Addressing addiction has changed from force to care as the opioid epidemic has exponentially grown
Opioid addiction takes a personal toll, but it also has countrywide consequences.
On an average day in the U.S., someone begins nonmedical use of opioids every 22 seconds; someone starts using heroin every two and a half minutes; and someone dies from opioid-related overdose every 16 minutes, according to the Centers for Disease Control and Prevention.
Fatal accidents involving both legal and illegal prescription drugs surpassed those involving alcohol in 2015, a new Governors Highway Safety Association study finds. And, according to the Federal Bureau of Prisons, 46.3 percent of federal inmates across the United States are serving time for drug-related offenses.
Opioid abuse has skyrocketed in the last 15 years, and the U.S. government has started to change its approach to the problem, transitioning from a “war on drugs” mentality that pegged users as criminals to efforts to treat people as victims suffering from a disease – a move that many think comes down to black vs. white.
“We are very glad that this issue has national attention, and that we’re now changing the paradigm and talking about the disease of addiction, [but] we do need to point out that there is a racial component involved, too,” says Dr. Leana Wen, Baltimore City’s health commissioner. “When addiction primarily affected those in inner cities who are poor and minorities, … we were talking about addiction as a crime. And now that it is affecting white communities and potentially wealthier communities, it is seen as a disease.”
Karen Holliday, a recovering addict of 30 years who has been in and out of jail, agrees.
“That went on for a long period of time because they didn’t address my addiction or my mental issues,” Holliday, who is African-American, recalls. “It wasn’t a problem at first, it was acceptable to some people on a higher level; they didn’t care about those on the bottom level. Now that it’s climbed up the ladder, it’s becoming a priority for them.”
Drug abuse is not a new problem
Drug abuse is a complex, chronic issue that affects all 50 states and thousands of families each day. The solution isn’t simple, and there is no one size fits all approach.
One in seven Americans face substance addiction, according to the Surgeon General’s 2016 report.
“The biggest misconception that people have about opioid addiction, and any addiction, is that it is a choice that individuals make. Therefore the implication is that if someone is addicted, it’s a moral failing – if they end up dead, it’s their fault,” Wen says. “Addiction is a chronic brain disease, and needs to be treated like any other chronic illness.”
American opioid use, whether legal or illegal, is nothing new. People in the U.S. have been taking, smoking or injecting opioids in various forms since at least the 19th century. In fact, Bayer – the chemical, pharmaceutical and life sciences company many consumers associate with aspirin – used to sell heroin as a cough suppressant and pain reliever for children in the late 1800s and early 1900s.
But in 1909, Congress passed the Smoking Opium Exclusion Act – often seen as the first federal law against the use of nonmedical substances, it banned the importation of opium except for medicinal purposes. This act primarily affected Chinese immigrants and the working class, who smoked opium to relax much in the same way people enjoy an after-work drink today. The Harrison Act of 1914 further restricted all nonmedical use of opium, morphine and cocaine, imposing taxes on importers, manufacturers and distributors, but not on physicians.
The problem left unaddressed was, and continues to be, that people sought the addictive drugs whether they were legal or not. And while the list of prohibited drugs grew and the penalties became more severe, people still found sources to feed their addiction. Drug use exploded in the 1960s and ’70s, especially among the lower class and African-American communities. The number of people incarcerated on drug-related charges grew in the 1980s and skyrocketed in the ’90s.
Holliday was exposed to substance abuse at an early age. Growing up in the 1960s and ’70s in east Baltimore, she first tried marijuana at the age of 7 and was addicted by 11 to various other drugs. She started taking heroin when she was 13. Drugs were a way to numb the realities of a horrific home life: Her stepfather killed her mother while she and her sister watched, she says, but the abuse was rampant long before that.
“My stepfather was abusing me, from the time I was 3 ’til I was 15,” Holliday says. “I thought that drugs were my escape. It lead me to be somebody that didn’t have to feel that type of issue or pain.”
She was hooked on drugs for 35 years. Despite graduating from high school, she felt she had nothing to live for. She became pregnant. She had two children that she couldn’t take care of because of her addiction, and says she wandered the streets of Baltimore for 30 or so years “like a zombie.”
Physicians have turned to opioids to help with acute and chronic pain for years, though early on the risk of opioid addiction was not fully understood. A letter to the editor, written by a doctor and published in the New England Journal of Medicine in January 1980, was used by pharmaceutical companies to promote opioids for the next few decades, and doctors began to prescribe higher doses and larger quantities of opioid pills.
“They didn’t realize that these were addictive, or as addictive as they are,” says Dr. Mark Edlund, a research scientist for RTI International, an independent, nonprofit research institute.
But patients who received prescriptions for pain found out first-hand how addictive opioids can be.
Morgan, a recovering addict who asked that her full name not be used, was given opioids by her doctor when she was a senior in high school, after she was in a car accident. She became addicted and eventually moved on to heroin.
“I was in search of [opioid] pills and I had a friend and they were like, ‘Well you should try this because it’s cheaper and, you know, it’s better,’” recalls Morgan, describing the first time she tried heroin. “I tried heroin one time, and I never looked back.”
As the opioid crisis escalated dramatically between 1999 and 2015, physicians, pharmacists and researchers began to dive deeper into the long-term effects of opioids, and since 2005 have worked on offering lower doses and prescribing opioids to people at lower risk for addiction. But that level of change takes time, says Edlund.
“Now I think that the challenge is that we have a large number of individuals in the country who are addicted to opioids, and what do you do then?” Edlund continues. “You have a lot of people who are either addicted or they’re on high-dose opioids and maybe they’re not addicted, but it’s unclear whether or not they need those high of doses.”
In 2014, almost 2 million Americans abused or were dependent on prescription opioids, and more than 1,000 people are treated in hospital emergency departments for misusing prescription opioids every day, according to the Centers for Disease Control and Prevention.
Relapsing compounds the problem.
“It is estimated that at least 70 percent of patients administered to treatment programs will relapse in the first year,” says Dr. Nora Volkow, Director of the National Institute on Drug Abuse. “Certain environments, emotions can trigger these memories and lead to relapse. You can’t completely control those aspects of your life from pushing you into relapse.”
Opioids work by stimulating opioid receptors in the nervous system, reducing feelings of pain and flooding the user’s brain with dopamine, a feel-good hormone. The result: a calm and happy high. Once the opioid wears off, however, the person’s brain dopamine levels drop and the euphoria disappears, leaving the user craving more. The body rapidly builds up a tolerance to opioids, so it takes more and more of the drug to create the same pain-relieving and euphoric effects.
People who have been treated for opioid addiction or who tried to stop using are often unaware that they no longer have the tolerance levels they once had. When they try the drug again, often at the high doses they used to abuse, they end up overdosing.
That’s what happened to Scott Klima.
Klima first began taking nonmedical opioid prescription pills when he was in high school, his sister, Kristy Flower, recalls. He wanted marijuana, but his dealer was out, so he opted for something else.
“It was something that he tried. He said it was a one-time thing, that he was just experimenting,” Flower says. “He liked to smoke marijuana, basically. Once he tried heroin, that was it.”
While Klima struggled with his addiction for the next several years, their parents tried whatever they could to help him, Flower says. They tried group counseling sessions, a move from Maryland to Florida and multiple treatment centers, but nothing stuck.
In May 2006, the police came knocking on Flower’s door, saying that Klima had to answer charges against him in Florida for possession of marijuana. Shipped south, he spent months waiting to hear from his public defender and family, Flower says, and he was offered no treatment options while incarcerated.
When he was finally released in late December 2006, Flower says, Scott was far from home. He had no money or shoes, and he had nowhere to go and no way to contact his family. He managed to make it back up to Maryland by mid-April, but Flower recalls that something in him had changed. The whole ordeal, she says, “truly broke his soul and left him with little or no self-esteem.”
In the last year of his life, he tried to stay clean, Flower says.
Klima resumed working with their dad for a pool company, and received his first paycheck on Friday, May 18, 2007. The next morning, a cop was at Flower’s door to inform her that her brother was dead.
“It was just one more time – he had a paycheck, and tried it one last time, and he didn’t wake up the next day,” Flower says. “I honestly do believe in my heart that if he could have been given proper treatment versus incarceration, he’d still be here today.”
The way authorities and experts view addiction is changing, with treatment, and not incarceration or punishment, being heralded as a better way to combat addiction.
Holliday has been in recovery for three years, though she would tell you herself that it was not by choice. After three decades between jail cells and living on the streets, she woke up in a psychiatric ward and was informed that she had undiagnosed schizophrenia.
“Once I got the treatment for my issues and schizophrenia, I realized I didn’t want to use anymore. I didn’t want to be homeless, I didn’t want to go to jail again,” Holliday says.
Experts say they know treatment works, but people aren’t able to access the help they need when they need it. Only one in 10 people with substance abuse disorders receive the treatment and support to address their addiction, according to the Surgeon General’s 2016 report.
“We actually know what works, and the frustrating thing for us as public health officials is that we know what works, we just need the resources to be able to get there,” Wen says. “If we said that now there’s an Ebola outbreak, or now we need to cure cancer, the next question would be what are the resources we are going to commit? We should treat addiction with the same urgency and attention as we do any other illness.”