Recently, after trying to avoid the inevitable, I was scheduling a hip replacement. The young surgeon began talking about anesthesia options and his recommendations for postoperative pain management. He spoke about limited use of opioids along with physical therapy and alternative pain control.

After many years in recovery, I was comfortable with this conversation, but I was also aware of the larger context. My own last encounter with opioids in the hospital emergency room had come as they shot a dose of morphine into an IV inserted in my arm. Wow. It felt like liquid silver, smooth, and cool, and uplifting. I loved it… and feared it. I was glad the doctor today was addressing pain management directly. It made me feel more at ease. The other, less personal contextual factor, of course, was our current national opioid crisis. It got me thinking.

We are living in a nation experiencing an epidemic of legal and illegal opioid misuse, addiction, accidental and deliberate overdose, tragic and preventable deaths, and multiple other societal consequences. We are alarmed about this. We should be. The United States has less than 5 percent of the world’s population, yet consumes roughly 80 percent of the global opioid supply. The President has declared it a national emergency. What the hell is going on?

Looking Back

We’ve had a crazy history in this country regarding opioid drugs ever since the nineteenth century. For most of the 1800s and before, opioids were widely and legally available, and commonly used through patent medicines (such as Mrs. Winslow’s Soothing Syrup¹) and by doctor’s prescriptions as laudanum or Black drop, an opium-based pain reliever (Musto, 1987; Sederer, 2017). The mid-1800s saw the introduction of morphine (1827, Merck), the hypodermic needle, and use of opioids during the Civil War. Many soldiers became dependent; this was called “morphinism or “Soldiers’ Disease.” In the later 1800s Chinese railroad laborers used opium and Bayer Pharma became the first company to synthesize heroin. These were halcyon days for opioids.

Beginning in the 1900s, however, faced with increasing public pressure, various state and national entities began trying to regulate opioids. This was our first cultural rethink about opioids. In this way, we joined with many civilizations all the way from ancient times to the present that have attempted to find a balance between the medicinal benefits of opioids and the euphoric and soothing effects that can lead to misuse, overdose and addiction.

Congress began passing a series of legal restraints on opioids from the Opium Exclusion Act (1909), through the Harrison Narcotics Act (1914), which required medical providers of opioids to be registered, to the Pure Food and Drug Act (1906) and the Food, Drug and Cosmetic Act (1938), which created and gave jurisdiction over medications to the Food and Drug Administration (FDA). Oxycodone became available when it was approved by the FDA as Perdocan in 1950. The Controlled Substances Act (1970) gave us the federal “schedules” we live with today. The schedules are based upon each substance’s supposed medicinal value, harmfulness, and potential for abuse or addiction. Regulation and control of manufacture, distribution and use was the approach.

More recently

In the 1990s we began a second major rethink about opioids and the practice of medicine, largely as a social movement. Pain was the watchword. Patient advocacy groups, academics and others became more insistent, not simply accepting pain as an inevitable byproduct of injury or disease, but demanding an end to pain altogether. Guidelines began to emerge recommending that doctors “get patients to zero” on the pain scale, often displaying frowning and smiley face imojis to communicate the concept.

Nineteen ninety-six (1996) was a watershed year. At a meeting of the American Pain Society, James Campbell, M.D., a surgeon and President of the Society, in his keynote address recommended assessing pain levels as a “5^th vital sign” in patient care, along with temperature, pulse, breathing rate, and blood pressure. “We need to train doctors and nurses to treat pain as a vital sign,” he said. This became something of a mantra in the years that followed. In that same year, OxyContin was brought to market. Many providers and hospitals took up the battle-cry. Opioids were back in vogue.

The social trend was clear. Patients wanted their pain addressed and potentially eliminated. Big Pharma was willing to comply. Physicians were trying to meet the need, as they understood it, following the guidance they were given. An unintended consequence of the “vital sign” initiative was not just improved pain assessment but increasing focus on opioid-based pain management as well. A flood of opioid medications became the cultural solution to pain.

But, that is not the end of the story. Living with the consequences of this more drug tolerant social movement, people began to notice problems.

A Shift

Beginning in the mid to late 1990s, both medical and non-medical use of opioids increased once again. Without much delay, however, the news spread about dangers and negative outcomes among vulnerable populations. It gradually became clear that change was needed. One locality became the poster child.

 The Charleston Gazette-Mail in West Virginia found that from 2007 to 2012, drug firms poured a total of 780 million painkillers into the state, which had a total population of about 1.8 million souls. That is roughly 400-plus opioid pills per resident!

 The small town of Kermit in Mingo County, West Virginia, had a population of 392, but a single pharmacy there received nearly 9 million hydrocodone pills over two years from out-of-state drug companies.

 In Wyoming County, WV supplies of OxyContin doubled. Not surprisingly, the county now leads the nation in its annual overdose death rate of 54.6 per 100,000. Local physicians were prescribing to patients with migraine headaches a 30-day supply of hydrocodone or oxycontin.

 Out-of-state drug manufacturers and wholesalers were only too happy to saturate the West Virginia market with opioids and pocket the proceeds. West Virginia now leads the country in drug overdose deaths: The proliferation of opioid painkillers got people addicted to the drugs, in some cases putting them on a path to other opioids like heroin and fentanyl, or to overdose.

This story is not peculiar to West Virginia. It is indicative of what was happening elsewhere but especially in places with poverty, economic despair, low employment, low expectations, and broken dreams. USAToday lists the top two “most miserable states” in the Union as West Virginia and Kentucky. Number five is Ohio. This is the core of Appalachia and it is only one of many “distressed communities across the country.²

Figure 1: “Distressed Communities” Index

howldb.com

Notice in the map above that “distressed communities” tend to cluster in pockets of suffering. Someone landing from a distant planet might notice that these communities are fertile ground for addiction to take root (see Figure 2 below). When we add this susceptibility to increased supply of drugs, it is a combustible mixture.

With more opioids available, the public began to see increased diversion of opioids from legitimate medical use to non-medical use, more emergency room visits, more accidental or deliberate overdose deaths, more treatment seeking, more neonatal syndrome, more heroin use, more heroin-related mortality (Kolodny, Courtwright, et al., 2015). While non-medical use among teens and young adults peeked in 2002 and then began to decline, overdose deaths increased overall, along with addiction treatment admissions and adverse public health outcomes. Importantly, overdose deaths now occur most often in adults 45 – 64 years old, a significant change in victim profile.

In 2015 the New England Journal of Medicine published a controversial article that called for physicians to be cautious about assessing the intensity of pain.³ Other factors and considerations needed assessment as well.⁴ By the next year the American Medical Association rejected consideration of pain as the 5^th vital sign. This initiated a third societal rethink about pain and the use of opioid medications.

In 2017, articles appearing in the Annals of Surgery have called for a more common-sense approach to the issue of pain: “The goal of pain relief should be 30% to 55% improvement, and therefore the patient should be expecting tolerable pain levels, not 0 pain levels” (quoted in Kliff, 2017; emphasis mine). Noted physician and author Atul Gawande, M.D. recently advocated for “counseling patients preoperatively to expect adequate pain control to function but not to achieve zero pain” (2017; emphasis mine). This was the approach of my young surgeon.

Public Memory

This foray into America’s history with drugs and narcotics teaches several lessons. We can learn from our past as we contemplate drug policy and intervention now and into the future.

We are in the middle of a drug crisis but tend to forget our history. David Musto called it a “lack of public memory” about earlier waves of opioids and cocaine — yes, we have struggled with both drug classes before — that came on the scene initially as boons to humankind and then faded from fashion as the culture learned how thorough the seduction had been. Societies, it seems, can learn from their experience. They can demand that actions be taken to limit availability, once they see the full consequences. The risk, however, about effective action is that those same societies tend to forget lessons learned. The impetus for vigilance lessens with success over time. “We thus oscillate from periods of drug tolerance to drug intolerance. Equilibrium is a state in which drugs, including alcohol, have rarely been found in the United States” (Musto, 1987, p. x).

We see this oscillation in the earlier tolerance of opioids when the issue was couched in terms of pain and our attempts to reach zero pain medically. We forgot the hard won lessons of caution and prudence learned after the Civil War. Living with the consequences of wider availability once again, our current cultural attitude toward opioids and prescription drugs is beginning anew to turn toward intolerance in familiar ways. While this is a good thing, we must guard against several potential outcomes.

We must insure that our focus on, and limitation of, illicit use of opioids does not contaminate our view of opioids and other medicines for those who truly need them. Patients needing adequate pain control should be able to access it.⁵ We must treat patients with pain compassionately, while limiting the diversion of opioids for nonmedical purposes and curtailing unscrupulous or ignorant over-prescription of opioid drugs. We must also develop an attitude of empathy and understanding for those caught in the cycle of addiction with narcotics.

We must acknowledge that opiates are powerful analgesics/euphorics with benefits and risks. They cannot, however, eliminate pain entirely, at least not without inducing coma. Patients must be made aware of the risks AND limitations of drug seeking. The accepted goal should be pragmatic pain management to tolerable levels and return to productive living.

We must acknowledge that overdose deaths occur when patients misuse prescriptions or divert them to unintended uses, when street dealers adulterate them, or pharma companies and distributors start to act like drug cartels with unscrupulous practices.

We must understand that dependence is not the same thing as addiction. Dependence is a pharmacological concept that describes how the brain and body adapt, become used to the dosage, and rely on the drug’s impact. Dependence is an expected outcome when using opioids. Addiction is different; drug use becomes compulsive, driven; drugs are used despite negative consequences. Opioids have significant dependence liability but do not addict everyone who uses. In fact, just like other abused drugs, only a small percentage of users become addicted. We know that about 15% of opioid users strongly dislike the experience. About half of users find the experience mixed or neutral. Thirty percent, however, find the euphoria intoxicating, and about half of those continue to seek the high and become addicted (Szalavitz, 2014).

Addiction is a “substitute relationship” with the drug and the process of intoxication. In this case opioid use and addiction serve a purpose. Addiction is an individual’s solution for something else. Until we understand that, we cannot help others to let go. But, addiction is only one of the problems we face. Early deaths from overdose and drug use complications, such as viral or bacterial infections, are both tragic and preventable outcomes from harmful use, even in the absence of addiction.

Finally, we must also insure that our memories of this opioid abuse crisis do not fade away and leave us vulnerable to excess down the line. We must truly learn this time.

Where are we now?

Prescription opioids appear to be the “gateway” to trouble. Nationally, the majority who use illicit narcotics began with a prescription. Seventy-five (75%) to eighty percent (80%) of heroin users are hooked initially on prescription painkillers. One hundred million Americans took prescription painkillers this past year; at least 12 million did so without physician prescription.

Drug overdose is the leading cause of accidental death in the U.S., greater than death from guns or auto accidents, with opioids accounting for more than half of that number.⁶ There are nearly 142 opioid-related deaths daily in the United States, according to the CDC; this number is the equivalent of those lost on 9/11 every three weeks! Overdose deaths among women and teens have risen dramatically. Four in five heroin users began by misusing prescription painkillers or when access to painkillers was terminated prematurely. While overdose from prescription opioids may be levelling off, deaths from heroin and fentanyl are rising. Much of the available heroin is adulterated with fentanyl, a potent and potentially lethal painkiller. The combination is a leading cause of overdose deaths.

Overdoses appear to cluster by region with the highest rates in Appalachia, the former Rust Belt, the Lower West, and parts of New England (NewYork Times, 2017). Overdoses are “the canaries in the coal mine” for suffering in these areas. We must address the conditions of this suffering if the opioid epidemic is to be tackled.

Figure 1: Opioid Overdose Deaths by Region (2014)

https://clearskyibogaine.com/american-opioid-addiction-epidemic/

I live in a state (Pennsylvania) that leads the nation in drug overdose deaths among young adult men, 19 – 25 years old. In my county (Lackawanna) the 2016 per capita rate of opioid prescriptions (112.1; per 100) was higher than the national rate (66.5) and the PA rate (69.5). Victims reflect the demographics of the area, mostly white, often lower to middle income.⁷

The District Attorney’s office in Lackawanna County, in its Heroin Hits Home initiative, has suggested that some explanations for these rates may include aggressive pharmaceutical marketing, local physicians’ lack of knowledge regarding opiates and loose prescribing practices, and an enigmatic set of social influences including a large population of “depressed” people and the existence of “more suffering” in the county than elsewhere.⁸ (Here the DA is picking up a common theme about “distressed communities” being fertile ground for addiction.).

Interestingly, in 2015, telephone surveys conducted by the Centers for Disease Control and Prevention (CDC) indicated that the Scranton/Wilkes-Barre metro area was “the most unhappy place in the United States”.⁹ The connection of public misery with the opioid crisis is significant and challenging.

So, what do we do?

Focusing on the President’s declaration of a national opioid emergency, the media is calling attention to tactics such as (a) better informed national education on drugs, especially about opioids, (b) increased research and treatment resources, and (c) increased attention to first responders and law enforcement. These are traditional, reasonable and worthy applications of resources. But, they will not solve the problem. We have been pursuing this same set of strategies — public health and law enforcement — for some time now in the “war” on drugs with decidedly mixed results. Yes, we have more and better medicines (naloxone, buprenorphine, methadone) and non-opioid medications, more and better-informed treatment facilities and processes, even more alternative and complementary healing modalities. However, someone might be forgiven if she or he wonders, “Is this all we’ve got?” If nothing else, our history should have taught us that more of the same is not a winning solution.

I want to argue here for something different, for more “robust” and challenging solutions, for a more radical way of envisioning a 21^st century approach. I suggest that we imagine the opioid, prescription drug and heroin crisis as a “wicked problem.”

In a 2008 Harvard Business Review article, Professor John Camillus points out that “wicked problems” cannot be solved, but they can be tamed.¹⁰ “Wicked problems” are significant, confounding and defy definitive answers. Camillus points out that what makes a problem “wicked” is not just that it is tough or resistant to resolution, but rather that traditional processes cannot put an end to the problem.

A wicked problem is difficult to describe fully. It is dynamic and does not have one right answer, a single clear solution. Its roots are tangled and difficult to ferret out. It has multiple causes and there is no consensus about what they are or the priority of their impact. It is socially complex and involves many stakeholders, individuals, groups and systems with different values, opinions, and priorities. It appears to be intractable with many attempted solutions but no clear successes, no “righteous” solutions. It morphs when acted upon, presenting unforeseen difficulties and challenges. There are few ways to judge whether a proposed solution is on the right path or even achievable.

While there may not be clear solutions, wicked problems can be “tamed.” To do so, however, often requires courage, a willingness to act when all the pros and cons are NOT clear or even known. Consequences may remain unclear, but stakeholders must dream bigger. Experiments, pilots, prototypes, may be the best way forward. Promising moves forward and alternatives will present themselves as actions are taken. Resolving to learn from these actions, revising, and then acting again may be the best strategy. Determination, tenacity, agility and imagination are required.

In business, “robust actions” involve exploring new and out-of-the-box strategies. These often utilize social planning processes, such as brainstorming, retreats, focus groups, visioning exercises among stakeholders. The goal is inclusion and community-building, creating a kind of intentional and action-oriented community, with a shared understanding of the problem and a joint commitment to possible ways of resolving it.

Opioids as a wicked problem

The opioid crisis conforms to many of the criteria for a wicked problem. A set of national and regional strategies have already begun to address the problem.

 Expanding treatment capacity is already underway. Providers, insurance and third-party payers need to get on board and get toward reimbursement.

 Law enforcement and first responders are already receiving more resources, such as emergency deliverable Narcan and training, as well as support for burnout and “compassion fatigue.”

 ER visits and hospitalization are being seen as opportunities for assertive linkage to further resources through SBIRT (Screening, Brief Intervention, and Referral to Treatment¹¹), helping to identify those who can benefit from earlier intervention.

 Neuroscience and medical research are pursuing new therapeutics.

 Training and re-training medical providers, especially primary care providers, is moving forward.

 Discussions are beginning about support for medically-assisted and a range of psychosocial treatment options and peer-based recovery support.

 Communities continue to fight stigma (and the racial and class bias that lurk beneath) and reach out to those who still struggle. We must help communities to support individual and family recovery.

But other ways of thinking and acting must be brought to bear as well:

 Too many Americans struggling with drug use are over-looked in our communities and treatment systems. Only a small percentage of those who need help – not just those struggling with addiction but the even bigger population of “harmful users” – actually receive any kind of treatment. This is a treatment secret: Millions (!) of people who struggle with drugs, and could benefit from earlier treatment, receive no professional help.¹² This must change. We need enhanced capacity, easier access, earlier intervention, and revised social marketing to capture and assist those who need help.

Figure 3: Demand Reduction in the 2010 Drug Control Strategy: Prevention, Intervention, Treatment & Recovery.

[Notice that those receiving treatment are included in the tiny red triangle at the top of the pyramid]

In addition, too many people with an opioid problem are incarcerated and languishing in our jails and prisons. These drug sufferers are often off our radar and outside our circle of care, but they also need access to treatment.

 We must acknowledge that a good bit of the treatment that is provided now is inadequate. This is another little secret that the treatment industry does not want us to know. Too much treatment is geared to an acute model of care, more appropriate for a broken leg or diseased appendix than for a chronic illness like addiction or harmful use (McLellan et al., 2000; White, Boyle & Loveland, 2003). In addition, while inpatient and outpatient facilities give lip-service to individualized treatment planning, this is not often available. There are many wonderful people involved in helping those struggling with addiction, but the systems in which they work need serious revision.¹³ There are centers of excellence but many systems require overhaul.

 Thinking of opioids as a chronic problem, addressing the need for long-term recovery management (not “graduation from treatment”), aggressively linking recovering people with community resources, assertive follow-up and continuing care (often for years following treatment), and helping to build recovery capital for individuals and communities, could help to re-frame a more modern approach and offer people the length and quality of treatment they need (Laudet & White, 2008; White, 2008; White & Cloud, 2008). That is, we must augment our traditional strategies with a social ecological approach.

I suggest that we pay attention to two other, often neglected, factors that are crucial from a social ecological point of view: (a) the “adverse childhood experiences” understanding of trauma and addiction vulnerability, and (b) the wider social, cultural and economic environment in which addiction is embedded. And, not surprisingly, these two factors are inter-related.

We know that addiction takes root and grows when the soil is right. This is another way of saying that a significant factor in vulnerability to addiction is its social ecology (Alexander, 2008). This goes beyond the traditional view of disease, genetics and psychological vulnerabilities. Research is revealing a powerful vulnerability that involves the interplay of early childhood experiences, adversity and trauma, family dysfunction, neurobiology, and psychological impairment. Each of these factors is intertwined and operates simultaneously to place the (potential) addict at a serious disadvantage. Histories of physical and sexual abuse and co-occurring mental disorders are associated with opioid trajectories.

Social science research also indicates that the wider societal, cultural and economic environment has profound effects on the ecology in which opioid addiction is imbedded. Family, social systems and employment support can facilitate recovery (Hser, et al., 2015). While we consider doubling-down on traditional strategies to combat opioids, we should also consider newer social ecological interventions. Because the causes and contributing factors for wickedness are multiple, one can begin from several different starting points and explore “righteous solutions.” Traditional and more radical, ecological strategies must be attempted.

In the 1990s both Portugal and Switzerland had serious addiction problems and a runaway opioid crisis. Many countries in Europe had a similar profile, but were willing to try something different. Several EU members, including Portugal and Switzerland, attempted decriminalization of drug use and had some successes. The important thing about Portugal and Switzerland, however, is that they didn’t stop there. They added something even more powerful than decriminalization to their drug strategies. Both countries de-emphasized the punitive role of law enforcement and promoted health-related services, working to provide medication replacement and therapeutic alternatives for people struggling with addiction. Police became points of contact and agents of outreach to addicts, along with social workers, therapists and locally-based accessible facilities. The government helped to provide social services, employment and housing assistance, and reintegration into main-stream society, even going so far as investing capital in start-up business ventures by recovering people. In other words they assisted “drug outsiders” in finding paths of inclusion into their society, bringing them “out of the shadows” and offering a sense of meaning and purpose.

Now more than a decade later, the results in both countries indicate that they have made great strides in overcoming their “wicked problem.” Journalist Johann Hari recounts the basic stories of Portugal and Switzerland in Chasing the scream: The first and last days of the war on drugs (2015), and in an Op-Ed in the Los Angeles Times (2017, Jan 12) titled, “What’s really causing the prescription drug crisis?.¹⁴

While it is likely that neither model is a perfect fit for the United States, and decriminalization is only a far-off possibility, nevertheless the ingenuity and courage of these approaches can give us hope. Strategies of healing and reconnection need to be considered. We must find ways to pilot alternatives and learn from them. Robust and courageous actions are needed to catalyze hope.

References

Alexander, B.K. (2008). The globalization of addiction: A study in poverty of the spirit. New York, NY: Oxford.

Camillus, J. (2008, May). Strategy as a Wicked Problem. Harvard Business Review.

Hiroi, N. and Agatsuma, S. (2005). Genetic susceptibility to substance dependence. Molecular Psychiatry, 10, 336–344.

Hser, Y., Evans, E., Grella, C., Ling, W., and Anglin, D. (2015, March/April). Long-term course of opioid addiction. Harvard Review of Psychiatry, 23 (2), 76-89.

Kliff, S. (2017, June). The opioid crisis changed how doctors think about pain. Vox. https://www.vox.com/2017/6/5/15111936/opioid-crisis-pain-west-virginia

Kolodny, A., Courtwright, D.T., Hwang, C. et al. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559-574.

Laudet, A. B., & White, W. L. (2008). Recovery Capital as Prospective Predictor of Sustained Recovery, Life satisfaction and Stress among former poly-substance users. Substance Use & Misuse, 43(1), 27–54. http://doi.org/10.1080/10826080701681473.

McLellan, A.T. (2010). A New Demand Reduction in the 2010 Drug Control Strategy: Prevention, Intervention, Treatment & Recovery. Executive Office of the President of the United States. Office of National Drug Control Policy.

McLellan, A.T. (2011, 30 August). “Through the Maze: Making Treatment Better.” 2011 Drug Policy Symposium, Wellington, NZ . Downloaded: March 13, 2015. Available at http://www.youtube.com/watch?v=ofJ8Zpk1J8M

U McLellan AT, Lewis DC, O’Brien CP, and Kleber HD.(2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA 284(13):1689-1695.

Musto, D.F. (1987). The American disease: Origins of narcotic control, expanded edition. New York: Oxford University Press.

Sederer, L. (2017, Aug). “What the Washington Post gets wrong about opioids.” Huffington Post.

Szalavitz, M. (2014, April 24). Building the perfect pain killer: Inside the quest to conquer addictive drugs. Nautilus. https://www.scribd.com/article/338357023/Building-The-Perfect-Painkiller-Inside-The-Quest-To-Conquer-Addictive-Drugs

Vance, J.D. (2016). Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. New York, NY: Harper

Walker, R. (2015). So, Is Addiction Genetic? Or Not? The Fix. https://www.thefix.com/Genetics-addiction-connection-regina-walker0901

White, W.L. (2008). Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices. Northeast Addiction Technology Transfer Center, the Great Lakes Addiction Technology Transfer Center, and the Philadelphia Department of Behavioral Health/Mental Retardation Services.

White, W., Boyle, M., & Loveland, D. (2003). Addiction as chronic disease: From rhetoric to clinical application. Alcoholism Treatment Quarterly, 3/4, 107-130.

White, W. & Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27.