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Just Sayin

April 10, 2017

“Opioid addiction is a chronic medical condition that is receptive to effective treatment. Methadone, buprenorphine, and naltrexone are among the most effective interventions.”

--Rosalie Pacula. RAND Drug Policy Research Center

          It is no secret that there is a serious and growing opioid crisis in the United States. Opioid abuse is a serious public health issue and drug overdose deaths are the leading cause of injury death in the United States. Opioids—prescription and illicit—are currently the main drivers of drug overdose deaths. These deaths continue to increase.

          The overdose death rate in 2008 was nearly four times the 1999 rate. In 2014, there was a sharp increase in heroin-involved deaths and an increase in deaths involving synthetic opioids such as fentanyl. More than 33,000 people died from opioids in 2015 — more than any other year on record, according to the Centers for Disease Control and Prevention (CDC). Maine, Connecticut, Kentucky, Massachusetts, Ohio and Florida are among the states that saw double-digit percent increases in deaths from opioids between 2014 and 2015.

          Surgeon General Dr. Vivek H. Murthy in a landmark report this past November 2016 — the first time a full Surgeon General’s report, Facing Addiction in America, was devoted to the subject — called substance abuse disorders "one of the most pressing crises of our time." The Report documented that 90 percent of people with a substance abuse disorder are not getting treatment. In response, President Trump established a Commission on March 29. 2017, chaired by Governor Chris Christie of New Jersey, to tackle the opioid crisis.

          As stated above, there is no doubt that opioid addiction has physiological and medical aspects and that new medications can be helpful. Only a fool would disregard the scientific consensus around this and discard the advances that are being provided by scientific researchers. In addition, other medical interventions are being designed to fight substance-related disorders, such as “Screening, Brief Intervention and Referral for Treatment,” or SBIRT, and implemented across the country. Some progress is being made.

          NOW, can we please address the notion that opioid addiction is NOT JUST a medical or physical condition. The dominant scientific view is that addiction is a chronic disease of a hijacked brain. Fair enough. However, there are subjugated minority views that must also be taken into account. We should at least entertain the idea that the dominant view may be limiting our vision, potentially leading us astray, and hindering us from progress in treatment and prevention. Let’s discuss this briefly through the opioid crisis.

          In agreeing to chair the Opioid Commission, Gov. Christie described the initiative as "incredibly important to every family in every corner of this country." True enough. However, it is now well understood that the opioid crisis is focused in specific “hot spots” around the country. This cannot be easily explained by medical or neurobiological data. What exactly is the medical vulnerability of these crisis zones? They are, it seems, more a consequence of other factors that are more sociological, political and cultural in nature.

          In 2015, the five states with the highest rates of death due to drug overdose were West Virginia (41.5 per 100,000), New Hampshire (34.3 per 100,000), Kentucky (29.9 per 100,000), Ohio (29.9 per 100,000), and Rhode Island (28.2 per 100,000). According to the CDC, significant increases in drug overdose death rates from 2014 to 2015 were primarily seen in the Northeast, Mid-Atlantic and South. States with statistically significant increases in drug overdose death rates from 2014 to 2015 included Connecticut, Florida, Illinois, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Washington, and West Virginia (https://www.cdc.gov/drugoverdose/data/statedeaths.html).

          If anyone is paying attention, it could be said that many of the states and local areas won by President Trump in the recent election were tied in with the opioid epidemic. Perhaps we need to consider unemployment, socioeconomic status, cultural anxiety, despair, and desperate desire for change as “root causes” for both the electoral and opioid phenomena!

          Suppose we were to take such a suggestion seriously. What “facts” might we pay attention to?

  • Have we really tried to wrap our minds around the data that says nearly two-thirds of people in opiate abuse treatment say that they were physically or sexually abused as children (http://www.anrclinic.com/latest-statistics-on-opiate-addiction/)? Historically, societies have been resistant to examining the quality of child experiences and the role adversity/trauma in both child and adult disease. Can we really entertain the suggestion that childhood adversity may underlie substance-related disorders and the opioid crisis?
  • Are we willing to solicit and fund research to help us understand the connections between economic and sociological anxiety and addiction? After all, we have some data now about the “Trump voters.” Perhaps correlating this information with addiction risk and overdose liability would provide new insights. The results of this research are likely to be considered more “squishy” by some since the outcomes cannot be measured by blood levels or fancy MRI pictures. Nevertheless, the importance of such data cannot be overlooked.
  • If we ae willing to consider a wider scope of causes for substance-related disorders, addiction, and overdose then we may be able to adopt a “social ecological” model of addiction as a more penetrating and comprehensive perspective on addiction than the dominant disease model.

The contours of such a new perspective are being developed in a forthcoming book titled, Tending Hungry Hearts: A Vital New Clue for Unlocking the Secrets of Addiction. Look for it.