Shedding Light on the Opioid Epidemic: We Are Our Own Enemy

We’ve all heard the phrase “Six Degrees of Separation.” The idea has spurred websites, books, plays and movie plots, but it’s actually based on the small world theory that states you’re connected to people through an average of six relationships with others. Originating back in the 1920s, the theory brings to light the common phrase “I know a friend who knows a friend…” and shows just how interconnected human relationships have become. In some instances, it can be fun to see how many “degrees” you are away from a celebrity, or the president, or the Pope.

But, step back and consider America’s opioid epidemic; suddenly the game takes a much darker turn.

2.7 million people battled a dependency or addiction to opioids in 2015. The following year, 59,000 people died from an overdose of opioids. Each day, 91 people die at the hands of the drug, or about 1 person every 15 minutes. With these statistics in mind, it’d be difficult to find someone who falls outside the “six relationship degrees” and who hasn’t been either directly or indirectly affected by the opioid crisis.

As I type this, I realize just how close I am to it myself. My cousin is my most direct link to the epidemic, having battled opioid addiction for a number of years. My co-worker’s boyfriend, the next degree of separation, passed away from an overdose. Add one more separation link, and I have my friend’s friend’s friend who likewise faced a prescription drug battle that morphed into a heroin dependency.

What exactly caused the crisis that has touched the lives of so many? We could analyze the factors that contributed to the rise of prescriptions and subsequent addictions and dependencies. But, these have been talked about. We know that Big Pharma heavily marketed painkillers in the mid-90s. We know doctors overprescribed through the encouragement from Big Pharma. We know pharmacies dispensed more than they should have. Finally, after years of letting the crisis build up to its epidemic status, steps are being taken to combat it.

But, could there be a greater issue at hand? Does America have an underlying cultural problem that fueled the country’s dependency and enabled the nation to consume 80% of the world’s opioid market?

The answer is deeply rooted in our society’s misunderstanding of mental health. There is a clear disconnect between wellness of the body and wellness of the mind, one that places the former ahead of the latter. Pain of the mind that comes in the form of mental illness can be subjective to each individual and isn’t always showcased through physical symptoms, making it very difficult for physicians to diagnose and tough for those who aren’t suffering to grasp the severity of the situation.

America’s view of mental health is one that combines two distinct stigmas to create an overall negative view of mental illness and the act of getting help. On one hand, there’s the presence of a social stigma, the discriminating behaviors against individuals dealing with a mental illness because of long-standing views that these people are dangerous and unpredictable. Add to this the self-stigma of mentally ill individuals who internalize feelings of shame and resist seeking out treatment. Because of these ignominies, less than half of all adults struggling with a mental health condition actively try to receive treatment, and yet this is the leading cause of disability in the country.

Now, compare the culture surrounding mental illness to that of opioid prescriptions. There are individuals choosing to not seek out treatment for mental health conditions, and yet doctors and Big Pharma fuel the act of over-prescribing for everything from chronic pain to post-surgery recovery.

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16 thoughts on “Shedding Light on the Opioid Epidemic: We Are Our Own Enemy

  1. Now, compare the culture surrounding mental illness to that of opioid prescriptions. There are individuals choosing to not seek out treatment for mental health conditions, and yet doctors and Big Pharma fuel the act of over-prescribing for everything from chronic pain to post-surgery recovery.

    I don’t necessarily disagree with you, but it strikes me that you are stealing a base in this conclusion.

    You imply there is a link, but you need to do more work to show it.

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    • One problem with the conclusion is that a lot of the time mental illness is also treated with pharmaceuticals, and many of those are pretty aggressively marketed to both physicians and patients.

      On the other hand, I wonder if by making that leap, the OP is overlooking a more profound and troubling possibility. It’s a long-known thing that people with undiagnosed mental illnesses often try to “self medicate” through use of recreational drugs.[1]

      How many of the people abusing opioids are doing so, at least in part, because they have undiagnosed mental illnesses that aren’t receiving proper attention due to the invisibility of mental illness and the stigma associated with it.

      [1] As a minor and relatively benign example, I took up smoking largely as a way to manage ADHD, and used to seriously load up on caffeine. I was able quit smoking pretty soon after getting it diagnosed and receiving real medication for it, and my coffee consumption now resembles that of a normal human being.

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  2. Living in Colorado, my first thought was “I wonder what impact legal weed is having on the opioid crisis in Colorado…” and found two links that I’m trying to reconcile in my head.

    The first one is Newsweek (yeah, I know) but it says:

    After analyzing hospitalization records from 1997 to 2014 in 27 states, nine of which legalized medical marijuana within that timeframe, researchers from the University of California San Diego found hospitalization rates of people suffering from painkiller abuse and addiction dropped on average 23 percent in states that offered medical marijuana. Opioid overdose cases at hospitals in states with legal weed also dropped by an average of 13 percent, the study said.

    But The Denver Post says this:

    Overdose deaths from prescription opioids in Colorado likely dropped last year to their lowest level in six years, but the state also saw a possibly connected increase in heroin and cocaine overdoses, according to preliminary numbers from Colorado’s Health Department.

    Overall, the total number of opiate deaths — meaning deaths from both prescription painkillers like fentanyl or from illegal opiates like heroin — fell by about 6 percent, from 472 deaths in 2015 to 442 deaths in 2016. That marked a rare yearly downturn in opiate deaths, which have been climbing year-over-year in Colorado since at least 2000, with a couple other exceptions.

    So deaths are down but ODs are up… and the ODs are probably up because of the crackdown on the pills in the first place.

    So…

    I dunno.

    I thought maybe an increase in Medicinal would actively help things and maybe it would nudge things in a better direction…

    But I dunno.

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  3. This is a great post on an important and interesting topic.

    There is a very strong, very clear scientific literature on the genetic basis of addiction that has been around since before the opioid crisis. Nevertheless, most lay people, even most physicians, continue to think of addiction as a moral problem. This worldview is probably responsible for the lion’s share of blame for the opioid epidemic.

    When physicians prescribe narcotics to “normal” people, they say, this person is “normal”. They will never become an addict. What they should do is inquire about family history of addiction – in a few years we may even have genetic testing – and then prescribe an alternate regimen that controls acute – i.e. post-surgical – pain to a minimally acceptable level while also minimizing harm and likelihood of a patient developing dependency. A lot of this kind of thinking is already being put into place in response to the opioid crisis, and it’s making getting surgery a lot less fun than it used to be but a lot safer in the long-run.

    (By the way, I see you’re new here. Welcome! I used to write a lot more and am looking forward to getting back to it within the next few months. My unsolicited advice is: don’t think the number of comments a post gets has anything to do with its quality. My best posts get crickets, and my worst posts often get hundreds of comments. If you’re shooting for a raucous reaction, write about libertarianism, atheism, or unions, preferably all three at the same time. You could, for example, entitle your post, “Are Atheists Just Libertarians When It Comes to Unions?” It doesn’t even have to make sense. You’ll get at least 300 comments. I may even generate 300+ comments just by mentioning libertarianism here. Libertarianism.)

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    • In general I agree with you but there are dangers to this approach as well (er, approach to opiate prescription, not approach to getting comments :P).

      “What they should do is inquire about family history of addiction – in a few years we may even have genetic testing – and then prescribe an alternate regimen that controls acute – i.e. post-surgical – pain to a minimally acceptable level while also minimizing harm and likelihood of a patient developing dependency. ”

      I have an enormous family history of addiction on both sides and I took (still lean toward taking) that approach to my own pain. Both in acute cases, after surgery (oh, you’re going to put ME in charge of the button? yeah, you’re going to end up lecturing me that I’m putting myself through too much and swamping me with high doses anyway, good thing since I wouldn’t have done it myself) and also when dealing with chronic pain.

      Which led to me underdosing my own pain for most of my life, and shoving a lot of really physically painful conditions under the rug because I didn’t want to get swamped with pain pills if I was honest about how awful the pain was.

      It was only once my family doctor convinced me I could trust her when she told me I really wasn’t a high addiction risk (which, looking at a much broader base of information than just genetics, I really *am not*) that I was able to allow myself the freedom to treat my pain to where it stops making me miserable instead of to where I could pretend it wasn’t making me miserable (which is what “minimally acceptable” means for a lot of patients).

      Turns out she can prescribe me all the vicodin in the world, and I’ll still only take one or two every month or two. Same thing with other pain medicines that carry a risk of dependency…. I have some “at will but at least once a day” meds, and I struggle far more with remembering I’m allowed to take more than one a few times a month, than with any desire to overdose. (I could actually take more than one a few times a week. But I don’t. Nor do I feel any desire to.)

      This despite 3 out of 4 alcohol addict grandparents and a very drug addicted father.

      I think there are both genetic factors and also self-medication factors at play. And if my doc had treated me like someone at serious risk of becoming an addict despite my non-history of addictive behavior, especially once I started to get my mental health under control enough to ask for the help with physical ailments that I needed… I would have bailed on her. And gone back to hiding all the hurts I was feeling.

      I’m not the only person in that situation that I know, either.

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      • At the risk of diverting the discussion sideways

        We don’t have, I think, a proper medical understanding of pain mechanisms, and, therefore, of pain management.

        I am a pain outlier. I have a very high pain tolerance. Very, very, high. High enough that I’d rather not use anesthesia in dental work (the numbness is more uncomfortable than the “mild” pain) ; local anesthesia surgery isticklish instead of painful. I broke a rib and waited two days to get X-rays because it was just a mild ache to me (“you can’t have a broken rib, you’d be rolling in the floor with pain”, I was told) when doctors ask me “does it hurt?” I have to engage with him at length to determine exactly what “hurt” means in his mind. I normally have to ask: “Do you mean, can I feel it? Or do you mean, is it an unbearable pain?”

        I’m sure there’s people at the other end of the spectrum. I wouldn’t dare tell them to just bear it. But I believe we should be able to research quantitatively what pain means for different people, and prescribe painkillers appropriate to each person(*).

        I understand the ethical implications of studying pain in humans (or in animals) and I don’t have a suggested way around (**). But until we understand better what is pain and how to measure it and block it, we are at risk of ruining many lives.

        (*)I’ve had one Vicodin pill in my life I didn’t feel it made any difference, and didn’t take any more. I had a two weeks prescription.

        (**) I actually do: something like the Gom Jabbar test. You touch something, like an electrode, and the doctor registers when you (a) first feel it; (b) when it starts being uncomfortable; (c) when is it “painful”; and (d), when you can’t withstand if any more. That way you can create an objective pain tolerance graph for each individual patient.

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        • @j_a I don’t disagree with you that our understanding is poor. For that reason I’m going to criticize what you said even though I largely agree with you:

          What you are talking about seems to be both pain threshold (you have a high one) and pain tolerance (whether you can function regardless of the pain you may be experiencing).

          My pain threshold is very low and my pain tolerance is very high. A lot of abuse survivors fit this profile, actually, my doc has explained to me very patiently that it’s common and I am one of them.

          So the Gom Jabbar would be either really not very useful – wow, she hurts near instantly and yet can withstand it for hours – or inaccurate because I’d have the common sense to not subject myself to even more pain than I already have to feel, fairly quickly.

          “When you can’t withstand it anymore” is not at all objective, unless you’re willing to torture people. And even leaving the far more important ethical considerations aside, data obtained that way is suspect.

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          • I stand corrected on your threshold vs tolerance difference, something I hadn’t thought much about, because, with a very high threshold, high tolerance is automatically included (“Hey, you can’t have a broken rib, you wouldn’t be going on for days if you had a broken rib”)

            (My broken rib story: I went scuba diving, and slipped climbing onto the boat after a dive, hitting my chest against the border of the boat. I dived again that evening. Twice more the next day. Packed and carried to tanks and equipment and drove home. Went to the office the next day. Finally went to the doctor on Tuesday, since the “pain” wasn’t going away. Letf the doctor and went back to the office, with a painkiller prescription that I didn’t bother to fill up, because it was that bad, as long as I didn’t cough)

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            • @j_a Yeah, I have a sister like you. It’s caused her more problems than it’s helped with, IMO. Though once she got to be an adult she got pretty bullish about making sure the doctors got it, and eventually found a doctor who respected what she knows about her own body, which helps for mundane stuff, not so much with emergency room stuff.

              (As a kid she broke a lot of bones – horseback riding, playing rugby, etc. – so she came to figure out “this is what a break feels like” even though she wasn’t all that bothered.)

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        • The best science has done is the fun pain chart with the faces.

          And it’s because pain is very, very subjective. What causes one person mild discomfort might be almost unbearable agony to another.

          And needlessly suffering pain is just as bad for healing as overuse of painkillers.

          A nurse had to talk my mom into a morphine shot, because she was clearly in 7 or 8 on the pain chart — but didn’t want drugs, because she was afraid of “getting addicted”. The stress from the pain was making everything worse — and harder to diagnose, because her BP and pulse were skyrocketing because of extreme pain.

          My experience lately has been that doctors are willing to give immediate relief (stuff like morphine shots, and single doses of drugs) because they can control use — and that when it comes to prescriptions, they are starting to be very careful with how much they hand out and what.

          In general on the opiod addiction, I think John Oliver’s piece of oxycontin is pretty useful — in addition to being heavily marketed to both doctor’s and patients (and billed as ‘non-addictive’) it was advertised as 12 hour pain relief when it was…8 hours.

          Which led to patients upping their own dosages to try to “make it” to the next dose without suffering, which…was ineffective and upped the likelihood of addiction.

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        • One of my friends doesn’t feel pain or fear. He’s carved into his arm just out of curiosity. He’s odd.

          In Iraq he drove a wrecker because it was the most exciting job to have. The Iraqis would plant an IED to damage a convoy and then the medevacs would come in for the dead and wounded and everyone else would clear out. Then the Iraqis would set up an ambush around the disabled vehicle, waiting on the wrecker to show up. He was the guy driving the wrecker. He loved it.

          Then he got hit with an electrical explosion and blown across a hangar. He got up and went back to work until other soldiers sent him to the hospital. It was all on camera. The doctors figured out that he was wildly abnormal, found a heart murmur, and gave him a medical discharge.

          So he returned to the civilian world and took a job driving a wrecker, working as a repo man. He uses a tilt bed for the repos, which no normal repo man will do because it gives the former owner too much time for a violent confrontation. My friend uses it because he gets off on violent confrontations. That’s why he’s a repo man.

          He’s studied multiple martial arts all his life and has only been stymied by a master in an obscure Vietnamese stick art, but after a few months of training he handled that too. On his first day of Marine combat training the instructor said anyone who could take him would get the rest of the day off. After the first bout he realized his instructor wasn’t skilled at ground fighting, so he took the instructor down twice in a row and got the day off. He is not someone who loses many fights.

          That leaves guns. He loves having people pull guns on him. On his first day as a repo trainee a guy came up behind him and put a pistol in the back of his head near the base of his skull. He leaned his head back open the gun’s slide and the gun went click. (This does not work on revolvers). Then he turned around and grinned and the guy freaked out in panic. The experienced repo man who was training him resigned the next morning, saying he wouldn’t work with a psycho. Since then he’s had guns pulled on him over thirty times. He lives for that. He also loves it when people hit him in the face, which makes him smile. On several occasions he’s freaked out a driver by denting their car with his fist as he screams at them to get out and hand over the keys.

          All this because when he was nine his little sister hit him in the head with a golf club, causing significant brain injury. Doctors should study how that worked because it’s way better than having people zonked out on opiates. The only downside would be a society filled with people who live on adrenaline and aren’t afraid of injury or death.

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            • No I haven’t, but I’ve always heard great things about it.

              As an aside, a few weeks ago my friend had the repo of a lifetime, a Ferrari Enzo whose owner still owed $300,000 on it. He had the pics on his phone. He is supposed to get 20% of the value owed. We’ll see if that happens.

              Perhaps the oddest thing about my repo friend is that he’s super friendly and helpful. If he’s been at work for 20 hours straight and someone 20 miles away needs a tow, he’s there for them.

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