Opioid Addiction

Our knowledge of the causes of addiction has dramatically improved in the last decade.  Yet despite advances in our understanding the brain and genetic underpinnings of addiction, the myth that it is a moral failing persists.  If dependence on drugs and alcohol is not the result of poor ethics, then what is it?

The American Society of Addiction Medicine (ASAM) defines addiction:

“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.

Prevention efforts and treatment approaches for addiction are as successful as those for other chronic diseases.”

Let’s unpack that and more closely look at what the definition means.  Nowhere in this widely accepted definition is the concept of a moral failure.  Rather, addiction is defined as an illness that can improve with proper treatment.

Diseases come in two basic categories.  Acute illnesses, like the flu or an infection, are sudden, sometimes severe, and end.  A chronic disease has a more gradual onset, can last a lifetime, and is managed but not cured.  Diabetes, arthritis, and heart disease are excellent examples of chronic illnesses.

Diabetes is the perfect disease to compare to addiction because of the course of both illnesses.  Addiction and diabetes both occur in people with a genetic susceptibility for them.  A person is far more likely to develop these disorders if they have a biological family member who also suffers from it.  While many people are at risk because of their genes, not all of them develop lifelong illness.  For that, certain lifestyle choices come into play.  For diabetes, years of a sedentary lifestyle coupled with poor food choices ends in disease.  For addiction, repeated use of addictive chemicals creates a compulsion to use.  Not everyone who sits on the couch eating ice cream becomes diabetic, just like not everyone who uses drugs loses control over their use. In both substance dependence and Type 2 Diabetes, the combination of life experience and genetic underpinning interact in the development of sickness.

Part of the above definition discusses the compulsive nature of an addiction that drives people to continue to use despite mounting consequences like loss of family, job, and health.  To understand how a generally good individual falls to this state, we need to examine what traits the genetic susceptibility creates and how those traits interact with environmental stress.

Certain structures in the brain circuits driving addiction vary depending on genetics.  Dopamine is the brain chemical driving almost all addictive behavior.  Whenever you get a reward you were really looking forward to like a sweet treat, your paycheck, or a drug high; the chemical floods a part of the brain called the reward circuit.  Think of it like the release of thousands of tiny keys.  When those keys find a lock on the brain cells, called a receptor, that’s when the magic happens.  It feels great!  And the reward drives people to repeat the behavior.  The Lay’s company understands this perfectly in their potato chip marketing.  No one can eat just one.

Neuroscientists have discovered that people susceptible to addiction are born with fewer dopamine receptors than the average person.  This means they experience less pleasure from day-to-day things and would be more likely to try drugs.   This is why a 3 month prescription for opioids can send some people down the road to addiction.

The situation gets more complicated when stress gets added to the mix.  The rates of addiction in veterans and people who suffered other traumas are dramatically higher than in the general public.  Turns out experiencing high levels of emotional pain reduces the number of dopamine receptors, often driving a person to seek comfort in more extreme substances like opioids which flood the receptors to a degree where relief is possible.

The addictive cycle of compulsion begins when an individual’s use repeats.  The more frequently someone uses opioids in response to stress, the fewer receptors they have.  Stressors come from more than trauma.   Financial instability, job stress, or the death of a loved one are all the kinds of things that trigger a vicious cycle where each use of opioids reduces the number of receptors and intensifies the craving for relief in increasing amounts.  Essentially the reward circuit goes on runaway.  Once the brain makes this adjustment to substances, the structural changes become permanent.

None of the people coping with these issues suddenly lost their moral compass and decided to ruin their lives.  The good news is that with proper treatment, addicted people can and do recover.  Just like with diabetes, there are setbacks and relapses along the way.  Interestingly, the relapse rates for addicted people are within the same range as the rates for other chronic illnesses like diabetes or heart disease.  Between forty and sixty percent of people suffering from one of these diseases have relapses and for the same reason.  Lifestyle change is extremely difficult.

More about addiction.
How drugs affect the brain.
The disease model of addiction.
Kiwi bird video shows the progression of addiction.
The Rat Park shows a possible cause of addiction.

Opioids are class of drugs that include the illegal drug heroin and many prescription medications including Vicodin, Percocet, Oxycontin, Fentanyl, and many more.  Prescription opioids are prescribed by a doctor primarily to treat pain.  All opioids are highly addictive because of the intense feelings of pleasure they create.

More about opioids.

In the 1990s, US pharmaceutical companies created new, more powerful forms of opioids.  These companies handed doctors millions of free samples while reassuring them the addictive potential of the medications was very low.   The result was a market saturated with the drugs.  Exposure to opioids led to record-breaking numbers of people becoming addicted.  When people could no longer get a prescription, most turned to buying them on the street.  The cost of prescription opioids reaches upwards of a dollar per milligram.  Supporting a growing habit with them is quickly costly, prompting most people to resort to cheaper alternatives like heroin.

A brief history of the opioid epidemic.

Overdose deaths continue to rise year over year. Every 11 minutes someone in the United States dies of an opioid overdose. In 2019, for the first time a person was more likely to die of an overdose than from a car accident, making it the 5th leading cause of death and the leading cause of death for young adults.

Rural and rust belt states have been the hardest hit by the epidemic. Pennsylvania continues to have a higher than average death rate.

Overdose deaths began a sustained spike beginning in 2013 in part due to the introduction of fentanyl produced illegally overseas and shipped to the US.  Fentanyl is an opioid 50-100 times more potent than heroin.  In 2016 an even more powerful substance found its way to the US:  Carfentanil.  Used as an elephant tranquilizer, Carfentanil is up to 10,000 times more powerful than morphine.  A lethal overdose can occur by merely handling it.  Both of these dangerous drugs are far cheaper to make in a lab than heroin is to refine from the opium poppy.  As a result, dealers mix these into their product to cut production costs.  Not knowing the bag they bought contains something more powerful than heroin, people overdose.

The facts about Fentanyl.
What is carfentanil?

It can be difficult to tell if someone you care about is abusing opioids.  Any severe addiction causes personality change in person using substances.  Some physical and behavioral signs to look out for include:

• Needle marks on arms and legs due to IV use.
• Stopping activities and hobbies.
• Increase in impulsivity.
• Frequent nodding out.
• Pinpoint pupils.
• Slurred speech.
• May scratch a lot, because of itchy skin, or pick at scabs.

More signs of opioid use.

Because most drug users really don’t know if what they are buying contains a lethal dose of synthetic opioids, it is important to know what an overdose looks like and how to respond to one fast and effectively.  Someone’s life might be saved by you knowing what to look out for and how to respond!

Taking too many opioids can make someone stop breathing and eventually die.  Signs someone might be the victim of overdose include:

• Unresponsive to attempts to wake them up.
• Breathing may be shallow and slow or stop altogether.
• Skin paler than normal and may feel clammy.
• Blue tint on lips and/or fingernails.
• Choking or gurgling sounds.

More symptoms of overdose.

It is possible a person is overdosing, you need to act fast.   The Pennsylvania Drug Overdose Immunity Law protects both the caller and the person overdosing from prosecution.

1. Briefly attempt to wake them up.  Shout their name.  Rub your knuckles across their sternum.
2. Call 911 or emergency services.
3. If you have Naloxone overdose reversal medication, administer it.
4. Start rescue breathing.
5. If they wake up or breathe steadily on their own, roll them over to their side in the recovery position.
6. Remain with them until help arrives.

Naloxone, also called by its brand name Narcan, is a medication that immediately reverses an opioid overdose.  Every person in the State of PA has a standing prescription for Narcan.  If someone in your family abuses opioids, having a supply on hand can save a life.

More symptoms of overdose.  
Printable brochure showing how to respond to an overdose.
Overdose response training video.

TREATMENT OPTIONS

Like other chronic illnesses, opioid addiction can be successfully treated.  Treatment options are available if you or someone you love is suffering from opioid addiction.  Counseling along with medications are available.  There is help in the event a person has no health insurance through county drug and alcohol programs.  Often, contacting these county programs is the best way to access treatment.  The office has lists of programs that have been vetted and are evidence-based and they will be able to direct you to resources for payment assistance.

Lehigh County Drug and Alcohol
Government Center
17 South Seventh Street
Allentown Pennsylvania 18101
Phone: 610-782-3555

Northampton County Drug and Alcohol
2801 Emrick Blvd.
Bethlehem, PA. 18020
Phone: (610) 829-4725

Carbon/Monroe/Pike Drug and Alcohol
430 South 7th St.
Lehighton, PA. 18235
Phone:  (610) 377-5177

Schuylkill County Drug and Alcohol
410 N Centre St.
Suite 2
Pottsville, PA. 17901
Phone:  (570) 621-2890

Below are some further resources on treatment and self-help meetings.

Treatment options for addiction.
National treatment locator tool.
Narcotics Anonymous meeting finder.
Celebrate Recovery Christian-centered meetings.
SMART Recovery scientifically based self-help.
Nar-Anon support meetings for family members of the addicted.
Oasis Community Center in Bethlehem, PA.  Help for local families impacted by opioids.

The negative stereotypes about addicted people are still very much alive today, and it costs lives.  A 2014 study by Dr. Colleen Barry of Johns Hopkins University revealed how deep that stigma really is.  Her study found:

• 64% of respondents said companies should be able to deny employment to people with addiction, as compared to 25% for mental health conditions.
• 43% said we should deny people with a drug addiction health insurance benefits.  21% of people said the same thing about mental health issues.
• Only 22% of respondents said they would work closely with a person who suffered from addiction compared to 62% being willing to work with a mentally ill coworker.
• Over 30% of respondents said recovery from drug addiction is impossible.

These attitudes are an enormous part of the reason communities block the construction of treatment centers.  With no treatment available, most continue in their addiction.  On an individual level, fear of being labeled a ‘junkie’ or worse keeps people from opening up to others about their struggles and seeking treatment.

Hearing inspiring stories from those who beat their addiction and entered a fulfilling life in long-term recovery gives hope and shatters the public image of the hopeless, immoral addict.

Inspiring stories of opioid recovery.
Pennsylvania’s stigma website.

Besides believing lives and communities can heal, each of us can take a stand and help:

1. Be vocal.  Talk about recovery and stigma.  Be willing to point out positive examples of recovering people leading productive lives.
2. Pay attention to labels.  The labels we use when talking about people with substance use disorders can color perception.  “Junkie” and “Dope Fiend” conjure up very real negative images.
3. Know the facts about addiction.  Addiction is a disease that affects the body and the brain.  It is not a lack of willpower.
4. Encourage people to seek help.  Making the call to enter treatment is difficult.  Encourage and support people who reach out.
5. Speak up when people invoke stereotypes.  It is easy to go along to get along when people are voicing toxic opinions about addiction.  To make progress against stigma, it is important for us to, with loving kindness, offer a different viewpoint.