Opioids, become no choice. Many parents may remember Nancy Reagan’s anti-drug slogan, “Just say ‘No’ to drugs”, or the anti-drug campaign that used a frying pan and eggs to highlight the effect of drugs on the brain. The messages were simple and catchy. Neither slogan, however, gave parents the full scope of tools to address the risks of drug abuse with their kids. And that is because the physical effect of drug abuse on the human brain was not yet fully understood, especially for dangerously addictive opioids.
Underlying these anti-drug messages was the assumption that drug abuse is a matter of “choice” made with full knowledge of how these drugs may affect the brain’s ability to exercise free will and judgment. The result was that, on the whole, society passed moral judgments on drug addicts. A significant segment placed blame, and then shrugged off addicts on the basis that “they deserve their fate.”
As a consequence, drug addicts were often shunned by society (similar to the morality judgment passed on gay men during the AIDS/HIV epidemic in the 1980s and 1990s). Those addicts who were incarcerated for drug-related behaviors were treated as criminals, not patients. Those who sought treatment were often treated for the myriad of symptoms of addiction, but not the root causes.
If the AIDS/HIV epidemic taught us anything, however, it is that morality and blame have no place in solving the opioid epidemic, or any epidemic for that matter. Human suffering, regardless of cause, should be a call to action. Few amongst us are untouched by the debilitating effects of opioid addiction. The death toll alone is frightening. According to the Center for Disease Control (CDC), deaths from overdoses of opioids have exploded exponentially — fourfold — since 1999. In 2015, deaths exceeded 33,000, almost half of which resulted from overdose of prescription opioids (e.g., morphine, oxycodone [Oxycontin], hydrocodone [Vicodin] and fentanyl). Opioid overdoses now kill more annually than automobile accidents in the U.S.
And why? What’s driving the epidemic?
History Repeats Itself
Today’s opioid crisis is not a new phenomenon. Most opioids, which are technically synthetic chemical compounds, were not in use until more recently (e.g., fentanyl). However, opiates, which are derived directly from the poppy plant, have an extensive history. (Today, the term “opioid” is most often used to include both naturally derived opiates and synthetic opioids.)
Opiate abuse in the U.S. dates to pre-Civil War years, which then mushroomed in the post-Civil War era, as veterans sought ways to deal with chronic pain from battlefield injuries. The drug of choice was typically morphine. Like most, if not all, opiates and opioids, morphine is highly addictive. Opium dens soon became an unwanted public scourge, particularly in New York and San Francisco. Eventually, the perceived threat to public morals and safety prompted a government crackdown on dens that ultimately led to the passage of federal regulation and a subsequent ban on morphine use in the early 1900s, except under limited medical circumstances.
Like cocaine, heroin use was initially legal — and encouraged by the medical profession and pharmaceutical companies — for many years. It was first introduced by the German pharmaceutical company, Bayer, in the late 1890s as a non-addictive “wonder drug” (a heroic substitute) alternative to morphine and a common treatment for bronchitis and common colds. A hero, it was not, despite being approved and recommended in 1906 by the American Medical Association. Over the ensuing decades, the human carnage caused by heroin addiction is generally considered to be the first opiate epidemic in U.S. history. By the early 1920s, an estimated 200,000 heroin addicts lived in New York City alone.
By the early 1920s, an estimated 200,000 heroin addicts lived in New York City alone.
Opiate use and abuse, particularly heroin, continued to increase in fits and starts in the 1940s, 1950s, 1960s, and 1970s, often re-fueled by post-war drug use by veterans of WWII, the Korean War, and Vietnam War looking for relief from chronic pain and psychological distress. Little was yet known about the triggering mechanism for addiction. No one yet understood how opioids disrupted the brain’s normal functions. Addiction was generally
viewed by the public, at least, as a matter of choice, as lack of self-discipline. Efforts to control or reduce opioid abuse, therefore, largely centered on anti-drug laws designed to restrict access to and to criminalize use of prohibited drugs. The net result?
Our jails and prisons are full of addicts. Moreover, without the benefit of modern medical diagnostic tools of today, treatment options for addiction were limited and had limited effectiveness. Treatment generally focused on programs where patients were administered methadone, naltrexone, or like equivalents under the care of physicians.
In other words, if an addict was fortunate to be enrolled in a methadone program, for example, the course of treatment tended to control the symptoms of addiction (e.g., anxiety and physical symptoms), but resulted in the addict simply becoming a perpetual, life-long addict under professional care.
That was then, this is now.
Recreational use of opioids continues to play, and will always play, a part in any drug-abuse related epidemic. No matter the severity of warning signs, a certain percentage of our population inevitably disregards the risks in search of the euphoric feeling from an opioid high. For them, knowledge of risk does not necessarily cause changes in their behavior or decision-making.
Cigarette smokers today, for instance, know the risks associated with smoking and yet they make the “devil’s bargain.” This aspect of human nature may never change. Human nature, being what it is, if the consequences aren’t absolutely certain and severe, or if the payback may be decades in the future, many individuals choose immediate gratification and pleasure.
Today’s opioid epidemic, however, is different. Natural and synthetic opioids are now being prescribed to the general public for pain relief at frequencies and levels never before experienced in U.S. history. The risk of addiction, therefore, is now global, or at least much more pervasive, where in past history the risk was typically limited to a more discrete percentage of the population.
Is there anything inherently wrong with broader use of opioids for medical purposes? No, not necessarily, if used properly. Today’s risk exposure is simply the dangerous downside to the legitimate pain management concerns of treating physicians. Let’s face reality — most of us prefer pleasure over pain, and if pleasure isn’t an option, such as in post-op recovery from hip or knee surgery, we opt for Door No. 2, pain avoidance.
But what if the risk of opioid addiction is significantly greater than generally understood by the common person on the street, or even the medical profession? Not everyone is a historian, or a student of past drug epidemics, or a researcher on the cutting edge of brain chemistry. Nor should they be. As a society, we only know what we know, and we defer to and trust science and the pharmaceutical and medical industries to fill in the knowledge gaps for us. In short, we trust but don’t have the knowledge or ability to verify.
Have the trustees of this knowledge breached our trust? This remains an open question. No doubt that operator error explains the launch point for many addictions. When in pain, patients don’t always follow instructions or heed warnings. However, rightly or wrongly, parallels between pharmaceutical companies and the decades-long tobacco industry cover-up are also being drawn, and “bad apple” physicians are under fire. Certainly, the ugly head of
the greed of a few may have surfaced yet again to potentially taint the medical industry, one of the noblest of professions.
Advances in Medicine:
Understanding the Human Brain
Whatever the explanation and regardless of blame, social attitudes have been slow to change. And again, the reason often comes back to the issue of free will, choice and public perception. An addict doesn’t deserve empathy or sympathy because, even once addicted, they can choose to say “No.” They can choose not to lie, they can
choose not to steal.
And therein lies the ethical rub, the most fundamental of moral judgments underlying why resources haven’t been redirected as quickly or in amounts that the seriousness of the epidemic demands. Why help someone, even someone worthy of saving, if that person is responsible for his or her plight? Fortunately, thanks to advancements in medical research, and in particular through the advent of neuro-imaging of the brain, researchers now know that the underlying premise for the question is fundamentally flawed
Research reveals that opiates radically rewire the brain… to the point where the frontal lobe has little or no control.
The truth is that addiction is a treatable disease, not a simple binary exercise of free will, and the time has come for all of society to hit the “refresh” button on our knowledge and use some common sense. If decisions to use or not use opioids were simply a matter of “choice,” why don’t more addicts choose to stop? Who wants to be an addict? Consider this: No instinct in life may be stronger than the protective instincts of a mother or father, and yet, addicts put their children at risk every day with their addictive behavior, even at the risk of having their parental rights terminated. That’s how strong the compulsion is — so incredibly strong, in fact, that the need for a “fix” literally
overcomes the brain’s “choice” check valve, the prefrontal cortex, and becomes the addict’s only priority, even above primal needs for food and sleep.
Before passing judgment, we all owe it to ourselves to educate ourselves anew, to bring ourselves current in our knowledge of the root causes of addiction. For skeptics, challenge yourself to learn. Do some homework. And as you search for answers, ask yourself a few simple questions: What is the brain chemistry behind extreme compulsive behavior? And how does the human brain function under the influence of opioids, even when used for short durations?
The medical literature tends to be dry, technical, and complicated. If you want quick answers in simple layman
terms, the Sundown M Ranch in Yakima, which is one of the state’s most successful drug and alcohol treatment centers, uses a short informational video, “Pleasures Unwoven,” (available at www.instituteforaddictionstudy.com or www.pleasuresunwoven.com) to explain the brain chemistry behind addiction of any type. The video should be required watching for every doubting parent or educator, and every doubting person before applying their
moral yardstick to addicts. Cost is $30.
What is it, then, that makes saying “no” so hard?
In a healthy, functioning brain, the frontal lobe is where rational thought occurs and “choices” are made. This lobe serves as a governor of sorts, a moral and logic check valve, regulating our behavior by controlling, amongst other things, our primal impulses to eat, sleep, and procreate. For non-addicts with no genetic predisposition to addiction, the frontal lobe (more accurately, the prefrontal cortex) essentially enables us to discipline the brain’s hedonic pleasure system. Most non-addicts, therefore, have the self-control to say “no” to drugs.
Not so with addicts. Research reveals that opioids quickly and radically rewire the brain — in particular, the frontal lobe and the brain’s hedonic pleasure system — to the point where the frontal lobe has little or no control. This defect is no different, in principle, to when the pancreas malfunctions and can’t regulate sugar levels through the release of insulin. With opioids, the frontal lobe is essentially the pancreas of the brain. Damage it, disable it, or exceed its capacity to exert control, and the brain’s hedonic pleasure system completely drives the addict’s behavior.
The Need For The “Fix” To Avoid Painful Opioid Withdraw Becomes The Only Choice
In layman’s terms, the euphoric high from opioid use causes an extreme positive reaction from the brain’s pleasure center, then pleasure-causing dopamine is released in heightened quantities, which, in time and with sustained use, the brain eventually craves on the same or higher level as the basic life functions. Once addicted, the addict’s need for an opioid high essentially becomes an uncontrollable compulsion, a near primal instinct, that overwhelms and neutralizes the frontal lobe’s control panel. And when it ceases to function properly, the drug’s grip on the
addict is brutal.
For the full-blown addict, everyday pleasures do not even register. The addict goes numb to ordinary life. The brain’s
new baseline for registering and recognizing pleasure is fed by opioids, and only opiates, and the pleasure-inducing dopamine spikes that they cause. If the addict tries to stop, withdrawal symptoms start, symptoms so severe and painful that they can cause death. Ultimately, the addict becomes frantic, unable to focus or to hold employment, and will move heaven and earth in search of pleasure and/or to avoid pain regardless of the legal or societal consequences.
In the extreme, fear of shame and loss of self-respect have no impact. The addict’s compulsion causes him or her to lie, cheat, and steal, especially from trusting targets like family and friends. And why? Because the rewired brain is in control, not the person that you knew. The primal need to survive by feeding dopamine spikes to the brain has priority over even food, which, in turn, often leads to extreme weight loss.
Is there any wonder, therefore, why just saying “no” is an “ask” too far? If the compulsion is so severe that the addict will break the sacred trust between parent and child and the bonds of longstanding friendship, the addict is beyond self-help, beyond “choice.”
Call to Action
We need, as a society, to retool our thinking and our moralistic attitudes. Like it or not, all of us are stakeholders in this national emergency. Whether the addiction started by recreational use or by use of prescriptive painkillers, the full risks associated with opioid use were underappreciated by the public. The majority of addicts unknowingly became addicts in weeks or months — teenagers, college students, blue-collar workers, and professionals alike. Opioid addiction does not discriminate.
One thing is clear, however. Blame and stigmatization are not the answer. Treatment is — for the addict and the addict’s family. Drug addiction is a family disease, often pitting parent against child, father against mother, and siblings against siblings. Parents of addicts live in mortal fear of suicide, overdose, or perhaps just as gut-wrenching — when to stop caring and disown a child in the crushing grip of opiates. No parents should be forced to face or
fear these thoughts, even fleetingly, or to drain their family savings without a safety net to save themselves if they do.
In-patient treatment clinics like Sundown M Ranch offer hope. Their successes, through detoxification, aggressive counseling and out-patient support, have healed deep wounds and launched countless “graduates” into productive, healthy, drug-free lives. But they are just the tip of the spear in the fight with too few soldiers to win the war. Like the 300 Spartans at the Battle of Thermopylae against the Persian empire, the Sundown M Ranches of the world need help. For every patient who is fortunate to receive treatment for drug or alcohol abuse, current estimates are that as many as five addicts are untreated for their addiction.
This is unacceptable for the richest country in the world. We need emergency funding for increased age-appropriate drug educational programs in our schools, more specialized treatment centers and counseling resources, longer in-patient stay periods, and lower costs or government subsidization of costs. The crisis is a systemic problem that requires a systemic response by our federal, state and local governments.
Please, call or write your state and federal representatives. And when you do, make it personal because “there but for the grace of God” could affect any one of us.