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Opioid Awareness

Experts Speak Up on the Scope of, Stigma Around and Solutions for Our Public Health Crisis

Deni Carise, Ph.D.

Chief Scientific Officer, Recovery Centers of America

What is the scope of the opioid problem in the United States?

The scope of the opioid problem is tremendous. Deaths in the United States from drug overdose increased 21 percent last year alone, and for the second consecutive year, overdose deaths have reduced the average life expectancy in the United States. Also, in the past year, fentanyl and its analogues were responsible for more deaths than prescription pain medications and heroin. This is a major shift in the landscape, as 115 Americans die every day from an opioid overdose.

What solutions are being developed to address this public health crisis?

Some aspects of the crisis are getting better. The expansion and even interstate availability of Prescription Drug Monitoring Programs allows physicians to monitor whether their patients have been prescribed opioids and other medications from multiple physicians, thereby greatly decreasing the chances that a patient can get multiple prescriptions for the same medication by several providers. Additionally, physicians are being educated (by someone other than the pharmaceutical companies) on the true dangers and correct uses of opioid pain relievers as well as alternatives to opioid use for pain. As a result of both of these initiatives, prescribing of opioids is going down significantly.

What drives negative perception of the disease and those suffering from a substance use disorder? How does stigma create barriers to treatment and recovery — and what is the impact?

The stigma associated with substance use disorders is perpetuated by the history of the field, the language we use and by the intense focus on the activities of those who relapse as opposed to those who get well. The National Institute on Drug Abuse has defined addiction as a chronic, relapsing brain disease. Legislation in health care has deemed its treatment one of 10 essential benefits that must be covered by health insurance providers. Both of these have solidified its status as a medical problem. Keep in mind, it wasn’t that long ago that cancer and tuberculosis were heavily stigmatized diseases. When that stigma starts to decrease, more people seek treatment.

Let’s face it, words have power, and using language that defines someone by his or her disease perpetuates stigma, evokes damaging stereotypes and counters our scientific understanding of substance use disorders. In short, words like “addict” or alcohol “abuser” are harmful relics of the past, so much so that the Associated Press included in its 2017 Style Guide efforts to eradicate the stigma of addiction that is conveyed by language. For example, the new AP Stylebook directs writers to “avoid words like abuse or problem in favor of the word use with an appropriate modifier such as risky, unhealthy, excessive or heavy.” It also declared that “addict” should no longer be used as a noun.

Finally, stigma is propagated by the intense media focus on celebrities who have struggled with substance use disorders and had multiple “relapses” to the disease — and the profound lack of coverage of those who have gone on to live healthy, productive, successful lives in recovery.

This stigma causes a multitude of harms, from difficulties obtaining zoning permits for siting new treatment programs, to the fear people with substance use disorders have regarding taking time off for necessary treatment, to accessing their health insurance to pay for treatment, or even just being seen in support group meetings.

I have personally sat in dozens of meetings where zoning boards, township planning commissions and even members of the county’s Drug and Alcohol Abuse Council have said: “To be honest, I wouldn’t want this in my neighborhood” and “I just know that when you have those people (individuals voluntarily seeking treatment for substance use disorders) here, you’re going to have drug dealers and crime.”

Because of all the stigma, many people are reluctant to get treatment. It’s estimated that over 21 million Americans (8.6 percent of the population and over 16 percent of 18-25 year olds) meet criteria for a substance use disorder, yet only 2.5 million (12 percent) receive substance abuse treatment. The public would be outraged if only 12 percent of people with any other medical disorder received treatment.

How can family members and friends talk to individuals with an opioid addiction?

People are often afraid to ask others if they’re using opioids. Their concerns range from saying the wrong thing, to having the person get angry, to worrying, “what if I ask and they say no, but they get so angry they start to use again?” Here’s the other side of that concern: what if you don’t ask and the answer is yes?

Bring up your concerns, but don’t be confrontational. One way to ease into the conversation is by saying something to the effect of, “I noticed you’re having trouble with things that would usually come easy to you. Is there something going on?” The more you can state your concerns factually while not sounding judgmental, the better. If they deny there’s a problem, come back with the facts you’ve noticed, whether they’ve missed work recently or they’ve been nodding off during dinner.

I think the two most important things to remember are always ask if you have a concern and never give up. Recovery from substance use disorders is possible. In fact, the science says the more times in treatment predicts better success. So keep voicing your concern in a loving and supportive way.

Randy Kellogg

President and CEO, Omron Healthcare

What is the scope of the opioid problem in the United States?

Opioid addiction is a major problem in the United States. It has reached epidemic proportions. The CDC reports that the issue has even directly contributed to a drop in United States life expectancy, which fell by 0.1 years for the second year in a row to 78.6 years in 2016, and the CDC is concerned that the decline looks likely to continue for a third consecutive year. More than 115 Americans die every day from opioid overdoses. The estimated economic burden of prescription opioid misuse in the United States is $78.5 billion a year, including the costs of health care, productivity lost, addiction treatment and criminal justice involvement. Opioid addiction has become a serious national crisis that affects public health as well as social and economic welfare.

What solutions are being developed to address this public health crisis?

Treatment of opioid addiction must be a national health priority, and we also must prevent further opioid misuse and further addiction. I’ll speak to the prevention part. Pain management technology now offers a clear alternative to opioid medication. There are currently many safe, effective, drug-free alternatives to pain management on the market. TENS (transcutaneous electrical nerve stimulation) technology has been used by physical therapists and pain specialists for years as a drug-free pain management alternative, and it’s now accessible to those seeking drug-free pain relief at home. This technology blocks pain signals to the brain, providing instantaneous and safe relief from pain. Omron recently announced the Avail, a new wireless TENS device that uses two contoured pads that can be programmed separately to alleviate multiple pain areas at the same time. The Avail is our first wireless TENS device and it is FDA-cleared to alleviate chronic pain. With more awareness of alternative options on the market, pain sufferers no longer need to see opioids as their only option for relief.

What drives negative perception of the disease and those suffering from a substance use disorder? How does stigma create barriers to treatment and recovery — and what is the impact?

Addiction is often misunderstood. Fear of the stigma that comes with that misunderstanding may keep someone in the early stages of opioid addiction from seeking help. There is greater understanding behind the cognitive functions associated with addiction, but it can still be viewed as a personal weakness or a moral shortcoming. This association is reflected in recent statistics that show that only a small percentage of Americans with substance use disorders receive treatment. For some, the ongoing stigma prevents them from seeking the medical attention they need, but for others, their access to addiction treatment may be limited. The impact is that there continues to be an increase in opioid addiction cases and it’s estimated that more than half a million Americans may die from overdose in the next decade. It’s important to note that the opioid crisis is closely related with another epidemic — the national pain epidemic. Millions of Americans live with pain every day. The National Institute of Health found that nearly 40 million adults experience severe levels of pain and 25.3 million adults experience chronic pain every day. A lot of times, opioid abusers started out as people in pain who slipped into prescription misuse unintentionally.

How can family members and friends talk to individuals with an opioid addiction?

Having those honest, hard conversations with loved ones is difficult but necessary. Start with acceptance and an openness to provide encouragement and support. Do your research to support your loved one on their recovery journey, not only to understand what they are going through but also what options are available for them. There are professional therapists and support groups who can provide information on structured recovery programs and help those who are struggling with an opioid addiction make those important first steps to cessation and recovery.

Javier Francisco Vilasuso, M.D.

Member, American Board of Anesthesiology

What is the scope of the opioid problem in the United States?

The severity of the opioid crisis in today’s health care system cannot be overstated. In order to understand the impact, patients need to realize the toll it has taken on our population. On a daily basis, over 115 Americans die from opioid overdose. From 2000 to 2016, the amount of deaths due to opioid overdose has continued to surge. In 2014, 19,000 deaths were attributed to prescription opioid overdose. This increased in 2015 to 22,000 deaths. Over the last several years, the worsening of this trend was attributed to be a combination of heroin and illicitly made fentanyl. Due to the escalating use, abuse and diversion of opiate medications, a negative perception has grown, affecting the ability of patients with severe acute and chronic pain symptoms to achieve adequate pain control. Many patients today are not appropriately diagnosed and treated. Subsequently, they are mismanaged, rendering them susceptible to increased pain and dependence on opiates.

What solutions are being developed to address this public health crisis?

It is paramount that something be done to address this epidemic as urgently as possible. Unfortunately, acute or chronic pain affects the majority of people at some point in their lives. Specialty trained pain physicians have begun comprehensive management strategies to address the challenges in treating pain and its mismanagement. Preventative management as well as proactive measures focused on patient and doctor education are now being used. Physician prescribing patterns with monitoring of opioid dependent pain patients, as well as opioid overdose prevention programs, are now utilized. These methods are used at our office at Anesthesia Pain Care Consultants in Fort Lauderdale to create a systematic approach by which our doctors and patients communicate and achieve a better understanding of how to treat their patient’s pain. Through clear communication and education, potential side effects and dangers of overuse and abuse of opioid medication becomes minimized. Abuse deterrent medications are also a focus which our practice has adopted. These medications are created to prevent overdose and aberrant use of opiates such as crushing or injecting.

Interventional pain procedures have been used as a way to effectively treat and diminish the dependence of opioids. These techniques include but are not limited to epidural steroid injections, selective nerve root blocks, sympathetic nerve blocks, facet and peripheral nerve ablation.

What drives negative perception of the disease and those suffering from a substance use disorder? How does stigma create barriers to treatment and recovery — and what is the impact?

Like many pain medicine practices throughout the country, we understand the difficulty of balancing pain control despite the social stigmas associated with pain medication. Non-opiate medications, which address nerve, musculoskeletal and inflammatory pain are also essential to effectively spare the necessity of solely relying on a single opiate based treatment. By adopting a multimodal approach including physical therapy, behavioral modification, medication management and procedural treatments, we are able to lessen dependence on pain medications.

How can family members and friends talk to individuals with an opioid addiction?

As a society, it is crucial that friends and family of opioid dependent pain patients maintain an open line of communication and seek the help of a trained pain medicine physician to optimally manage their pain. By implementing this structured mindset in the health care community and the general population, there will be a light at the end of the tunnel for this challenging opioid crisis.

How has technology evolved to manage pain and prevent overprescription of opioids?

At Anesthesia Pain Care Consultants, we utilize a variety of biotechnologies which have given us an edge in facilitating pain control and lessening opioid dependence.

Electrical signals have been used by patients as an alternative to opioid medication offering a seamless, nonmedicinal way to aid in relieving pain, anxiety, insomnia and depression. Alpha-Stim is a FDA-cleared cranial electrotherapy stimulator device which uses a patented waveform to stimulate neural pathways in a user-friendly manner. Earclips or probes connected to a handheld battery powered device decrease the pain response and stimulate the parasympathetic (calming) nervous system. This creates an analgesic (pain relieving) response, allowing patients to have better control of their pain in the comfort of their own home. We have utilized this device on many of our most challenging opiate dependent patients and have seen promising results. Most patients are finding that they need less opiate medication to control their pain. They also mention that their stress levels are much improved.

Many of our patients have adopted intra-spinal drug delivery systems, allowing for opioid medication to have a significant affect at minuscule doses, avoiding the risk of side effects or overdose. Spinal cord stimulation (similar to a pacemaker for the spine) uses electrical signals which pass through the epidural space. These signals intercept the transmission of pain traveling along the spine to the brain.

Maria G. Guevara, Pharm. D.

Director, Clinical Affairs Education and Training, Millennium Health

What is the scope of the opioid problem in the United States?

According to the Substance Abuse Mental Health Services Administration’s (SAMHSA) annual National Survey on Drug Use and Health, in 2016, 21 million people needed treatment for an illicit drug or alcohol use problem, which accounts for 7.7 percent of the U.S. population aged 12 or older. Of these, only 2.2 million received treatment at a specialty facility, and 1.8 million reported opioids as their primary substance of choice. The Department of Health and Human Services (HHS) reports that 90 percent of Americans struggling with substance use disorders (SUDs)/addiction are not currently receiving treatment.

Generally speaking, the rate of SUDs has stayed relatively stable in the last decade. Abuse of prescription opioids is appearing to plateau, with increasing use of heroin overtaking prescription opioid abuse. Data from the CDC indicates that drug overdose is a leading cause of injury death in the United States, surpassing deaths from suicide, homicide, firearms and motor vehicle crashes. Over an estimated 64,000 drug overdose deaths were reported in 2016. To help prevent these deaths, it is important to appreciate the extent with which certain drugs contribute to these rates. The National Vital Statistics System reports that overdose deaths involving heroin tripled from 8 percent in 2010 to 25 percent in 2015, while deaths involving natural and semisynthetic opioids, such as oxycodone and hydrocodone, decreased from 29 percent in 2010 to 24 percent in 2015.

One of the contributions to the shocking rise in deaths with heroin is the addition of the synthetic opioid fentanyl. Fentanyl is 50 to 100 times more potent than morphine and is available as a prescription medication for treating severe pain, including cancer-related pain. The CDC reports that while fentanyl prescription rates have remained relatively stable, there have been dramatic increases in the number of drug overdose deaths involving synthetic opioids, including fentanyl, and the number of law enforcement submissions testing positive for fentanyl. It has become evident that increases in fentanyl deaths do not typically involve prescription fentanyl but are primarily related to illicitly-made fentanyl. Illicitly-made fentanyl is often mixed with or sold as heroin — with or without the user’s knowledge, as well as distributed in counterfeit pills.

What solutions are being developed to address this public health crisis?

The solutions being created are multi-pronged in approach. The HHS has focused its efforts on five major priorities. These include improving access to SUD treatment, promoting use of overdose-reversing drugs (such as naloxone), surveillance to better understand the epidemic, support for research in pain and addiction and advancement of pain management practices.

There have been numerous state and federal committees formed in response to the crisis. Legislation has expanded access to medication-assisted treatment for SUDs, and programs at the state and community level are promoting the use of naloxone for emergency response teams and in some cases, for family members of opioid users. Certain states have mandated opioid prescribers to complete additional education on pain management practices. There are numerous professional guidelines and resources (such as Painweek.org) to help educate health care professionals on responsible opioid prescribing. Additionally, certain states have placed restrictions on opioid prescribing, particularly as it relates to prescriptions for acute pain. However, it should be noted that, while efforts designed to regulate opioid prescriptions may restrict access to these medications, it does not address the pressing issues stated above regarding SUDs, particularly the gap between the number of people needing treatment for an illicit drug use disorder and those who actually receive it.

What drives negative perception of the disease and those suffering from a substance use disorder? How does stigma create barriers to treatment and recovery — and what is the impact?

Despite decades of research, there is still the perception that SUDs are a weakness, a choice and not a “real disease.” There is also a misconception that abstinence from a drug (simple sobriety) can cure a person of addiction. The American Society of Addiction Medicine defines addiction (SUD) as a “primary, chronic disease of brain reward, motivation, memory related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” Essentially, SUD is a chronic brain disease requiring a multi-pronged, lifetime, individualized approach to treatment, and should be approached as such by health care professionals and society. In Facing Addiction: The Surgeon General’s Report on Alcohol, Drugs and Health, Vivek Murphy points out that the criminal-justice based model for SUD treatment has not been effective and calls for a public health systems approach to treating SUDs. He goes on define this approach, stating: “A public health approach seeks to improve the health and safety of the population by addressing underlying social, environmental and economic determinants of substance misuse and its consequences, to improve the health, safety and well-being of the entire population.”

Currently, there are barriers in the form of access to comprehensive treatment for various reasons to those who need it, including identification of the need for treatment, availability of SUD treatment in the community and affordability/coverage of treatment. Additionally, the recognition that SUD is a chronic disease of relapse (much like managing diabetes or high blood pressure) means that maintenance of recovery requires a lifelong strategy beyond what acute care can provide.

How can family members and friends talk to individuals with an opioid addiction?

It’s important to start the conversation early. There are numerous resources available to help educate parents on the issues and equip them to discuss substance abuse with their children. For example, the Partnership for Drug-Free Kids has been educating the public on substance use for over 30 years. Their website (drugfree.org) has a host of ideas on how to get involved in prevention efforts within the community and offer support for those who are currently facing a SUD.

Additionally, SAMHSA has a number of resources available to friends and family members caring for a loved one with SUD, including a national helpline which provides referrals to local treatment facilities, support groups and community-based organizations. They also publish booklets to help educate families on the disease of addiction, including “What Is Substance Abuse Treatment? A Booklet for Families” and “Alcohol and Drug Addiction Happens in the Best of Families.” These and more can be found at https://www.samhsa.gov/.

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