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This January President Donald Trump gave his first State of the Union Address to Congress and the Nation. As part of his America First agenda, he outlined several pillars of a plan to provide critical reforms the country needs.

Three months prior to this address, Trump declared opioid addiction a public health emergency. However, in the hour and a half, 5,000-word speech, the word opioids was used only once in a 213-word section. Trump pledged commitment to better drug treatment and the opioid problem. “In 2016, we lost 64,000 Americans to drug overdoses: 174 deaths per day. Seven per hour. We must get much tougher on drug dealers and pushers if we are going to succeed in stopping this scourge,” he said.

Although 90 days has passed since the health emergency was declared, and little time was spent discussing opioids during the State of the Union address, the crisis has not been forgotten. Several branches of government stepped in the weeks around the State of the Union and announced action.

The Acting Secretary of the U.S. Department of Health and Human Services, Eric Hargan, renewed the public health emergency status for the opioid crisis though funding was not mentioned.

On the day of the Address, U.S. Attorney General Jeff Sessions went to Louisville, Kentucky, a city named by the Major City Police Chiefs Association of America as the 11th most dangerous city in the United States. Speaking to an audience of law enforcement officers, he inferred violent crime goes hand in hand with the drug crisis. The Administration’s focus on law enforcement was highlighted rather than the actions they could take to support the medical community in the war on drugs.

Sessions said, “For Americans under the age of 50, drug overdoses are now the leading cause of death.” Sessions went on to say, “Meanwhile more people are dying from drug overdoses than ever before. More than 1,400 Kentuckians died of overdoses in 2016. Nearly half of these deaths were the result of fentanyl, and a third involved heroin.”

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FDA Joins in on the Fight

On the same day, FDA Commissioner Scott Gottlieb, M.D. outlined new steps to help prevent new addiction, curb abuse and overdose related to opioid products. Tackling the supply side of the problem, Gottlieb affirmed this complex issue remains one of his highest priorities. “We believe it’s going to take carefully developed, sustained, and coordinated action by everyone involved to reduce the tide of opioid addiction and death afflicting our communities; while maintaining appropriate prescribing for patients in medical need. We recognize both the urgency and complexity of this crisis and are taking several steps today toward these goals.”

“With 11.5 million Americans misusing prescription opioids in the past year and more than 40 people dying every day from overdoses involving prescription opioids, it has become abundantly clear that more vigilant action is needed from the FDA and others to get ahead of this crisis,” Gottlieb continued.

Since legally prescribed medications like Vicodin and Percocet are frequent gateways to new addictions, the FDA is asking the medical community and the pharmaceutical industry to get involved. Professional communities could rethink expert guidelines and recommend dosages designed to minimizing prescriptions of highly addictive substances such as pain killers. Manufactures could align their manufacturing to include these smaller dosage quantities used with routine procedures, making it easier for physicians to prescribe them in smaller quantities. To help reduce abuse, blister packaging could make it more difficult to bundle large quantities of opioid pills.

The FDA is taking action. Requests have been issued to health care partners asking for changes in labeling and packaging of a frequently abused drug, Loperamide. Opioid users abuse the medication to achieve a euphoric high. Serious heart problems and deaths have occurred in people who had purposefully taken these in high doses.

Online distributors of drugs with potential for abuse are being asked to make changes. “You have a social contract to take voluntary steps to help address public health challenges,” said Commissioner Gottlieb, hoping distributors will do their part to stop the tide of new addicts.

No doubt the FDA Commissioner has heard about the new congressional investigation into massive, disproportionate shipments of opioid painkillers. Between 2006 and 2016, out-of-state drug companies shipped nearly 21 million to two pharmacies within two blocks of each other in Williamson, West Virginia, population 2,900. It is no wonder the state has THE largest percentage of death by overdose in the nation according to the Center for Disease Control statistics.

This year the FDA also began requiring cold and cough medicines containing opioids to change safety labeling limiting its use in children younger than 18 years old. FDA Commissioner Gottlieb said, “Given the epidemic of opioid addiction, we’re concerned about unnecessary exposure to opioids, especially in young children. We know that any exposure to opioid drugs can lead to future addiction. It’s become clear that the use of prescription, opioid-containing medicines to treat cough and cold in children comes with serious risks that don’t justify their use in this vulnerable population.”

Codeine Cough Syrup

Credit: NBC News Bay Area

This is all part of the FDA’s ongoing work to shrink the epidemic of opioid addiction. The FDA is also supporting treatment for those with opioid use disorder, fostering development of novel pain therapies, and improving enforcement.

In 2015 investigated the abuse of cough syrup in a feature on Purple Drank which is a toxic cocktail comprised of prescription cough syrup with the opioid codeine and promethazine (an antihistamine). Users typically add lemon-lime soda and hard candies for color and sweetness, and sip the beverage for hours, concealed in foam cups.

“Everyone knows about codeine and promethazine in the South. It’s almost like asking someone if you’ve ever heard of marijuana,” says Dr. Ronald J. Peters, who conducted studies on cough syrup abuse as associate professor of public health at the University of Texas Health Science Center at Houston.

“It’s very addictive. You can have an overdose, people have had what is called “syrup comas,”’ Peters says. “There have been many under-reported accidents with kids trying to drive cars and actually falling asleep at the wheel because of this (codeine-promethazine abuse).”

Here’s what an expert from the National Institute on Drug Abuse said about the steel grip of addiction in a 2014 interview with

“When we talk about addiction, we are dealing with a disease. It’s not just someone who is weak-willed or choosing to go down this particular path . . . We can visibly see, through the use of imaging technology, where drugs bind in the brain and what impact they have on the brain.”

— Dr. Jack Stein, Director of the Office of Science Policy & Communications
The National Institute on Drug Abuse (NIDA)

Relapse rates for addiction are similar to other chronic diseases, Stein said. He notes that Type I diabetics, for example, have a relapse rate of 30 to 50 percent (i.e., compromising their treatment by not taking insulin). For hypertension or asthma, relapse can be as high as 50 to 70 percent. And while someone makes the initial choice to do drugs, addiction alters the neurochemical and molecular structure of the brain, clinical studies show. Judgment and decision-making functions are impaired in people with addiction, and this can fuel self-destructive behaviors.

DJ Lil Randy

“Kids need to understand, it’s a very addictive drug”
–– DJ Lil Randy, friend of the late hip-hop pioneer DJ Screw, who died after a Purple Drank overdose

With each new Administration comes new vision and a promise of better times ahead. One of the campaign promises President Donald Trump made to the American people was to ramp up the fight on drug addiction and the opioid crisis. For a look at what has been done in the U.S., investigated the progress in the Fall of 2017.

Front Line Action from Enforcement
Rural Areas Now Have Access to Care

In 2000 Drug Abuse Treatment Act was passed and allowed only specially trained physicians to treat addicts with buprenorphine for opioid addiction. Buprenorphine is a semi-synthetic opioid. Although buprenorphine is an opioid, and thus can produce typical opioid effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of heroin and methadone. There is less euphoria, less physical dependence, less dependence and a milder withdrawal, allowing time for the user to hopefully seek additional help for their addiction.

But the need for this live saving treatment is not always found in the major urban areas. According to a 2017 report published by the National Rural Health Association, 9 out of 10 physicians are practicing in urban counties. This meant there were no physicians who could provide this care in more than half of all rural counties – a staggering 30 million people were living in counties where this type of help was unavailable.

On January 23, 2018 the Drug Enforcement Agency’s Diversion unit followed up the Administration’s promises with action as they announced new steps to reach long term addicts in underserved areas by allowing physician’s assistants and nurse practitioners to prescribe a drug that is enlisted to help addicts break the iron clad fist of opioid addiction. They now can dispense the opioid maintenance drug buprenorphine directly to the addict from their offices.

“Right now we have thousands of people addicted to heroin in our county, most of whom desperately want help to quit or reduce their use,” said Dr. Caleb Banta-Green, Senior Research Scientist, University of Washington Alcohol and Drug Abuse Institute. “Treatment with medications like methadone or buprenorphine cuts the chances of dying in half.”

Nurse practitioners and PAs can also make referrals as needed to hospitals, treatment centers and physicians. These rural areas also have less access to inpatient and day treatment resources. Ninety-two percent of substance use treatment facilities are in metropolitan areas.

Out of the Box Thinking to Reach the Long Term Addict
King County Seattle Fights Addiction

In 2016, an estimated 20.1 million people met the diagnostic criteria for drug or alcohol addiction (about 1 in 13 Americans ages 12+), according to the National Survey on Drug Use and Health. But only 10.6 percent received treatment at a specialty facility such as a hospital, drug or alcohol rehabilitation center or mental health facility. There is great need to meet the addict where they are in order to prevent death from overdose.

King County in the Seattle area of Washington is in the thick of the drug crisis. In 2016, Seattle Mayor Ed Murray, Auburn Mayor Nancy Backus and Renton Mayor Denis Law convened the Heroin and Prescription Opiate Addiction Task Force to recommend actions immediately to confront the epidemic.

2016 Chart

King County Council member Jeanne Kohl-Welles has always worked to advocate for affordable housing, health and mental health services and homelessness programs. There is no doubt that the opioid crisis has hit King County hard. She told, “From 2010 to 2014 the number of people who entered the publicly funded treatment system for heroin use disorders annually in King County grew from 1,439 to 2,886.” She continued, “The increase occurred while the number of people receiving treatment for all other primary drugs of choice declined.” The number of heroin-related deaths in King County is the highest in 20 years.

Statistics provided by the University of Washington Alcohol and Drug Abuse Institute’s principal research scientist, Caleb Banta-Green, PhD MPH MSW, reports that for 18-25 year olds, highly addictive heroin is one of the most commonly used drugs of choice. Opioids, meth or coke are also responsible for drug-induced deaths in King County.

Public Health Seattle & King County reported from their survey of syringe exchange clients in the county that they were overwhelmingly white (73%) and mostly homeless (43%) or in temporary housing (25%). In 2017, 62 percent of them injected their drugs in public. The survey showed a staggering 20% of these experienced an opioid overdose in 2017. When asked how interested they were in reducing or stopping opioid use, 58% said they were very interested and another 20% were somewhat interested.

In order to help addicts King County recognized they first must keep them alive. Naloxone kits are currently being passed out to homeless shelters in King County to help prevent overdose. Naloxone is an opioid antagonist which helps block the effects of opioids, especially in an overdose. The syringe exchange programs in the county have also been extremely successful and opened the door for additional help with addiction to those who were unreachable before.

He saved his neighbors life

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Despite the desire to break the addiction, many addicts living on the street or in temporary housing have lost their home, jobs, and their connection to family. It is this marginalized group who is particularly susceptible to dying from an overdose. Council member Jeanne Kohl-Welles says that one of the ways the task force hopes to help these people who are estranged from their families and the community is to provide Community Health Engagement Locations (CHELs) as a harm reduction step, where adults with substance addictions can have access to on-site services while consuming opioids or other substances under the supervision of trained health care providers. She says, “CHELs might be the only support and way for these people to get treatment.” King County and the City of Seattle are researching potential locations now.

Studies have shown that injection centers provide a way to meet the addict where the addict lives, keep them alive, and reach them on an individual basis with medical treatment and intervention, sometimes leading to drug treatment. If an overdose occurs at the site, the medical staff would be there to immediately provide the user with a life-saving treatment of naloxone that would block the effects of the substance and prevent death. Safe injection sites have worked well for years in Europe and Canada, preventing deaths from overdose and providing services to those who generally don’t utilize health care and mental health services currently.

Would these sites be legal?

“The CHELs would not provide drugs, rather the health care professionals working within their ethically bound duty to ensure that no one died of an overdose,” Council member Kohl-Welles said. When King County began providing needle exchanges originally to reduce HIV/AIDS, the state courts ruled that these sites were fulfilling a public health role that superseded the state’s drug paraphernalia laws. “In King County our Prosecuting Attorney and Seattle Police say that they would not take action against CHELs,” Kohl-Welles said.

Seattle and Philadelphia are both working to implement what would be the first centers for safe injections in the United States. There is reportedly one safe injection site operating in the U.S. by invitation only in an undisclosed location.

Melvin Patterson with the Drug Enforcement Agency says they will work with the U.S. Attorney General’s office in regards to enforcement operations directed at the safe injection sites. “The DEA is one facet of the enforcement arm of the AG’s office and will follow the guidance of the AG,” Melvin said. “When a user purchases heroin (or fentanyl) for injection, those transactions stimulate the heroin market and put money into the hands of profit driven dealers and drug trafficking organizations.” He continued, “The DEA Diversion unit concentrates its efforts on reviewing and enforcing the regulatory side of the controlled substances handled by manufacturers, distributors, practitioners, and researchers. DEA will also utilize its Tactical Diversion Squads to conduct any enforcement operations where violations of the controlled substance act have been discovered. The actions described above are tactics and methods the DEA has long been exercising to combat the opioid crisis.”

The overall issue of drug addiction is complex and not always clear cut. What is undisputed is in 2016 a record number of people died from drug overdose and numerous people in the federal government, local government, advocacy groups and health care professionals are all working to help solve the problem.