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America’s opioid plague has no mercy. Drug overdoses are killing more Americans than car accidents, gun deaths or total U.S. casualties in the Vietnam War. “Equal to September 11th every three weeks,” is how one presidential commission describes the nation’s death toll from drug overdoses – at an all-time high for the second year in a row.

Most Americans know someone who are suffering.

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Overdose fatalities are projected to exceed 64,000 in 2016, according to a new report from the U.S. Centers for Disease Control and Prevention (CDC). That’s a 21 percent increase over 2015 – the deadliest annual jump ever recorded in the United States.

As families hold more funerals, a diverse army is mobilizing to stymie the epidemic. More than ever before, steps are being taken to curb the abuse of opioids – responsible for nearly two-thirds of all drug overdose fatalities. This includes opioid prescription painkillers (i.e., Oxycontin®, Vicodin®), heroin and highly potent street fentanyl.

“A Public Health Emergency”
President brings urgency to opioid crisis but no new funds

President Trump declared the opioid crisis to be “a public health emergency” at a White House ceremony on Oct. 26, 2017. What remains to be seen is whether that declaration will mobilize the money needed – billions of dollars – to blunt the epidemic.

In August, the president promised to officially declare a “national emergency” on opioids. That designation would have treated the drug epidemic as we do extreme hurricanes or other natural disasters – triggering emergency funds and manpower from the Federal Emergency Management Agency (FEMA).

What President Trump did instead – declare a “public health emergency” – was more tailored to the opioid crisis, according to Administration officials. The White House says it will work with Congress to increase federal funds for addiction treatment, and redirect existing grants to better fight the epidemic.

Senior officials also said they will expand access to telemedicine so that doctors can treat more patients in rural areas, and launch an ad campaign to convince young people not to try opioids. Other steps include making it easier for addiction professionals to be hired, and requiring training in safe opioid prescribing practices.

“We cannot allow this to continue. It is time to liberate our communities from this scourge of drug addiction,” President Trump said.

Critics noted that without committing new funds, the president’s declaration is empty.

“How can you say it’s an emergency if we’re not going to put a new nickel in it?” Dr. Joseph Parks, medical director of the National Council for Behavioral Health, told the Chicago Tribune. “As far as moving the money around, that’s like robbing Peter to pay Paul.”

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This photo illustration from the Drug Enforcement Administration (DEA) shows how little it takes for fentanyl to kill someone. The white residue is 2 milligrams of fentanyl – a lethal dose for most people.

“Illicit fentanyl and fentanyl analogs are the next grave challenge on the opioid front,” reports the President’s Commission on Combating Drug Addiction and the Opioid Crisis.
Source: dea.gov

Addiction scientists, state governors and health experts shared their ideas in 2017 with the President’s Commission on Combating Drug Addiction and the Opioid Crisis, led by New Jersey Gov. Chris Christie.

“We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation,” the commission stated in its interim report on the crisis, released July 31, 2017. The report acknowledges that people are increasingly turning to dangerous street opioids such as heroin and fentanyl, as access tightens around prescription opioids.

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First lady Melania Trump, left, visits Lily’s Place on Oct. 10, 2017. The West Virginia recovery center treats infants born with neonatal abstinence syndrome (in withdrawal after being exposed to addictive opioids in the womb).
Lily’s Place also provides services to parents and families who are in recovery from addiction
Photo Credit: Chris Dorst /Charleston Gazette-Mail via AP

Here’s a brief summary of the commission’s key recommendations to defeat America’s opioid epidemic, which claims 91 lives each day:

  • Declare a national emergency to fight the opioid crisis. “You, Mr. President, are the only person who can bring this type of intensity to the emergency . . . ” the commission wrote, urging in July for an immediate declaration.
  • Grant Medicaid waivers that eliminate the IMD exclusion, in order to rapidly expand treatment capacity in each state. “This is the single fastest way to increase treatment availability across the nation,” the report stated.
  • Require training in substance use disorders and opioid prescribing at medical and dental schools
  • Immediately fund greater access to Medication-Assisted Treatment (MAT) such as naltrexone and buprenorphine, which have been proven to help prevent drug relapse and overdose deaths
  • Expand access to naloxone (Narcan®), which can quickly reverse an opioid overdose. The commission wants to equip all first responders with the antidote, and require a naloxone prescription to go with high-risk opioid prescriptions
  • Rapidly develop sensors that can detect fentanyl, the highly potent synthetic opioid, and distribute them to law enforcement agencies nationwide
  • Support federal legislation to stem the flow of deadly synthetic opioids through the U.S. Postal Service
  • Increase federal funds to enhance prescription drug monitoring programs (PDMPs), the statewide electronic databases that track a patient’s opioid history
  • Change privacy laws to allow information on substance use disorders to be shared by healthcare providers, so that patients with addiction are not prescribed drugs with high-abuse potential
  • Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) to prohibit health insurers from imposing less favorable restrictions on addiction and mental health treatment than they do for medical or surgical diagnoses. “Not providing real parity is already illegal. The Commission urges you to direct the Secretary of Labor to enforce this law aggressively . . .” the report states.

You can see the commission’s complete interim report on fighting the opioid crisis here. The final report will be released in November 2017.

Here’s a look at some of the other key actions underway to restrict opioid access, get more people into treatment, and save the next generation from addiction.

Lifting Barriers To Overdose Rescue

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Above: A campaign promotes the Good Samaritan Law in Maryland, one of 41 states (as of Oct. 2017) to pass legislation that protects people who report a drug overdose.

Don’t run. Call 911. That’s the message authorities want people to heed if they witness a drug overdose. Most states now have Good Samaritan laws that exempt people from prosecution if they report a drug overdose.

And rapid changes in state laws are making it easier to get naloxone (Narcan), the life-saving antidote that can rapidly reverse an opioid overdose.

Under new state protocols, naloxone is available without an individual prescription at Walgreens in 45 states; at CVS Pharmacy in 43 states; and at Rite-Aid in 24 states (as of Oct. 2017. About half of Rite-Aid stores are in the process of being sold to Walgreens).

A shot of naloxone – either injected into a muscle or sprayed into the nose – can stop an opioid overdose within minutes. Essentially, the opioids are bumped off the brain’s opioid receptors, reversing the effects of overdose and enabling the victim to breathe more normally. This buys time to get the person emergency medical help.

Once available only to first responders and medical professionals, naloxone is increasingly given to lay people through “standing orders” at health departments and local nonprofits, in addition to pharmacies.

A staggering 26,463 overdose rescues were made between 1996 and 2014 by people who received naloxone kits from community groups, according to the CDC. That number is likely far higher today, given the rise of opioid overdoses and increased access to naloxone.

To save more lives, health experts are urging the Food and Drug Administration to make naloxone universally available by changing its status to an over-the-counter medication.

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Above: Naloxone awareness campaigns in New York, Ohio and Utah.

As the death toll from overdose escalates, most states have also adopted Good Samaritan laws. These vary by state, but generally provide immunity from prosecution for people who observe an overdose, call 911 and remain on the scene until help arrives. States that do not have Good Samaritan laws (as of Oct. 2017) are Arizona, Iowa, Idaho, Kansas, Maine, Missouri, Oklahoma, Texas, and Wyoming.

Advil, not Vicodin – The New Normal
Crackdown Intensifies on Opioid Prescribing

America is the world’s biggest consumer of sugar, crude oil – and opioid narcotics. In 2015, the United States held a colossal 99.7 percent of the total hydrocodone use worldwide, and 69 percent of the global oxycodone consumption.

America is also the top consumer of morphine, hydromorphone and fentanyl, according to the International Narcotics Control Board.

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Photo Credit: .hj barraza, flickr

In the wake of the opioid crisis, dentists and oral surgeons are re-thinking their reliance on opioids such as Vicodin and Percocet to manage post-operative pain.

Research shows that Advil combined with Tylenol provides better pain relief, with fewer side effects, than opioids after wisdom tooth extractions.

The explosion of prescription drug abuse and fatal overdoses has led to fewer opioid prescriptions being written in the United States. But rates are still far greater than in other countries, and doctors wrote three times as many opioid prescriptions in 2015 as they did in 1999, according to the CDC.

More aggressive measures are evolving to restrict opioid access:

  • CVS Pharmacy, which manages drugs for 90 million people in the United States, says it will limit opioid prescriptions to 7 days for patients taking them for the first time. Beginning in Feb. 2018, CVS will also cap the daily opioid dosage and require use of immediate-release formulas before extended-release opioids are dispensed.
  • Attorney generals from 37 states sent a letter in September urging health insurance companies to prioritize coverage of alternatives to opioids. This includes therapies such as acupuncture, chiropractic care, massage and non-opioid pain medications.
    • “Although the amount of pain reported by Americans has remained steady since 1999, prescriptions for opioid painkillers have nearly quadrupled over the same timeframe . . . The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable.”
      – Letter from Attorneys General (37 states) to America’s Health Insurance Plans (AHIP), 9-18-17
  • Physicians for Responsible Opioid Prescribing (PROP) petitioned the FDA in August to remove OxyContin 80 mg and other ultra high-dosage opioids from the market.
  • The first-ever national guidelines on opioid prescribing – which have been highly influential – were introduced by the CDC in 2016. These stress that non-opioid therapies such as ibuprofen (Advil, Motrin) should be the preferred, first-line treatment for pain. Exceptions are active cancer, palliative and end-of-life care.
  • When opioids are indicated, doctors are urged to use the “lowest effective dosage.” “Three days or less will often be sufficient; more than seven days will rarely be needed,” the guidelines state.
  • Following the CDC’s lead, many state legislatures are putting limits on prescription opioids. At least 11 states (as of Oct. 2017) restrict the initial prescription of opioids to between 3 and 7 days, depending on the state. Some insurance companies are also setting a limit on opioid prescription coverage, and federal legislation has been proposed to limit initial opioid prescriptions to 7 days.
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The United States consumes more fentanyl (29.3%) than any other country. Source: International Narcotics Control Board

The American Medical Association (AMA) does not mandate how doctors prescribe, but endorses the new CDC guidelines.

“Unless the benefits are expected to outweigh the risks and opioids are clinically indicated, we recommend following the CDC guidelines of start low, go slow,” said Dr. Patrice Harris, chair of the AMA Board of Trustees, speaking at the 2017 AMA State Legislative Strategy Conference, as reported by AMA Wire.

When properly prescribed, opioids can mitigate pain for people with serious, debilitating conditions. But prolonged use can increase addiction risk and distort pain receptors, making a person actually more sensitive to pain stimuli. For an in-depth look at alternative therapies for managing pain, see this article from DrugRehab.org:

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Increasingly, doctors and dentists rely on another weapon to curb opioid abuse: the prescription drug monitoring program (PDMP). These statewide electronic databases show what controlled substances a patient has received in the past six months (including dosage, quantity and prescriber).

Consulting the PDMP, a clinician can identify people who may need intervention for addiction, such as patients who are “doctor shopping” – getting opioids from multiple doctors. The PDMP also targets “pill mills” that illegally dispense vast quantities of opioids.

“In 2015, we saw a 40 percent increase compared to the previous year in consultation of state PDMPs,” said the AMA’s Dr. Harris, in her conference speech. “That was both in states that had mandatory checking and states that did not.”

Every state now has a PDMP (Missouri, in July, became the last state to launch the program) but many are voluntary. In Ohio and Kentucky – two states that require doctors to check the PDMP – opioid prescribing rates have fallen dramatically (85% drop in Ohio and 62% drop in Kentucky, between 2010 and 2015, according to a CDC report).

A ‘Game Changer’:
Police champion initiatives that favor treatment, not incarceration

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Source: The Police Assisted Addiction and Recovery Initiative (P.A.A.R.I.)

New programs such as “Hope Not Handcuffs” and the nationally acclaimed Gloucester ANGEL Initiative herald an encouraging new trend: police are diverting more people with drug addiction into treatment centers instead of jails.

More than 230 law enforcement agencies in 30 states have partnered with the nonprofit Police Assisted Addiction and Recovery Initiative (P.A.A.R.I.) to help people battling substance use disorders. Rather than arrest, P.A.A.R.I. aims to :

  • Encourage people with opioid addiction to seek recovery
  • Help distribute life-saving naloxone to prevent and treat overdose
  • Connect those in need with addiction treatment programs and facilities
  • Provide resources to communities that want to do more to fight the opioid epidemic

“Having law enforcement demand access to treatment is a game changer in the struggle to recognize addiction as a disease, not a crime,” David Rosenbloom, Ph.D., an addiction expert and professor at Boston University School of Public Health, said in an interview with DrugRehab.org in January.
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“Thousands of individuals suffering from addiction are walking into police stations all over the country and getting immediate help into treatment and recovery because the cops won’t take “no” as an answer,” Rosenbloom said. “All too often, these same people have been turned away from emergency rooms and treatment programs that have stigmatized them as nuisances and ‘bad patients.’”

For decades, a punitive approach has been the status quo for drug-related offenses – and stigmatized people with addiction. Just ask anyone affected by the crack cocaine epidemic of the 1980s.

The consequences of criminalizing addiction are “far worse than anything caused by the individual users themselves,” writes J. Robert McClure, president and CEO of The James Madison Institute (a Florida think tank), in an article for The Hill.

“Research has shown that the child of a prison inmate is seven times more likely to be incarcerated in the future than is the child of someone who does not spend time behind bars,” McClure writes. “By incarcerating small-time users, we have broken up families, greatly increased the likelihood that spouses and children will fall into the social services safety net, and set up a generation of children for failure.”

In its mission statement, P.A.A.R.I. says it works to “remove the stigma associated with drug addiction, turning the conversation toward the disease of addiction rather than the crime of addiction.” The organization helps police departments start programs such as the Gloucester ANGEL Initiative, created in 2015 by Gloucester Police Chief Leonard Campanello. Under his plan, people with addiction who reach out to the police for help are not arrested, but immediately taken to a hospital or placed in a treatment program.

Hope Not Handcuffs, created by Michigan-based Families Against Narcotics, partners with police, county health departments and treatment centers to connect people with recovery options. The Arlington Opiate Outreach Initiative in Arlington, Massachusetts, and the Hope Squad in Raleigh, North Carolina are similar programs that provide support without judgment to people with addiction.

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Sheriff Anthony Wickersham introduces the “Hope Not Handcuffs” program in Macomb County, Michigan (Photo by Deb Jacques, C&G Newspapers)

Shattering the stigma:
A cultural shift is underway

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Massachusetts’ campaign to change the way people think about, talk about and treat people with addiction.

It was a watershed moment for public perceptions about addiction. The 2017 Associated Press Stylebook – used by thousands of journalists worldwide – states that the word “addict” should no longer be used to describe a person with addiction. Instead, the AP recommends phrasing such as “he was addicted, people with heroin addiction or he used drugs.”

There’s good reason to change the language that surrounds addiction, according to the Office of National Drug Control Policy:
“Research shows that use of the terms “abuse” and “abuser” negatively affects perceptions and judgments about people with substance use disorders, including whether they should receive punishment rather than medical care for their disease. Terms such as “addict” and “alcoholic” can have similar effects. As a result, terms such as “person with a substance use disorder” or “person with an alcohol use disorder” are preferred.

The neutral, first-person language is part of a cultural shift taking root in America. More people are beginning to see addiction the way scientists do: as a disease, not a moral failing.

Reducing harmful stereotypes (such as words like “junkie”) will get more people the care and support they need, health experts say.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” said U.S. Surgeon General Vivek Murthy, M.D., in the first-ever report on addiction issued by a surgeon general.

There are signs the stigma is changing. Families across the economic spectrum are putting a human face on the epidemic, lobbying for greater access to effective drug treatment that eluded their loved ones.

Public rallies for recovery, social media campaigns to confront stigma, and the explosive growth of recovery community organizations (RCOs) fuel the momentum.

Drug overdose deaths are not shrouded in secrecy anymore. Many surviving family members write candid obituaries and hold public vigils to honor lives claimed by addiction.

College students with substance use disorders are much more likely to find structured support on campus. The number of collegiate recovery programs, which may include sober living dormitories and on-site counselors, tripled between 2013 and 2015, according to the Association of Recovery in Higher Education (ARHE).

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Remembering lives lost to drug overdose at Connecticut Overdose Awareness Day.

People are also shedding the stigma of addiction by going public with personal accounts of recovery. They share their journeys on websites such as I Am Not Anonymous, Faces and Voices of Recovery and Heroes in Recovery.

DrugRehab.org has one of the largest collections of online recovery profiles. More than 100 men and women from all walks of life illuminate their paths to long-term recovery. They describe what worked for them, and offer advice to encourage others who are rebuilding their lives.

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Above: Some of the men and women in long-term recovery who share their stories to inspire others and erase stigma, as part of the “Profiles in Recovery” series on DrugRehab.org.

Despite a gradual shift in how Americans view addiction, only about 10 to 11 percent of people with a substance use disorder currently receive any type of specialty treatment, according to multiple government sources.

Lack of screening and the inability to access or afford care – as well as the long history of discrimination and stigma associated with addiction – are some of the reasons why more people don’t seek help.

Now more than ever, advocacy groups are fighting to change public policy and society’s attitudes, so that more lives can be saved.

“We envision a world in which recovery from addiction is a common, celebrated reality – a world where individuals will not experience shame when seeking help.

We are passionate about sharing our stories of recovery in the hope of inspiring others to join us on the rewarding yet diverse path to wholeness. Together we will demonstrate the power and proof of recovery from addiction.

— from the national advocacy group Faces and Voices of Recovery

Taking this simple step to saves lives

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Left: A pill drop-off event in Indiana, sponsored by the 525 Foundation, part of a nationwide effort to curb opioid abuse. Right: A drop box station at Walgreens, where consumers can get rid of unused drugs.

How do we keep powerful narcotics out of the wrong hands? Community pill drops are part of the solution.

You may have seen the new drug disposal kiosks at your local pharmacy. In response to the opioid epidemic, both CVS and Walgreens have added hundreds of drop boxes in their stores for free disposal of expired, unused or unwanted medications.

The goal is to reduce accidental poisonings, theft and drug diversion. Some teens, for example, raid the family medicine cabinet looking for opioids to share at house parties.

“Nearly half of young people who inject heroin surveyed in three recent studies reported abusing prescription opioids before starting to use heroin,” reports the National Institute on Drug Abuse. Most experimented with prescription opioids after obtaining them from a relative or friend, often without their knowledge.

When prescription opioids are not stored safely, there’s also a much higher risk of harm to young children. A study published in the journal Pediatrics in 2017 shows that a child’s risk of overdose more than doubles if the mother was prescribed opioids (such as codeine, oxycodone or methadone). Safe storage of medication – and prompt disposal of unused pills – is essential to prevent misuse or accidental poisoning, experts say.

Walgreens says it has collected more than 155 tons of unwanted prescription drugs since adding the kiosks in 2016. CVS says it has donated more than 800 pill disposal units to police departments nationwide, in addition to offering in-store kiosks.

You can also drop off leftover medications at many police stations or one of the “Take-Back” events sponsored by the U.S. Drug Enforcement Administration (DEA). To find a collection site near you, and learn more about proper drug disposal, click here.

Holding Big Pharma Accountable

State by state, opioid addiction has ravaged local communities. Now they’re fighting back by taking on the drugmakers and distributors – accusing them of flooding their counties with highly addictive pain pills.

A wave of lawsuits, filed this year by at least two dozen state and local governments, claims the pharmaceutical industry committed fraud: aggressively marketing their drugs as they misled doctors and the public about the addictive nature of opioids.

A typical complaint details the misery of a community hooked on painkillers:
“Like thousands of children born every year Plaintiff BABY DOE was born addicted to opioids. The first days of his life were spent in excruciating pain as doctors weaned him from his opioid addiction. Plaintiff BABY DOE’s mother fell victim to an epidemic that has ravaged Tennessee, causing immense suffering . . .”

Purdue Pharma, the maker of OxyContin, has paid more than $678 million since 2007 to settle lawsuits accusing the company of false branding practices (Purdue Pharma claimed OxyContin was not addictive). Three executives were found guilty of criminal charges.

“Purdue Pharma ignored the devastating consequences of its opioids and profited from its massive deception. It’s time they are held accountable and pay for the devastation they caused,” said Washington state Attorney General Bob Ferguson, announcing a lawsuit that blames Purdue Pharma for fueling the opioid crisis in Washington. Opioid sales there rose more than 500 percent between 1997 and 2011.

In West Virginia – the state with America’s most overdose deaths – one lawyer is using a novel legal strategy to enact change. Personal injury attorney Paul Farrell is going after the distributors – the middle men who move opioids from the drugmaker to the pharmacies – by declaring them a “public nuisance,” a hazard to human health and safety. You can hear NPR’s interview with Farrell here.

A massive civil probe is also underway to investigate opioid marketing practices. Forty-one states have banded together and issued subpoenas for five pharmaceutical companies and three opioid distributors, to determine their role in the epidemic.

One of the areas hardest hit by opioid abuse is Cherokee Nation, which comprises 14 counties in Oklahoma. Like the states, Cherokee Nation is fighting back, with a lawsuit against multiple drug distributors and three retail giants: CVS, Walgreen’s and Wal-Mart.

“These drug wholesalers and retailers have profited greatly by allowing the Cherokee Nation to become flooded with prescription opioids,” the petition states.

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Cherokee Nation housing program in Vinita, Oklahoma Source: Cherokee Nation, Facebook

Cherokee Nation accuses drug distributors of fueling the black market for opioids by turning a blind eye as they filled suspicious orders from pharmacies. Those pharmacies routinely ignored “red flags,” such as a patient trying to fill multiple prescriptions from different doctors or traveling far from home to get a prescription filled, the petition said.

Opioid abuse has claimed more than 350 lives in Cherokee Nation since 2003. The lawsuit chronicles babies born dependent on opioids, children losing their parents by death or court order, and American-Indian students using heroin and OxyContin at rates 2-3 times higher than the national average. “These impacts are so severe, cumulatively, that Defendants’ conduct threatens to decimate Cherokee Nation,” the petition noted.

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