exactly a word to describe my eating habits.

2. Refresh: Hydrate better

While factors like the climate we live in, our weight, and how much we exercise dictate how much water we need, most of us don’t drink nearly as much as the 2-3 liters (8-10 glasses) of water per day that is generally recommended.

Drinking more water removes wastes, regulates body temperature, detoxifies the body, and carries nutrients to where they are needed, influencing our energy levels and ensuring overall optimal bodily function.

Start your day hydrated after a night’s sleep with a tall glass of water and some fresh lemon juice squeezed into it. Some believe this will help flush out toxins and help you have daily bowel movements (which I would say is the sixth key to living a healthy life!), but even if this isn’t true, it’s still a great way to start your day.

If you drink coffee or soda, which dehydrate the body, you will need to drink even more water. Caffeinated drinks are diuretics, meaning they speed up the rate of urine production, and can lead to dehydration. Signs that you aren’t getting enough water include dark yellow urine, dry or chapped lips, and not urinating often.

3. Restore: Sleep better

Studies have shown that we are a sleep-deprived nation, with most of us not getting the recommended 7-8 hours per night that is essential to keeping us energized and mentally alert throughout the day.

As I was mostly passed out or just so drunk I felt I was sleeping during my addicted years, sleep was not something I cared about. Getting the optimum amount of sleep, however, is linked to a reduced risk of chronic disease and a longer lifespan. In addition, a regular routine, consistent sleeping hours (going to bed at the same time every night and waking up at the same time every morning—something that was unfathomable to me when I was consuming), as well as getting to bed an hour or two before midnight every night can work wonders for your body and mind.

Wondering how you can get to bed by 10 or 10:30 pm? Sometimes all it takes is shutting off the tv, computer, or cell phone and picking up a book!

4. Reinvigorate: Exercise better

Daily exercise is linked to a better and longer life, improved mental and physical health, reduced stress, lower rates of disease, boosts to any other ongoing addiction recovery treatments, and improved physical appearance.

The key, however, lies in choosing a sport or style of exercise that is the right fit for you; one you truly enjoy and want to do every day rather than a gym membership where you force yourself onto the treadmill until you give up even more miserable than ever before.

Your options are endless: From sweating it out to music you love or just processing your own thoughts while alone on a running or cycling trail to signing up for a local team or competitive sports (think local beach volleyball, slow pitch league, or joining a squash or tennis facility), if you’re more of a people person that likes being part of a team. Daily walks with a friend can be a good way to get out and get some exercise, while being social at the same time. And classes (think aerobics, yoga, Zumba, or wakeboarding) are a fun way to exercise, meet new people, and learn something new. Furthermore, the commitment involved (including the economic commitment of paying for a weekly or biweekly class) can help you stick to your exercise routine.

5. Relax: Stress better

Stress is a natural part of life that everyone experiences from time to time and it can even be a good thing (Eustress)! Everything from work or family obligations to traumatic events such as an accident, the death of a loved one, or even a natural disaster can trigger stress. As a physiological response to harmful or potentially dangerous circumstances, it can actually help us better cope with these in the short term. It can even be considered nature’s way of helping us survive life-threatening situations.

However, if stress levels stay elevated for longer periods of time (chronic stress), this takes a major toll on your health. Chronic stress is often a factor in drug and alcohol abuse and is linked to many health problems such as high blood pressure, type 2 diabetes, ulcers, and acid reflux (heartburn), to name just a few. It also weakens the immune system, leaving you more susceptible to the flu, colds, and a whole host of common infections.

So how can you relieve chronic stress? All of the points above!

Furthermore, walking in nature or calming the mind with meditation can be especially effective. Sit in a quiet space, close your eyes, and concentrate on your breathing. Start small—even 5-10 minutes of meditation a day is incredibly beneficial. Then, work your way up to longer periods of 15-30 minutes. Yoga is another fantastic way to relieve stress that combines the benefits of meditation and exercise. Listening to calming music, talking to a friend, or taking a long bath with essential oils (lavender is a great choice) are some other great ways to beat stress. The key here is to find ways to not only minimize stress but rather accept that stress is inevitable and discover ways to cope with stress better. Stress can even be good and with the right stress busters that work for you to channel the stress in constructive ways, it can become what drives you in a positive way.

The secret to a healthy happy life is simple

Everyone wants to live a healthy and happy life and my life was anything but healthy and happy before my recovery. For me, the starting point of my new life was getting off drugs and alcohol, which I did by focusing on repairing and rebuilding my whole self through healthy eating, drinking more water, sounder sleeping, getting daily exercise, and reducing the stress in my life. Nobody said it would be easy, but it is simple.

That our bodies truly are a unique physical shell, home to our spirits while we traverse this world and our irreplaceable vehicle through this crazy, complexly beautiful journey called life, was a truth I could no longer deny. Now, nine years later, I feel better than I ever have in my life. I hope these tips can help you to live healthier and much better.

Which essential tips for living a healthy and happy life would you add to this list? Tell us in the comments below!

Over and over again, we hear about the opioid epidemic on the news, online media outlets, social media, and the radio. It’s no surprise there is such a prevalence of coverage surrounding this topic because so many people are dying from opiate-related overdoses. A number of these fatalities have resulted from overdosing on heroin often laced with fentanyl.1 Discussing the opioid epidemic and addiction problem in the United States is a powerful way to bring attention to the problem, and begin to rally treatment providers and policymakers to the important cause and necessary steps of finding solutions.

In regards to the opioid epidemic, Jacob Levenson, CEO of MAP Health Management recently wrote:

“The statistics behind the opioid epidemic are harrowing. A lot of people are dying at an alarming rate from opioids. But, why are people now suddenly paying attention to this when drug addiction has taken so many lives for decades? When you look at the statistics of overdose going back to 1999 you see a dramatic increase in overdose deaths—which became exponentially more severe in the past decade. In 2016 alone, there were over 20,000 overdose deaths just from synthetic opioids.”2

In the article, Mr. Levenson highlights the positive impact of President Trump declaring the opioid epidemic a national emergency. Namely, that declaring a national emergency will fuel the fire of much-needed policy changes to restrict the amount and inappropriate prescriptions of opioids, fund state electronic prescription monitoring systems, and fund research to explore medication-assisted therapies and perhaps to even find a vaccine to combat to effects of heroin.2

Heroin is a powerful and dangerous drug

Heroin is a powerful drug, to say the least. From the National Institute on Drug Abuse:

Once heroin enters the brain, it is converted to morphine and binds rapidly to opioid receptors. Abusers typically report feeling a surge of pleasurable sensation—a ‘rush’. The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the opioid receptors. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, which may be accompanied by nausea, vomiting, and severe itching. After the initial effects, users usually will be drowsy for several hours; mental function is clouded; heart function slows; and breathing is also severely slowed, sometimes enough to be life-threatening. Slowed breathing can also lead to coma and permanent brain damage.3

It cannot be overstated that sometimes the slowing of breath and heart function from heroin use is life-threatening and can cause brain damage. Even more frightening, when taken in large quantities, and/or laced with Fentanyl, the impacts of heroin can be deadly.

A heroin vaccine?

The idea of a heroin vaccine has been around for a number of decades, with research and studies pushing the effort to find something effective. However, recently a group of researchers including Bremer, Scholosburg, Banks, Steel, Zhou, Poklis, & Janda (2017) published an article regarding a vaccine that has shown particular promise in blocking the drug effects and potency of heroin in mice and monkeys.

From the authors:

An efficacious heroin vaccine has been identified through optimization of the adjuvant (CpG ODN + alum), carrier protein (TT), and hapten (HerCOOH). The vaccine is efficacious in basic preclinical mouse and NHP models over a wide range of heroin doses, accomplishing an important milestone in the drug development process to human clinical trials.4

Based on their work, moving this heroin vaccine into human clinical trials is the next logical step. The impact of a heroin vaccine on the opioid epidemic is exciting but still unclear. Many have argued that a heroin vaccine such as the one presented here is not broad enough to cover all forms of opioid-based drugs including morphine and fentanyl. Others have also stated that opioid addiction is not just about curbing the effects and potency of the drug, but also addressing the underlying factors that contributed to the addiction. Another concern is that a vaccine such as this is only effective for people who want to stop using versus those who do not. All are viable concerns and show the limitations that are inherent in a shot or pill solution for a complicated disease like addiction.

Biopsychosocial model

The biological and genetic impact of the creation of a heroin/opioid addiction vaccine as well as the treatment of addiction from a biological perspective is an important arm of combating the current epidemic as well as addiction in general. However, given the impact addiction has on individuals, families, communities, and nations, we cannot forget the emotional, familial, social, and even spiritual impact of this chronic brain disease on those who suffer and those who love them. A human-centered, multi-pronged approach is needed to effectively identify and treat addiction properly.

A good example of utilizing a multi-dimensional approach can be found in the American Society of Addiction Medicine’s six dimension assessment helping professionals know the appropriate intensity of treatment/intervention services. The six dimensions include:

  1. Acute Intoxication and/or Withdrawal Potential
  2. Biomedical Conditions and Complications
  3. Emotional, Behavioral, or Cognitive Conditions and Complications
  4. Readiness to Change
  5. Relapse, Continued Use, or Continued Problem Potential
  6. Recovery Living Environment.

From ASAM:

The ASAM Criteria structures multidimensional assessment around the six dimensions to provide a common language of holistic, biopsychosocial assessment and treatment across addiction treatment, physical health, and mental health services, which also addresses the spiritual issues relevant in recovery.5

Indeed, a biopsychosocial approach to addiction is not only important in the assessment and decisions regarding level of care, but also all the way along the treatment and recovery support continuum.

The new data about a heroin vaccine working in mice and monkeys is exciting indeed. I look forward to seeing the data and impact of human clinical trials in blocking the drug effects and potency of heroin. Such a vaccine could contribute in saving many lives by reducing relapse and overdoses. I see the day coming soon where a vaccine is utilized effectively in combination with other treatment modalities.

However, let us not forget that substance addiction is complicated in its formation as well as in its treatment and recovery. We must continue to get better in addressing not only the biology of addiction and treatment but also the psychological and social aspects of disease formation and recovery. By addressing all aspects of the disease we have the best chance of interrupting the opioid epidemic and addiction in general.

References

1. Kimball, T.G., (2017). Fentanyl makes the opioid epidemic so much worse. https://thedoctorweighsin.com/fentanyl-makes-the-opioid-epidemic-so-much-worse/
2. Levenson, J., (2017). The opioid crisis is a national emergency—now what. https://www.huffingtonpost.com/entry/the-opioid-crisis-is-a-national-emergency-now-what_us_59d3f222e4b02508a0a07acb
3. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/research-reports/heroin/what-are-immediate-short-term-effects-heroin-use
4. Bremer, P.T., Scholosburg, J.E., Banks, M.L., Steele, F.F., Zhou, B., Poklis, J.L., & Janda, K.D. (2017). Developing a clinically viable heroin vaccine. Journal of American Chemical Society, 139 (25), 8601-8611. httpss://pubs.acs.org/doi/abs/10.1021/jacs.7b03334
5. American Society of Addiction Medicine. httpss://asamcontinuum.org/knowledgebase/what-are-the-six-dimensions-of-the-asam-criteria/

Benjamin Franklin famously observed that “Lost time is never found again,” and every extra minute we take to find meaningful solutions to the addiction crisis, while worthwhile, may mean lives lost.

Recent research from the Centers for Disease Control and Prevention shows that opioids have contributed to a shorter life expectancy in the U.S. From 2000 to 2015, the U.S. saw an uptick in drug-related overdoses, with opioids identified as a major cause.

The net result? A reduction of 3.5 months in life expectancy for someone born in 2015 compared with someone born in 2000. Not surprisingly, opioid overdoses accounted for 2.5 months of that decrease.

But almost no statistic would surprise me, given what I see on a near-daily basis. My current position as Editor-in-Chief of Point of Care Content at Elsevier, where we strive to offer resources that can assist in the diagnosis and treatment of addiction, complements my work practicing addiction medicine at Northland Intervention Center in Milford, Ohio. This combination of roles provides me with a different viewpoint on the Trump Administration’s current efforts, including the recommendations of the Commission on Combating Drug Addiction and the Opioid Crisis.

Reseach Referencing Opioid Addiction (2011-2016)In an earlier article, I offered my opinions on several of the commission’s recommendations, so I’ll continue where I left off.

Related post: Why We Have Shorter Life Expectancy in the U.S.

 

Fighting fentanyl

The commission suggests prioritizing funding and manpower to the Department of Homeland Security’s Customs and Border Protection, the FBI, and the DEA, “to quickly develop fentanyl detection sensors and disseminate them to federal, state, local, and tribal law enforcement agencies.” Additionally, it recommends support for federal legislation “to staunch the flow of deadly synthetic opioids through the U.S. Postal Service.”

Unquestionably, we need more resources to deal with this deadly drug. Since fentanyl is far more potent than heroin, dealers add it to heroin and sometimes totally replace heroin with it. “Customers” love its effect, which can often be fatal, but users are not the only victims. As the New York Times recently reported, “At the children’s hospital in Dayton, Ohio, accidental ingestions have more than doubled, to some 200 intoxications a year, with tiny bodies found laced with drugs like fentanyl.”

While development of fentanyl detection sensors will aid law enforcement in finding the drug in products, conventional urine drug screens at the point of care will not detect fentanyl. Separate testing often has to be done, in addition to the conventional screening. At the supplier level, the commission’s recommended action can stem the supply coming into our country, primarily from China. Decreasing the supply from outside of our borders has the potential to do more to help than decreasing the number of prescriptions being written. As with any criminal enterprise, dealers will find another way to obtain product and develop new analogs that can’t be detected by new sensors. As I write this, there likely is illicit research underway on a different opioid that can be synthesized for a lower price.

Related post: Fentanyl Makes the Opioid Epidemic So Much Worse

 

Enhancing monitoring programs

The commission calls for federal funding and technical support for states to enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs) in an effort to better track patient-specific prescription data and support regional law enforcement in cases of controlled substance diversion. It also advises that federal healthcare systems, including VA Healthcare, participate in state-based data sharing.

Most PDMPs identify any prescriptions for controlled substances obtained by an individual over the past year. This information includes the pharmacy where the prescription was filled, the date, and the provider who wrote it. PDMPs allow providers to determine if there is a pattern of unhealthy opioid prescription use.

In my home state of Ohio, we’ve seen positive results. According to the Prescription Drug Monitoring Program Center of Excellence at Brandeis in its “Briefing on PDMP Effectiveness,” a recent study of emergency departments found that “41 percent of those given PDMP data altered their prescribing for patients receiving multiple simultaneous narcotics prescriptions. Of these providers, 61 percent prescribed no narcotics or fewer narcotics than originally planned, while 39 percent prescribed more.”

When physicians are able to track prescriptions a patient is obtaining, it’s much easier to identify “doctor shopping”. One of the challenges, however, is that a provider must actively query the PDMP, and many providers who are not suspicious or do not have the time due to their huge patient loads may not evaluate the PDMP for every prescription written. While many states allow the PDMPs to be shared with neighboring states, a more effective approach would be to have a national database that can be shared by all. In addition, an alert system for providers that can send alerts when suspicious behavior is suspected, but doesn’t require signing into the system every time, would be extremely beneficial. Another benefit is that medical boards can use PDMPs to identify providers with suspicious prescribing habits.

 

Ensuring a more effective flow of patient information

The commission also urges better alignment, through regulation, of patient privacy laws specific to addiction, “with the Health Insurance Portability and Accountability Act (HIPAA) to ensure that information about [substance use disorders] be made available to medical professionals treating and prescribing medication to a DRAFT 8 patient. This could be done through the bipartisan Overdose Prevention and Patient Safety Act/Jessie’s Law.”

As healthcare professionals know, this is a complicated issue and must be dealt with carefully. While well-meaning privacy laws can sometimes interfere with good patient care, if electronic records were able to “talk” to one another, providers in different locations would have the ability to see potential issues related to addiction. In my experience as an addiction medicine practitioner, family members are often the best source of information and support for those suffering from addiction, and their input is vital. If the information is more readily available, we can identify problems and provide the necessary support earlier and more effectively.

 

Treating addiction like other diseases

Another commission recommendation involves enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA) “with a standardized parity compliance tool to ensure health plans cannot impose less favorable benefits for mental health and substance use diagnoses versus physical health diagnoses.”

There’s no doubt addiction is a disease that is often fatal. As a physician, I have to wonder why it isn’t treated with the same insurance coverage as treatment of other diseases. Some of my patients with private insurance are limited in the number of visits, while some of the patients with Medicaid are not. Additionally, some health insurance covers inadequate treatment that rarely results in long-term sobriety. This often involves a shortened course of treatment and/or lack of comprehensive treatment, including inpatient treatment, medication-assisted treatment (MAT), counseling, and more.

Related post: Addiction is a Chronic Brain Disease, Not a Character Flaw

 

Expanding treatment access to the incarcerated

We need to address the issue of treatment for the incarcerated. According to the Bureau of Prisons, approximately half of inmates in federal prisons are serving time for drug offenses. Among those in state prisons, 16% list a drug crime as their most serious offense.

These statistics likely underestimate the true number of drug-related crimes. Those seeking to fund a drug habit often turn to robbery, and as I have witnessed countless times, violence is often related to intoxication.

While addiction is a disease, leaving it untreated subjects not just the addict, but society in general, to the consequences of the condition. One solution involves treating the disease in our jails and prisons.

I’ve seen examples of locked down treatment centers for inmates and prisons that offer drug treatment, but MAT is not included. While buprenorphine-naloxone (Suboxone), heroin, and other drugs are sold in prisons, MAT is not available. Patients often have to report to jail while in MAT to serve time for an offense that occurred before their treatment. Frustratingly, I’ve seen patients doing well on MAT who are incarcerated in the middle of treatment, and MAT, however successful, abruptly ends. These patients then suffer from withdrawal and are at a higher risk for relapse. When treatment is interrupted in jail, the patient’s tolerance decreases. Upon release, many relapse and use the same amount of drug they used in the past. But with decreased tolerance, they are at higher risk for death.

Offering comprehensive addiction treatment for the incarcerated is, admittedly, a huge undertaking and will require a drastic increase in services and, as a result, an increase in government spending. In my county (Warren County, Ohio), drug court gives selected offenders the choice of 18 months of probation and participation in a strict outpatient treatment program or jail time without treatment. Many choose jail because it is “easier”. Perhaps, there should not be a choice. Or, perhaps, the treatment can occur during incarceration. Inmates are already receiving room and board and are a “captive audience”. By providing counselors, physicians, and other members of the treatment team increased access to jail treatment, such an approach should increase the chance of long-term sobriety and, for many, end the revolving door of addiction and imprisonment.

Ultimately, we’re faced with a choice of saving money or saving lives. And as a physician who works with the addicted in Ohio and someone providing resources to clinicians treating others, I find that the choice could not be clearer. In the end, if more people achieve long-term recovery, we may accomplish both.


Here is a link to other TDWI posts on substance abuse and addiction.

It is popular to talk about the decline of both American education and the country’s healthcare system as though the failings are intrinsic to the people working in them.

For instance, one common refrain holds that doctors are in the pocket of Big Pharma. Supposedly, they are over-prescribing and driving up costs for their own enrichment. At the same time, they fight quality measures because they would rather be paid for volume than reimbursed for their actual clinical performance.

In a similar spirit, a certain peanut gallery asserts that teachers hide behind standardized testing and combat meaningful quality measures because they don’t want to be held responsible for failing children. Public schools are letting the country down by protecting teacher tenure at the expense of hiring competent, effective instructors.

In both cases, entrenched interests like unions and professional associations exert outsized influence to delay change and fight accountability; government is both overly involved and ineffective at everything it attempts, while hard working American families who depend on these institutions are left paying for more than they get.

And so on.

The common thread seems to be that academic and medical professionals are somehow inept, corrupt, and/or fighting efforts to measure and compare their outcomes. The public, meanwhile, is at a loss to hold these ivory-tower dwellers to any standards of quality, efficacy, or affordability. Outcomes suffer, families pay, and the doctors and teachers of the world cash paychecks they don’t always earn. Everyone responsible for the problems in medicine and in education can be found working in their delivery; the people on the receiving end are blameless victims.

You don’t have to personally know a teacher or a physician to recognize that such vitriolic rhetoric is utter bunk. At best, they miss the whole point of measuring performance and devising qualitative metrics. At worst, they foment hostility, ignorance, and blame-shifting that does more to increase the problem than address it.

 

Fix this: The trouble with making the wrong demands

Parent-teacher relationships are fraught with difficult conversations in part because they have very different expectations for, and encounters with, the students. These often center on issues where parents aren’t taking ownership of behavioral and learning problems that exist in the classroom, but aren’t always apparent at home. Sometimes the relationships teachers have with students devolve into antagonism, rather than partnership: students expect or demand high grades, rather than working to earn them. Parents, more often than not, reinforce these demands, putting more pressure on teachers to acquiesce than on students to perform.

Doctors, likewise, must also have difficult conversations with patients about treatment and outcomes. Amazingly, patients demonstrate a similar tendency to pressure providers into writing prescriptions, ordering tests, and designing care plans according to patient demands, rather than clinical standards. Just as academic administrators often capitulate to student and parent pressure, so do medical administrators, preoccupied with satisfaction scores and reputation management, side with unreasonable patients against providers.

We have institutionalized a pattern of letting patients and students set expectations that relieve them of all accountability and which holds doctors and teachers to similarly unreasonable standards. We expect these professionals to take each and every case, no matter how far behind or out of compliance, and “fix” it. Teachers must take students years behind their classmates in literacy or social skills and get them up to speed by the end of the academic year. Doctors must suspend evidence-based practices and deliver care that meets patients’ expectations (formed in advance of soliciting clinical advice) while simultaneously curing them of all ills.

Matters of lifestyle are to be ignored once a patient sets foot in the exam room, or a student takes a seat behind a desk. The critical inputs of upbringing, maintenance, and personal responsibility, despite constituting the majority of time in an individual’s life, are given less importance than the discrete, limited encounters that occur at school or in the clinic.

 

The alternative isn’t victim blaming

In the case of both education and healthcare, the most important predictors of success are not what happens in the exam room or the classroom, but what goes on at home. That isn’t to say that teachers and caregivers have no responsibility, impact on quality, or obligation to those they serve. It does, however, suggest that measures of quality that focus entirely on one setting can never capture the full picture.

We know, for instance, that the most important and effective predictors of academic success—across all racial, economic, and geographic lines—is their home environment: whether or not parents are reading to their children, express the value of education, prioritize learning or academic achievement, or reinforce such attitudes. Just reading to a baby even before literacy is on the menu helps in brain development, socialization, and lays a foundation for future learning.

The point of studying and emphasizing this correlation isn’t to put the blame on parents for not being around enough, not reading to their kids, or failing to be effective teachers as well as breadwinners and role models. It is simply to remember that it is at least as unreasonable to expect teachers outside the home to be capable of wearing all these hats, yet that very expectation seems to inform how we approach teacher evaluations and the public image of schools. They are meant to do everything that parents are better positioned and traditionally responsible for doing, and they are expected to do it better with less face time than parents.

Doctors arguably face an even worse status quo. They face liability for undesirable outcomes, whether that takes shape as a low patient satisfaction score or incidences of morbidity and mortality. Physicians and other caregivers face the impossible task of taking ownership of clinical standards and best practices while having to placate a consumer mentality that has no basis in medical literacy. The result is that even as opioid abuse and dependency grow, doctors face unrelenting pressure to give patients whatever drugs they ask for.

 

From assigning blame to embracing influence

While it might help relieve some of the pressure on teachers and providers, simply shifting all the culpability back outside their places of work is not the answer. The average encounter between a doctor and a patient may only be 15 minutes, but those are 15 hyper-critical minutes. Teachers may have hundreds or even thousands of students among whom they must divide their attention and mediate their influence on a given school day, but they still have a disproportionate opportunity even in this environment to instruct and inspire.

Addiction is almost a perfect case study for how multiple factors need consideration in treating or changing behavior.

Because addiction is a disease, it is not always possible for either physicians or patients to prevent it. As a disease with strong genetic risk factors, there is little value in assigning blame to anyone or anything, be it behavioral, environmental, or chemical. Doctors have little basis to expect patients to simply change their behavior and stop being addicts; in the absence of genetic editing capabilities, addict patients have little basis to expect their doctors to simply “cure” them of their addictions.

That leaves both providers and patients—not to mention patients’ families—with the prospect of treating recovery as a partnership. Both sides share some measure of responsibility for the outcome, but neither can reasonably escape accountability for whatever outcomes emerge.

The notion of student-teacher relationships or doctor-patient relationships as partnerships is not especially novel. In the current atmosphere of blame, distrust, institutional misalignment, and unreasonable expectations, however, it may be a concept we collectively need to revisit. Teachers and caregivers are experts. As experts, they are held to high standards, and those standards should be both achievable, and measurable. The populations they serve have a right to know those standards, but they also have a responsibility to recognize their own role in both creating and reaching those standards.

We can’t set collective expectations for quality, value, or accountability without first accepting the partnerships which underly our healthcare and educational systems. Without them, both blame and praise are just so much more noise distracting us from meaningful work and achievement.

We are in the midst of an opioid epidemic. Since the turn of the century, we have seen a sharp increase in the number of overdose deaths and the manifestation of opioid addiction, a powerful chronic brain disease. The presence of the drug fentanyl is pushing the opioid epidemic into uncharted territories. Fentanyl, a synthetic opioid pain reliever, is a dominant catalyst of this outbreak due to its potency and alarming prevalence.

 

Why is “the opioid epidemic” considered an epidemic in the first place?

It is commonly accepted in the medical field that the steep rise in opioid addiction across the nation should be and is considered an epidemic. The President has recently called the opioid epidemic a national emergency. However, it seems that some people still have their doubts.

According to the Center for Disease Control and Prevention (CDC), an epidemic is “an increase, often sudden, in the number of cases of a disease above which is normally expected.”1 Some of the most infamous and deadly epidemics in human history include polio, AIDs, The Black Death, and malaria, causing the deaths of countless individuals.2

There are several specific factors that can increase the probability that an epidemic may manifest in the general population. The most applicable factors to the opioid epidemic include the following:

  1. a recent increase in the severity or harmfulness of a disease or poison (e.g., the potency of fentanyl),
  2. an introduction of a new agent into the environment (e.g., fentanyl), and
  3. factors increasing individuals being exposed (e.g., the prevalence of fentanyl).

In most cases, epidemics refer to “infectious agents” but also can apply to chronic diseases such as diabetes, obesity, and addiction in this case.1

Experts estimate that each day over 100 people will die from opioid overdoses in the United States. We have seen these numbers quadruple since 2000 with over 500,000 now dead from opioid overdoses. The increase in opioid overdoses is directly tied to the increase of prescription opioids administered legally and illegally by healthcare providers (both responsible and irresponsible) and others illegal manufacturers and distributors.3 Although the disease of addiction has taken countless lives over the history of our country, the opioid epidemic, now fueled by fentanyl, is alarming and disturbing.

 

The journey to addiction and the problem with fentanyl

The journey to the manifestation of the chronic brain disease of addiction can be illustrated by the following graphic. As can be seen, the journey starts with abstinence. Most people take the next step to experimenting with alcohol or some other drug. The experimentation of a potentially addictive substance (such as alcohol, marijuana, or something more powerful such as heroin) can lead to abuse, dependency, and eventually addiction. Once manifested, the disease of addiction most often has a sharp decline in the potential of the disease to be fatal. Many addicts die from overdose during a relapse that follows a period of recovery. Others may overdose by mixing drugs, using a drug in a manner they had not previously used before or using a known drug laced with something else. How quickly someone moves from experimentation to addiction is a product of several factors including genetic, environmental, and psychological.4

Fetanyl and the Opioid Epidemic

Addiction death at any stage

One of the scariest factors increasing the opioid epidemic and opioid-related deaths is the introduction of fentanyl. Its potency and prevalence place many individuals at risk of not only moving down the continuum to addiction more rapidly, but also increasing the risk that death may occur not only after the disease manifests but at any time within the continuum, including experimentation.

 

The potency of fentanyl

The potency of fentanyl cannot be understated nor taken lightly. According to the CDC, overdose deaths involving the presence of synthetic opioids including fentanyl, increased by 72% from 2014 to 2015.7 The potency of this painkiller and anesthetic increases the severity or harmfulness for individuals exposed. On April 1, 2016, the United States Drug Enforcement Administration issued this Public Safety Alert regarding the dangers of fentanyl.

Fentanyl, a powerful synthetic opioid, has been linked to multiple overdoses and deaths throughout the Sacramento region since last week. The overdoses are occurring at an alarming rate and are the basis for this public safety alert. Fentanyl is an odorless substance considered to be 25 to 50 times more potent than heroin and 50 to 100 times more potent than morphine. Fentanyl is potentially lethal, even at very low levels.5

In a groundbreaking documentary titled, Death by Fentanyl, Cristina Constantini, Darren Foster, and Mariana Van Zeller explored the increase of all types of fentanyl in the United States and how the potency of fentanyl is fueling the opioid epidemic. In Mexico, these investigative filmmakers were in Sinaloa interviewing heroin manufacturers and traffickers. They were told that no one was making pure heroin anymore because “fentanyl-laced” heroin was so much more potent. This fascinating and disturbing documentary is certainly worth a watch.6

 

The prevalence of fentanyl

The prevalence of fentanyl within the drug market is astounding. It is important to note that most of the fentanyl overdoses and deaths in our country are linked to illegally made fentanyl. Unbeknownst to the consumer, fentanyl is mixed most often with heroin, sometimes with cocaine, or made to look like painkillers in pill form. Although potentially fatal, the presence of fentanyl increases the high for the user.

The prevalence of fentanyl in our country is manifest by the significant increase in law enforcement seizures of the drug. For example, the number of seizures of fentanyl has increased seven times in the last few years.7 Suffice to say we have a drug market flooded with fentanyl fueling the epidemic.

 

Where is it coming from?

The deadly combination of fentanyl-laced heroine not only originates in Mexico, but also in the U.S. by way of China. U.S. manufacturers are securing chemicals from China and cooking it themselves. At times, raw fentanyl is being shipped directly from China. If not Mexico or China, prescription fentanyl made in our own country is being mixed with heroin to form this deadly combination.

According to StatNews:

“When it comes to the illegal sale of fentanyl, most of the attention has focused on Mexican cartels that are adding the drug to heroin smuggled into the United States. But Chinese suppliers are providing both raw fentanyl and the machinery necessary for the assembly-line production of the drug, powering a terrifying and rapid rise of fatal overdoses across the United States and Canada, according to drug investigators and court documents.”8

 

Conclusion

We are certainly in a midst of an addiction outbreak, an opioid epidemic. People are dying every day from fentanyl-laced heroin, possibly people we care about. The potency of the drug and its prevalence within our country is fueling the epidemic and putting all types of people at risk. People who are at risk range from those who experiment with drugs, those who have the disease of addiction, and everywhere in between. We, as a society, must not only be educated to its potency and prevalence, but also take meaningful action to combat the epidemic. Meaningful action comes in the form of prevention, advocacy, and intervention at all levels of our society. Be educated, advocate, and find out actions you can take to help.

For community ideas to combat the opioid crisis, go to https://icma.org/articles/9-ways-fight-opioid-crisis-your-community.9


References:
1. Center for Disease Control and Prevention: https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section11.html
2. Health Care, Business, and Technology: httpss://www.healthcarebusinesstech.com/the-10-deadliest-epidemics-in-history/
3. Center for Disease Control and Prevention: https://www.cdc.gov/drugoverdose/epidemic/index.html
4. Shumway, S.T. & Kimball, T.G. (2012). Six Essentials to Achieve Lasting Recovery. Hazelden.
5. United States Drug Enforcement Administration: https://www.dea.gov/divisions/sf/2016/sf040116.shtml
6. Death By Fentanyl: httpss://interactive.fusion.net/death-by-fentanyl/index.html
7. Center for Disease Control and Prevention: https://www.cdc.gov/drugoverdose/opioids/fentanyl.html
8. State News: https://www.statnews.com/2016/04/05/fentanyl-traced-to-china/
9. International City/County Management Association: https://icma.org/articles/9-ways-fight-opioid-crisis-your-community

While the term “existential crisis” sometimes gets overused, it’s no exaggeration in describing the current epidemic of opioid addiction gripping our nation.

The disease of addiction has claimed so many young lives and shows no signs of relenting. Today, overdoses are the leading cause of death in Americans under the age of 50.

In 2005, nearly 15,000 Americans died of an opioid overdose. But in 2015, U.S. fatalities more than doubled to 33,000, with Ohio accounting for 2,700 of those deaths—more than five times the state’s 2005 total.

The Opioid Epidemic in America by Elsevier

As an Ohio resident, I see a state reeling from the crisis. News outlets regularly report on Montgomery County, which is tragically gaining a reputation as the “overdose capital of America”. Bodies pile up at the county’s morgue, with the coroner estimating that 60-70% of them are due to opioid overdose.

As a medical toxicologist and emergency medicine physician practicing addiction medicine at Northland Intervention Center in Milford, Ohio, I have witnessed the damage first-hand.

Last month, President Trump declared the opioid epidemic a national emergency, acting on an interim report from the special Commission on Combating Drug Addiction and the Opioid Crisis. Besides recommending the declaration, the commission also proposed several other actions.

In addition to my work at Northland, I also serve as the Editor-in-Chief of Point of Care Content at Elsevier. Our goal is to offer substantial resources that aid in the diagnosis and treatment of addiction and to provide extensive information to families and caregivers of those who suffer from this disease. Between my roles at Elsevier and Northland, I believe I can offer a unique perspective on each of the commission’s recommended actions.

 

Eliminating barriers to treatment

The commission recommends rapidly increasing treatment capacity and granting waiver approvals for all 50 states to quickly eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases DRAFT 3 exclusion within the Medicaid program. This will immediately open treatment to thousands of Americans in existing facilities in all 50 states.

But the Medicaid program has strict limitations on the coverage of inpatient treatment for mental diseases, preventing many of those suffering from addiction from receiving inpatient treatment. Almost all of my patients have access only to outpatient treatment, leaving many of them to return to dangerous situations and environments every day. The risk of relapse in uncontrolled settings is much higher, and with the emergence of fentanyl and its analogs being mixed with most of the heroin, a single relapse is frequently fatal.

While expanding coverage for inpatient stays is a commendable goal, finding open beds will likely be a challenge. Providing additional money to pay for a service won’t help if there is no access. Most drug treatment inpatient centers have long waiting lists, so perhaps more existing hospital beds could be opened for patients suffering from addiction rather than looking only to dedicated treatment centers. This would require hospitals to increase resources and provide more specialized treatment. More funding will also be required to build additional inpatient treatment centers to meet the increasing demand.

The commission also suggests mandating prescriber education initiatives with the assistance of medical and dental schools across the country to enhance prevention efforts along with mandating medical education training in opioid prescribing and risks of developing a substance abuse disorder. This could be done by amending the Controlled Substance Act to require all Drug Enforcement Administration registrants to take a course in proper treatment of pain. Furthermore, the U.S. Department of Health and Human Services should work with partners to ensure additional training opportunities, including continuing education courses for professionals.

 

Medication-assisted treatment

Another commission recommendation is to immediately establish and fund a federal incentive to enhance access to Medication-assisted treatment (MAT) and require that all modes of MAT are offered at every licensed MAT facility and those decisions are based on what is best for the patient. The commission also suggests partnering with the National Institutes of Health and the industry to facilitate testing and development of new MAT treatments.

Medication-assisted treatment has been shown to be very effective when used appropriately, and there is a clear need to increase access to it. However, there are not enough trained and authorized providers to provide what is required. Many of the currently approved providers only administer MAT without providing any of the other services required to increase the chance of long-term sobriety. Primary care physicians with a DEA number can be “trained” to administer MAT and can add revenue to their practices by seeing these patients. The added revenue entices many to participate, but many have no experience in addiction medicine.

I do fear that with an over-reliance on MAT, we are simply replacing “pill mills” of the past with “strip mills” (buprenorphine often is in a soluble strip formulation). If a provider can make a substantial amount of money by seeing patients monthly and refilling prescriptions without ensuring other aspects of treatment, this presents a yet another new problem to solve.

 

Legislative solutions

Providing model legislation for states to enact is another commission recommendation. Such legislation would allow naloxone dispensing via standing orders, as well as require the prescribing of naloxone with high-risk opioid prescriptions. This is, as the commission writes, an effort to “equip all law enforcement in the United States with naloxone to save lives.”

In addition to providing naloxone to those at high risk of opioid overdose, the drug also should be readily available to family and friends of those at risk, including known opioid addicts and patients on high-dose opioid treatment. We also need to consider having naloxone available at public places, like airports and shopping centers, as we do for defibrillators. Librarians in Philadelphia describe “drug tourists” overdosing in the restrooms as heroin addicts flock to the city to find more potent drugs. But in response, the city’s librarians are armed with naloxone and conduct overdose drills.

Despite naloxone’s impact, some still oppose its use, particularly multiple doses in a patient who has had multiple overdoses. This is another unfortunate manifestation of a belief that addiction is a moral failing and not a disease. It’s also something we don’t observe in relation to other diseases. If a patient returns to the emergency department multiple times with an exacerbation of emphysema, we don’t limit the number of breathing treatments we give because the patient continues to smoke. Why should the administration of naloxone be any different?

 

Patience and persistence is required

We need to understand that opioid addiction is a multifactorial problem with multifactorial solutions. This crisis didn’t appear overnight and neither will any meaningful solutions. While President Trump’s declaration of emergency should produce more available resources, let’s hope the resulting action isn’t mired in a tangle of red tape. If there are more bureaucrats involved in the administrative aspects than there are addicts getting help, we are fighting a losing battle.

We must recognize that changing prescribing habits may be beneficial for the future, but unlikely to help those already in the throes of addiction. Educating the public, recognizing that addiction is a disease, and providing access to more effective treatment are all weapons we can use in this fight. We also need to arm ourselves with knowledge about the history of this crisis. At one time, the government mandated more extensive treatment of pain and linked reimbursement to the effectiveness of pain management. Every patient was asked about pain and told to choose a number on a pain scale. The faster that pain was treated, the more hospitals and providers were paid.

The idea that suddenly reversing this attitude will do much to curb our current problem is impractical, at best. If clinicians hadn’t been given such wide latitude in treating pain, things might be different in my state and across the nation. But limiting opioid prescribing has caused the price of prescription opioids on the street to skyrocket as availability decreased. This change in supply and demand hasn’t caused a sudden surge in addicts seeking treatment centers. Instead, it forces them to find a cheaper, more potent, and widely available alternative: heroin. The law of unintended consequences runs rampant when one looks at the history of this epidemic.

There must be increased discussion of alternatives to opioids in the treatment of pain, which can help to decrease the triggering of addiction. Chemical dependency can be triggered by appropriate or inappropriately prescribed medication: The disease of addiction does not know the difference. Unless we can prevent surgery, accidents, broken bones, and other common sources of pain, opioids will be hard to avoid, and without government working efficiently and effectively with physicians, hospitals, social workers, and families, it will be impossible to prevent opioid addiction.


Click the link to read Part 2 of Dr. Dye’s examination of the federal response to the opioid crisis.


Here is a link to other TDWI posts on substance abuse and addiction.

The American Society of Addiction Medicine defines addiction as “a primary, chronic disease of brain reward, motivation, memory, and related circuitry.” They characterize it as the “inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.” In this day and age, this can be applied to far more than just drug and alcohol abuse.

This definition and characterization can also be applied to certain individuals’ behavior as it pertains to something as commonplace as food, or shopping, or watching TV. Therefore, even if you’ve never touched drugs or alcohol before, you can still be an addict.

Addiction is often born of a need to escape certain stressors or circumstances. It can also be caused by the need to feel a certain high or rush that is hard to find in anything else. More often than not, addiction is merely a symptom of a number of other underlying issues such as depression, PTSD, anxiety, and so on.

Addiction is a chronic disease, which means that it is a condition that you will have to learn to manage for quite a long time. There is no one-stop shop when it comes to sobriety as there are many layers of healing that need to be dealt with in order to reach true success. Fortunately, there are many strategies that you can comfortably combine to help you get there.

1. Find your tribe

This may sound silly but it is very important that you surround yourself with people that are not only supportive but also trying to better themselves.

As human beings, it is completely natural and even vital to our well being to feel like we are not alone. For someone who is fighting addiction, this is a crucial step. There are many safe spaces for recovering addicts where you will not be judged but rather celebrated for making the effort to reach sobriety and live a more fulfilling life.

Alcoholics Anonymous and Narcotics Anonymous are just two of the free, accessible options available. You can also find the kind of people that may benefit you by engaging in some of the other methods of beating addiction that you will find below.

2. Get moving

Most addicts are not very active people; many find themselves feeling tired and sluggish all the time. Lack of activity, the desire to lounge around all the time, or not wanting to be productive may further dependence on the addiction.

Regular exercise in any form has been proven to boost confidence and resolve in recovering addicts. It is a healthy way to stay busy, get stronger, build your focus, de-stress, get better sleep, and help you feel much better about yourself. When you stop using drugs or consuming alcohol, the body has strong urges and craves the highs that it is used to experiencing. Intense exercise stimulates the body to release certain chemicals, such as endorphins and probably, more importantly, endocannabinoids, that produce a euphoric sensation often called “runners high.”

Related: 6 Reasons Why Exercise Helps During Addiction Recovery

You don’t have to go to a gym to work out or exercise in the more traditional sense (e.g., with cardio, weights, and such things). It all depends on your comfort level and what works for you. Yoga is an excellent choice for recovering addicts because not only does it help strengthen, increase flexibility, and create a greater sense of awareness between you and your body, but it also helps change the way your mind, body, and spirit respond to different situations. It can help reach a level of peace with yourself as well as with others.

3. Actively clear your head

Beating addiction is about more than just stopping the intake of drugs and alcohol. It’s about treating and attempting to heal the different factors that lead to substance dependency. Anxiety, stress, anger, and sadness are all negative feelings that can encourage an addict to stay stuck in the same cycle.

In order to get out of the cycle, you have to find effective ways to manage both highs and lows in life. There’s no way to completely avoid intense feelings and emotions. There are, however, ways to react to them in a healthier manner.

Meditation is a method that has helped many people, such as addicts, to manage their headspace. Setting aside some quiet time for yourself with some relaxing music or even a guide to give you a bit of direction during meditation allows you the opportunity to introspect and patiently work through feelings and emotions. This, in turn, will help you learn how to better react to triggers and negative stimuli as they happen. You can learn to master your emotions instead of them letting them take control of you.

The idea of meditation can be daunting, but there are several ways to do it that don’t involve sitting with your eyes closed for half an hour while holding your hands in unfamiliar gestures. The objective when meditating is simply to focus your mind and attain a sense of peace. This can be done through activities as well.

For example:

Gardening/Pet therapy:

Gardening or taking in a pet gives you an opportunity to care for something other than yourself. Often, people are more inclined to take better care of themselves when they know that they are responsible for other living things that count on them.

The slow, pensive, and gentle act of gardening helps bring those qualities into the way you treat yourself. Studies show that taking care of an animal or plants also helps to naturally reduce pain and stress hormones, lower anxiety, and even help you get a better night’s rest.

Art/Music therapy:

Learning to or simply creating works of art and music is a great way to express yourself without causing any harm to yourself or anyone else. Being able to vent feelings that you are not comfortable sharing out loud and ending up with something beautiful helps appreciate all parts of life without feeling overwhelmed by negativity. Art and music therapy have also been known to boost self-confidence and lower anxiety levels.

4. Vitamins and supplements

Addiction takes quite a toll on your health affecting everything from your liver, to your nutritional needs, and your sleep. Both the toxic effects of drugs and alcohol, as well as lack of proper nutrition and rest, cause a decrease in organ function which means your body isn’t able to absorb vitamins and nutrients as well as it should. This also results in irritability, mood swings, and heightened sensitivity which in turn adds to the want to use.

Some addiction specialists recommend taking certain vitamins and supplements during the initial phases of recovery. The strength of the scientific evidence to support these recommendations varies as you will see when you click on the links below:

  • Omega 3

Community Addiction Recovery Association’s executive director, Carolyn Reuben, believes that addiction, along with other psychological disorders, can be caused by the body’s reaction to some nutritional deficiencies. Omega 3 is an essential part of a balanced diet. Omega 3 essential fatty acids also help treat anxiety, depression, and mood stabilization, ease inflammation, and improve nerve communication.

  • Vitamin B Complex

Post-Acute Withdrawal Syndrome is something that many people experience right after the initial detox. The symptoms include depression, insomnia, cravings, memory problems, obsessive-compulsive behavior, and pessimistic thoughts.

Thiamine (B1) is found in many brain functions and will help with memory, thought process, and other brain-related symptoms. Pyridoxine (B6) helps produce the chemicals in the brain that aid in getting better sleep and lowering anxiety. Vitamin B12 also helps the digestion system so that your body can start processing the nutrients you consume more effectively.

  • Minerals

People recovering from addiction generally don’t have very good eating habits. Poor eating habits lead to poor organ function which then leads to poor nutrient intake. This may result in a mineral deficiency. Calcium and magnesium help encourage mood stability and improve nerve function, muscle, and bone health.

Potassium and selenium help improve heart health and lower blood pressure. Zinc helps to improve the liver, immune system, and brain functions. Iron helps to decrease headaches, depression, and tiredness. These are some of the more common mineral deficiencies found in recovering addicts.

  • Amino acids

Amino acids are key to all metabolic processes; they essentially transport and store all nutrients. Taking amino acid supplements can help reduce cravings and restore brain chemistry. There are certain amino acids that have been successful in helping recover from various addictions. For example, L-glutamine for alcohol; L-phenylalanine or L-tyrosine for caffeine, cocaine, methamphetamine, crack, tobacco and alcohol; and D-phenylalanine for marijuana, heroin, tobacco, and alcohol among various others.

The final caveat about vitamins and supplements is that we know that most people can get everything they need from a healthy, balanced diet, such as the Mediterranean diet. And, there is evidence that getting these nutrients in the context of food is better than taking them as individual substances in a pill.

5. Holistic healing

There are also a few unconventional, natural options that can help with both the physiological and psychological ailments found in recovering addicts. Aromatherapy, teas, and massage oils are all viable options. There are also specific herbs when used by themselves or in combination with each other, that can help attain a successful and long-lasting recovery.

Kudzu is a Chinese plant whose extracts have proven to fight cravings in alcohol addicts. It can be found in powder and pills in most health food stores.

Ginseng, Ashwagandha, and Rhodiola are all herbs that are said to help support adrenal function. During withdrawal, addicts undergo heightened amounts of stress which causes adrenal burnout from producing so much of the body’s stress hormone, cortisol. Supplementing with these herbs may decrease withdrawal symptoms and promote long-term sobriety.

Valerian, Passionflower, Lemon Balm, and Skullcap are used to help calm anxiety, soothe the nervous system, reduce stress, encourage relaxation, and aid in getting better sleep. They target a number of ailments that recovering addicts suffer while in the withdrawal stage.

Difficulty sleeping is a vexing problem for many recovering addicts that should be addressed. According to a review by the National Heart, Lung, and Blood Institute,

“Studies…show that sleep deficiency alters activity in some parts of the brain. If you are sleep deficient, you may have trouble making decisions, solving problems, controlling your emotions and behavior, and coping with change. Sleep deficiency also has been linked to depression, suicide, and risk-taking behavior.”

All of these brain changes can interfere with a successful recovery.

The National Sleep Foundation provides these tips to help improve sleep.

Addiction is a treatable disease

The most important thing to remember is that addiction is not a personal choice or a sign of weak moral standing—addiction is a treatable disease. It is a little more personal than most but it is important that the focus be on healing and treating the causes and symptoms rather than placing blame. It’s a long road ahead but with support and dedication, it can most definitely be done.


Related stories: You can find all of TDWI’s posts on addiction here

The words alcoholism and addiction are laced thick with stereotype and myth. Those who suffer from this brain disease feel the impact of stigma on a daily basis. Highly marginalized, many suffer too long without reaching out for help because of the fear of being misunderstood and unfairly labeled. Even in recovery when healing is taking place, individuals and families often hide their membership in the community of recovery from others due to not wanting to face harsh judgment.

For many, the marginalization of suffering from addiction is only part of the stigma and stereotype people face. Often, those who suffer from addiction are members of other marginalized groups based on several socioeconomic, cultural, and psychological factors. The journey of recovery is difficult enough without also being marginalized and misunderstood. We, in the medical and mental health professions as well as society as a whole, can learn much from the journey of those in recovery who not only suffer from addiction but who also experience multiple layers of marginalization and find healing anyway.

Addiction among Native Americans

One common example of an entire culture of people who have experienced strong bias, stereotype, myth, and marginalization on multiple levels are Native Americans (NA). This is particularly true as it relates to NAs and alcoholism. For hundreds of years, the world has believed NA cultures are particularly vulnerable to alcoholism and their prevalence of alcohol use far exceeds other populations by comparison. Research studies comparing alcohol use rates illustrate this long held belief may be highly exaggerated or altogether inaccurate.

In a recent study entitled, “Alcohol Use Among Native Americans Compared to Whites,” researchers Cunningham, Solomon, and Muramoto (2016) found that NA’s had a lower rate of drinking compared to whites. Their findings are revealing, to say the least. To reach their conclusions, they studied a number of recent government surveys assessing prevalence of use on the continuum from abstinence to excessive/severe use. Surveys utilized for the study included the National Survey on Drug Use and Health (NSDUH; 2014), the Behavioral Risk Factor Surveillance System (BRFSS; 2014), and other indicators. Upon examining the National Survey on Drug Use and Health they found the following:

  • 60% of Native Americans abstained from using alcohol altogether compared to 43% of whites.
  • Almost 15% of Native Americans were light/moderate drinkers compared to almost 33% of whites.
  • Native American binge drinking estimates were 17.3% similar to their white counterparts—16.7%.
  • Heavy Drinking was also similar with Native Americans at 8.3% and whites at 7.5%.

These results were further confirmed by the Behavior Risk Factor Survey.

As the numbers comparing Native Americans and Whites provide evidence for, addiction impacts individuals, families, and communities at an epidemic rate regardless of age, gender, race, culture, religion, socio-economic status, sexual orientation, etc. The truth is approximately 10% of the population 12 years and older meet the criteria for intensive substance use treatment and most likely suffer from the brain disease of alcoholism/addiction (NIDA).

Native American addiction treatment models

Often cultural differences and insensitivities make it hard for marginalized groups to access and do well in traditional healthcare or treatment models. Despite this, Native American cultures have a long history of helping those who suffer find recovery through combining modern techniques with long held tradition.

In an effort to combat the disease and to help those who suffer find long-term recovery, let’s examine a few ideas/efforts Native Americans have utilized successfully to combat this epidemic:

Wellbriety

Wellbriety is a term and a movement that began in 1994 to assist Native Americans who needed healing and recovery. From the website www.wellbriety.com:

The Wellbriety Movement is an interconnected web spreading across our Native Nations carrying the message of cultural knowledge about recovery for individuals, families, and communities. The web is a live entity that was born out of the work that White Bison created after the Elders told about a healing time that has come.

Wellbriety is more than just being clean and sober from alcohol and other drugs. It is the pursuit of growth and wellness. Wellness is achieved through a balance of the mental, physical, spiritual, and emotional parts of ourselves. This journey can only be made when one is connected to important values and natural laws. The sufferer must return to their culture for healing to take place. In a sense, return to what and who they know including themselves and themselves connected to others embedded in a culture of healing.

Coyhis and Simonelli (2008) in their work entitled, “The Native American Healing Experience,” make this strong case:

“For many Native Americans, [Wellbriety] also means recovering culturally. Return to the culture is a vision embraced by many American Indians as integral with addictions recovery. It signifies a desire to live through the best attributes of traditional Native cultures while standing firmly on the ground of contemporary life. Non-Native recovery approaches often look at addiction as an individual disease, ignoring the social, political, or economic roots of addiction. The indigenous experience adds a dimension of acknowledging sociopolitical causes without removing an individual’s need to do the hard work it takes to heal. This is new, culturally specific thinking that can also add to the field of mainstream recovery knowledge.”

Coyhis and Simmonelli (2008) go on to describe four important laws of change given to them by a Native American Elder in New Mexico in the 1980’s that are the root and beginning of the Wellbriety Movement. In my opinion, these laws of change have broad application to our pursuit to help others from all types of cultures, communities, and nations find recovery. These laws of change include:

  • Change is from within

Change from within is not only about being ready to change but also being willing to change. From someone to heal in recovery, they have to be willing to examine their own thoughts and also their connection to others.

  • In order for development to occur, it must be proceeded by a vision

Having a vision means to have some idea where you would like to be in the future. It is a hopeful vision. In this idea of vision, those who are part of the healing community (e.g., family, friends, community) share thoughts and ideas about what they see in the future. This vision is about a better life and future for all involved.

  • A great learning must take place

A great learning implies that the community surrounding the sufferer must take part in the discovery and learning for wellness to occur. Acting as an “integrated whole”, real healing and learning can take place (Coyhis & Simmonelli, 2008).

  • You must create a healing forest

Creating a healing forest is the culmination of the Laws of Change anchoring the pursuit of Wellbriety. In order to understand the healing forest metaphor, you must know the healing forest story. As recounted by Coyhis and Simonelli (2008):

Suppose you have a hundred-acre forest and in that forest, there is a disease or sickness. All the trees are sick. It is a sick forest. Suppose, then, you go to that forest one day and you take one of those sick trees and temporarily uproot it and put it under your arm. You walk down a road and you put it in a nursery where there is good soil. …So now, you have this tree in good soil, and it becomes healthy because it is getting sun and rain. It is getting well. It is turning green. You get this tree to be well and then you take this well tree back to the sick forest. What happens if you take a well tree back to a sick forest? It gets sick again (Simonelli, 1993; White Bison, 2002).

Healing the addiction epidemic

It should not be lost on anyone that in today’s acute treatment environment, we often take individuals who suffer from the disease of addiction out of their communities, stabilize them, and then send them back to their environment. We send them back without providing extended recovery support or help to the original soil—family, friends, and communities. No wonder so many people who come out of treatment immediately fall back into use and unhealthy patterns of behavior.

It is past time for a “great healing” to take place throughout our society. Healing from the disease of addiction starts when we are willing to change ourselves from within—all of us.  Our entire nation needs to embark on a great journey of learning and growing. What holds us back is seeing the vision of what we, when united, could do together as healthcare providers, policymakers, third-party payers, communities, and families. We must amend the soil of our community and our nations so it is good again. Until we do this, many more of those we love will continue to suffer and die from the disease of addiction/alcoholism.


References:

1. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013National Survey on Drug Use and Health: Summary of National Findings. Substance Abuse and Mental Health Services Administration, Rockville, MD.

Here is a link to other TDWI posts on substance abuse and addiction.

President Trump’s special Commission on Combating Drug Addiction and the Opioid Crisis released an interim report on July 31, 2017 that detailed its recommendations for dealing with the epidemic. In a letter to the President, the Commission stated,

“Our nation is in a crisis….Our citizens are dying. We must act boldly to stop it.”

It also declared that the “first and most urgent recommendation” of the Commission is for the President to declare a national emergency under the Public Health Service Act or the Stafford Act. This would free up funding and other resources to deal with this epidemic that is killing 142 Americans every day. The Commission’s letter went on to make a personal plea saying,

“You, Mr. President, are the only person who can bring this type of intensity to the emergency and we believe you have the will to do so and to do so immediately.”

Initially, President Trump failed to declare a national emergency. Instead, according to the Washington Post, he said,

{The} “best way to prevent drug addiction and overdose is to prevent people from abusing drugs in the first place.”

“If they don’t start, they won’t have a problem. If they do start, it’s awfully tough to get off,”

“So if we can keep them from going on—and maybe by talking to youth and telling them: ‘No good, really bad for you in every way.’ But if they don’t start, it will never be a problem.”

Yeah, right. That approach worked so well during Nancy Reagan’s War on Drugs that we really ought to try it again.

ADD_THIS_TEXT
 

Thankfully, two days later Trump did declare the opioid crisis a national emergency. Hopefully, this will mean that the administration and Congress will work together to free up desperately needed resources and implement the Commission’s recommendations.

 

The Commission’s recommendations

The Commission made eight other recommendations for action:

  • Rapidly increase treatment capacity by eliminating the federal Institutes for Mental Diseases exclusion, a part of the Social Security Act, that prohibits using federal Medicaid funds to pay for inpatient mental health services including substance abuse in facilities with more than 16 beds. Every governor and many experts and advocates have urged that this barrier to treatment be rapidly removed by granting waivers for all 50 states. The report notes that “this is the single fastest way to increase treatment availability across the nation.”
  • Mandate prescriber education initiatives. Since “four out of every five new heroin users begin their addiction with non-medical use of prescription opioids,” the Commission felt such initiatives could help reduce the misuse of these drugs. I find this recommendation ironic since I was mandated to take an opioid prescribing course to renew my California medical license a number of years ago. At that time, the emphasis was on being less reluctant to use opioids because pain was being undertreated.
  • Immediately establish and fund a federal incentive to enhance access to Medication Assisted Treatment (MAT). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT in combination with counseling and behavioral therapies is effective in the treatment of substance abuse disorders and can help people to sustain recovery. Despite this, there are many barriers to accessing this type of treatment: There are too few trained and/or authorized providers. Insurers, including Medicare, may not cover some of the options (e.g., methadone). Even if offered, not all of the MAT options are covered. Finally, we need to facilitate the development of new, hopefully even better, MAT treatments. All of these issues are addressed in this recommendation.

    Related Content:  Why We Can’t Punish Our Way Out of the Addiction Epidemic

  • Provide model legislation for states to allow naloxone dispensing via standing orders, as well as requiring the prescribing of naloxone with high-risk opioid prescriptions. This recommendation also calls for equipping all law enforcement in the United States with naloxone to save lives. I would go a few steps further and say that all opioid addicts and their families or friends ought to have access to naloxone to use in outpatient settings where they are most likely to overdose. This is important because some people will be reluctant to involve law enforcement when an overdose occurs. Further, there can be a delay in law enforcement getting to the scene in time to reverse the overdose. The one part of this recommendation that is controversial is the recommendation that primary care and other physicians be notified when someone in their care has overdosed and been revived with naloxone. Although the reason for this recommendation is said to be so the doctors can alter their prescribing habits, care must be taken to not infringe on privacy rights (see below for a recommendation on this).
  • Prioritize funding and manpower of various agencies (DHS, FBI, DEA) to develop fentanyl detection sensors. Fentanyl is more powerful than even heroin and is responsible for many drug deaths. It is coming into the country mainly via China, but our inability to detect it at borders and mail facilities “creates untenable vulnerabilities.” The commission again points out the important role the President could play in addressing this issue by stating that

“Only a presidential directive will give this issue the top level attention it deserves from DOJ, DHS, and USPS.”

  • Provide federal funding and technical support to states to enhance data sharing between state-based prescription drug monitoring programs (PDMPs). Addicted patients often doctor shop getting opioids and other drugs of abuse from multiple providers. On the other hand, there are some bad actors in the medical field who make a living providing prescriptions for drugs that can be abused to addicted people. PDMPs allow the identification of both. They are invaluable tools in the fight against drug addiction.
  • Better align, through regulation, patient privacy laws specific to addiction. The report notes that some privacy regulations act as a barrier to communication between providers and can make it difficult for family members to be involved with a loved one’s treatment. Alterations to privacy laws probably should be altered to eliminate these barriers but this needs to be done in a way that carefully balances the need for better treatment with respect for an individual’s privacy.
  • Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized parity compliance tool. MHPAEA has been the law of the land since 2008, but compliance with its mandate that mental health and substance abuse (MH/SA) benefits must be on par with physical health diagnoses has been variable. Health plans can discriminate against people with MH/SA issues not only by limiting coverage, but also by having requirements that certain inexpensive, but less effective treatments be tried first or by having onerous prior authorization requirements. Treatment, also limited with the provider network, fails to include enough individuals with the knowledge and training to provide addiction treatment. Having been involved in reviewing health plan benefits during my career, I cannot emphasize enough how important the use of a compliance tool is to preventing discriminatory behavior on the part of insurers.

The Commission’s report has received praise from some surprising places, including media outlets such as FiveThirtyEight, whose headline declared somewhat incredulously, Trump’s Opioid Commission Listened To Public Health Experts. Let’s hope that the President and his minions will as well.


This post was initially published on 8/10/17 with the title”Trump Ignores His Opioid Commission’s Most Urgent Recommendation.” We were pleased to update this post after he changed his mind.