Rossi

Elen Rossi

English 1201-Online

Professor Loudermilk

8 April 2018

Battling the Opioid Crisis

As they zipped the body bag and drove toward the morgue, Jan Brown sat

sobbing while her three-year old son Michael played with a toy truck on the kitchen

floor and she wondered how things had gotten so bad. A year ago, her husband had

a good job as car salesman, he made $120,000 a year, and they owned a Cape Cod

house in Dayton. Now, with her husband John dead from a heroin overdose, three

months behind on their mortgage and fearful the bank would evict them, and their

savings drained to feed John’s drug habit, she wondered where to go from here. To

her, it all seemed unreal. When John had hurt his knee at the job and was

hospitalized, the surgeon had prescribed some painkillers to help him to manage the

pain. When the prescription ran out and the doctor wouldn’t refill it, so John was

able to “borrow” some pills from his mother. Jan didn’t say anything because she

knew John was really tough yet he was noticeably in pain. When that supply ran

out, he found he could get the Percocet from a guy down the street. Jan saw the

vacation fund was draining but she couldn’t stand to see John in agony so she

remained silent. With the family’s savings drained and money tight, John’s “friend of

his” gave him some heroin to try and told him it was really cheap but really

powerful. This crossed the line and Jan wasn’t happy so she spoke up. They

regularly fought about John’s new heroin habit but that just made him angry and
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eventually he would shoot up again. Finally, John lost his job when they found him

passed out from an overdose in his office. John had become a shadow of the man,

husband, and father he once was. Now, months later down the road, Jan and little

Michael were alone with nothing. Her John was dead, they would soon be homeless,

and the social worker eventually would said she can help by placing Michael with a

temporary good family while Jan got everything sorted out.

Sadly, the Brown story is not an uncommon one. In Dayton, Ohio—which

was recently given the reputation as Number 1 in the nation for drug overdoses

(WHIO)—medical staffs of the local hospitals see variations of this story played out

daily.

Figure 1. Miamisburg EMS resuscitating a Miamisburg local heroin addict who

finally sought treatment after being revived for the fourth time. According to him,
"Heroin grabs ahold of you, and it won't let go. It turned me into somebody I never
thought I would be" (Nachtwey).

In this particular case, a legitimate medical prescription designed to help

with pain management turns out to be the first step on the path to opioid addiction.
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While the details of the individual stories about how people became addicts varies,

when stepping back and looking at many stories it is easy to establish

commonalities in how users start and move down the path to addiction, and how

addiction destroys their lives and the lives of the people who love them.

To develop solutions for the opioid crisis requires an understanding of what

opioids are, what is an addiction, and how people become addicted to opioids.

Everyday examples of pathways to addiction are shared and examined to determine

commonalities among scenarios that can be addressed as a means of fighting the

opioid epidemic. Whether or not genetic also plays a role in addiction is considered

as well. Finally, practical suggestions are provided. It is my contention that, with

improved understanding of addicts, addiction, and addiction pathways, practical

solutions may be implemented to fight the opioid crisis.

Opioids and Addiction

The National Institute on Drug Abuse (NIDA) stated “opioids are a class of

drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and

pain relievers available legally by prescription, such as oxycodone, hydrocodone,

codeine, morphine, and many others” (National Institute of Health). Once inside the

human body, they work on opiate receptors, causing analgesia and sedations, and

may cause people to experience pleasurable feelings (Lewis 152-153).

According to NIDA addiction is “a chronic, relapsing brain disease that is

characterized by compulsive drug seeking and use, despite harmful consequences“

(National Institute of Health). They further classify addition as a brain disease that

is brought about by drugs changes to the brain’s structure and function. In effect,
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drug addiction is a disease that potentially compromises a person’s body and mind,

social relationships with family and friends, and may impact behavior at both home

and work.

Four General Paths to Becoming an Addict

Armed with an understanding of what opioids are and that addiction is in

fact a disease, it is informative to explore how people become addicted to opioids.

NIDA argues that people generally start taking drugs “to feel good, to feel better, to

do better, or because others are doing it”(National Institute of Health). Sadly, as any

nurse who has worked with addicts for any amount of time can tell you, their stories

on how they became addicted to drugs tends to start with a version of one of NIDA’s

four reasons people start using drugs.

James Nachtwey produced an outstanding online video and documentary for

Time magazine, titled The Opioid Diaries, which provides profound and personal

stories of how people became addicted to opioids (Nachtwey). First- and second-

hand accounts of people’s stories provide persuasive proof supporting NIDA’s

identification of the four reasons people start down the path to drugs. The addicts

and their families describe their experiences, recounting how people fell into the

addiction trap, and the impacts on their lives.

When people think of people who use drugs “to feel good,” the recreational

marijuana user comes to mind. After marijuana use loses some of its “power”, the

user seeks in harder drugs to get the same euphoric feeling. While it is easy to see

how a recreational user can fall down the path to addiction, their actions can be as

or more damaging for innocents. For example, a recent patient, J. J., described his
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path to addiction (J.J.). He started smoking marijuana with his father at the age of 9.

Within a few years, he switched to heroin because he “wasn’t satisfied with the

marijuana effect anymore” and he felt stigmatized from his peers at school because

of his family situation. Everyone knows his entire family is addicted to drugs. Now,

at the age of 17, he was at a hospital for endocarditis, a serious infection of the heart,

which is one of the common and serious risks of heroin abuse.

Taking drugs “to feel better” is a recurring theme in addicts’ histories. One of

the common stories is that a person is injured, hospitalized, begins taking

prescription medication to manage their pain. When the patient is discharged with

a prescription to take pain medication “as needed” they begin to believe that “if the

doctor prescribed it for me, it’s okay for me to take.” Rather than dealing with some

discomfort, the reflex move to pain becomes taking medication. By the time the

prescription runs out, the person who has unconsciously and involuntarily become

addicted, starts seeking more prescriptions for pain medication. The doctor may try

to wean the patient off pain medication or cut the supply completely but the addict

finds a way to procure more pain meds. Family and friends are potential sources

and dealers on the street provide an expensive alternative when the inexpensive

supplies have run out. Buying prescription pain medications on the street gets

expensive fast and lower cost alternatives may be sought out. Ten $5 morphine tabs

can be purchased for the same price as a $50 Percocet pill. As the person becomes

accustomed to the “high” feeling, the body requires a stronger dose to create the

same effect. Addicts soon find that heroin is three or more times stronger than the

morphine or Percocet and is readily found at very low prices. What started with
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good intentions, as simple pain management, has somehow mutated into full on,

life-destroying heroin addiction.

Taking drugs “to do better” is also a common story starter. One common

subset is the well-to-do but aiming-to-do-better crowd. These tend to be people

with careers and disposable income. They are frequently the white-collar people

seeking to increase their performance to get a promotion or to relax from the

stresses of work. For many, it helps them with anxiety or depression. According to

Recovery.org, “more than 70% of workplaces have been affected by prescription

drug abuse” with opiates “the most commonly abused prescription drugs by white

collar professionals” (Mendez). And, according to Mendez, while marijuana remains

the illicit drug of choose for these middle-income workers, heroin abuse among this

demographic rose by 60% from 2002-2004 to 2011-2013. Sadly, Mendez notes,

these addicts are reluctant to get help because of the stigma of being an addict and

the consequences for their career.

The “everybody’s doing it” group is filled with those whom come into contact

with a peer group. While high school kids and teenagers fall into this category, they

are certainly not the only ones. Many come from an environment—possibly family,

work, or new friendships—where there are drug users fall victim to per pressure.

Addiction is a Disease, and may be in your Genes

It should be noted that there is a genetic factor to addiction, meaning that

physiological and psychological factors that predispose a person to addiction can be

inherited. At the simplest level, a drug might provide a “good” experience for one

person while providing a “bad” experience for another person. As the University of
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Utah’s Genetic Science Learning Center explains, “it may be harder for people with

certain genes to quit once they start” and some “factors that make it harder to

become addicted also may be genetic” (Genetic Science Learning Center). The

center is careful to point out that “susceptibility does not mean inevitability” and

that environment also plays an important role. Their findings, and those of the

National Council on Alcoholism and Drug Dependence, support what many medical

professionals already know—that if you have an addict in the family, you have a

higher chance of becoming an addict (Bellum).

Access to Drugs

Now, understanding how people start drug use, the question is how do they

get access to drugs? Upon leaving the hospital, patients may or may not have a

prescription for pain medication and associated refills. Once out of prescribed

medications, the person may shop around or visit doctors to find someone who will

fill a prescription. Using the unused medications of family members or friends also

provide alternatives. Finally, stealing is also a possibility. As the DEA reports, 812

pharmacies were robbed in 2016, with Ohio accounting for 42 (Fagerman). And

most nurses who work in addiction units have stories of their patients who lost

their jobs for stealing, such as a recent handyman who was fired for stealing

prescription medications from customers.

Apparently, illicit drugs are also big business and can be found everywhere.

According to the Drug Enforcement Administration (DEA), deaths from drug

poisonings outnumber “deaths by firearms, motor vehicle crashes, suicide, and

homicide” and have risen every year since 2009 (Drug Enforcement
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Administration). The DEA notes the US Department of Treasury estimates the illicit

drug trade in the US exceeds $300 billion annually. Increased demand for and

increased availability of, heroin has led to an increase in heroin deaths every year

since 2006 (Drug Enforcement Administration). And while heroin is not yet the

most commonly used drug in the US, “more people seek treatment for heroin use

than any other illicit drug” with more than 300,000 admissions to publicly funded

treatment facilities.

And with big business, and a broad customer base, drug dealers have gotten

more creative in seeking out new customers. Back in 1997 in major cities across

America, as the Baltimore Sun reported in Drug Dealers Give Free Samples to

Customers, new dealers moving to an area would provide “testers” or samples to

potential customers (Bloomberg). Now, as a television news affiliate recently

reported, instead of waiting for new customers come to them, dealers bring their

products to potential customers by throwing heroin testers into vehicles with open

windows as they drive past (WKYC Staff).

Alarming Statistics About the Opioid Crisis

DATA (cdc.org)

Overdose deaths from opioids show that they have increased drastically

since 2006 (Adams). Based on the CDC’s standard analysis, they showed that in

2016 there were 32,445 opioid related deaths, about 89 people died every day from

opioid overdoses (CDC). The CDC reports many statistics about opioid addiction,

with whites more likely to be addicts than all other races, men more predisposed to

addiction than women, and 18-25 years old the dominant addiction age group.
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Economic data shows that opioid addicts most likely come from houses with annual

incomes of $20,000-$49,000 and most likely have no insurance. Sadly, for our local

area, Ohio is reported as one of the locations with the highest heroin related deaths.

Practical Solutions

Numerous actions can be taken to improve the opioid crisis. First and

foremost, education should be a priority. People need to be better educated about

drugs, starting at a young age, to sensitive them to the issues and risks. Second, the

stigmatization of people with addiction has to be stopped. People need to realize

addiction is a disease and that it needs to be treated as such.

Third, a better job needs to be done providing emotional support to the

family members of those who fall into the addiction vortex. Concerted efforts need

to be made regarding support of the children of addicts and increased social worker

involvement. Children calling 911 for overdosed parents or grandparents has

become commonplace, even in Dayton. As Garbe pointed out in Across Ohio, children

are calling to report overdoses, last year a 9-year old had to call 911 because both of

her “grandmas are on the ground” (Garbe). As Gordon points out in The Opioid

Crisis’ Hidden Victims: Children in Foster Care, addicts fail to provide daily care their

children, and removing these children from the environment may prevent future

damage (Gordon). As I said earlier, there is much evidence that many users started

down the path to drugs because they lived with parents who were addicts.

Fourth, laws for drug-related offenses need to be strengthened, especially

those that apply to drug distributors and dealers. While I am in agreement with

President Trump’s recent statement that “we have to get tough on those people,
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otherwise we are wasting our time…” I do not fully agree that toughness must

include the death penalty (United States, Office of the President). It seems that life

in prison, with no chance for parole, would be a greater deterrent than the death

penalty. Frequently, based on conversations with users receiving medical care,

small time dealers will get fined or spend 30 days in jail and are then returned to the

streets where they sell drugs again. More severe laws could potential decrease the

willingness of people to deal drugs, reduce supply and access to drugs, pushing costs

higher and reducing the opioid problem and associated death rate.

A fifth important change would be to revise the patient satisfaction survey.

The survey asks, at the end of the hospitalization, about the experience at the

hospital. Then, if the survey comes out good, the hospital gets a higher score. As a

consequence, the reimbursement from Medicare / Medicaid will be higher. The

question #14 is about “how often did the hospital or provider do everything in their

power to control your pain?” Since the application of the survey in 2006, the opioid

abuse has dramatically increased. Changes to the survey may help to reverse this

trend.

Sixth, doctors should be more careful in prescribing opioid medication for

pain management. The United States prescribes and uses opioids more than any

other country in the world (Narcotics Anonymous). According to one of the

speakers as the National Press Foundation-American Healthcare Journalists

Association discussion, “changing prescription patterns would be the most

important step [in helping] to address the national opioid crisis” (Basen). Our

doctors should receive training to help them identify patients at higher risk of
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becoming addicts and be exposed to alternative means of managing patient pain.

For example, they can interview the patient about the past, how he manages the

pain, if he has any members with addiction, etc. They can dig deeper into patient

histories. Coming from a different country and being a nurse I can attest that

Europe doesn’t prescribe opioid pain medication as much as in the USA. For

example, Europeans prescribe morphine only for patients with terminal cancer or

major trauma while some doctors here even use morphine to alleviate headaches.

Seventh, medical professionals should also provide more information to the

patient about addiction, and specifically how opioids may lead to addiction. The US

should also consider use of placebos, as is common in Europe, for example those

with a history of addiction or those that are continuously seeking pain medication.

It can be given as a trial to test if the patient is really experiencing pain or if he is

faking or if it is psychological.

Eighth, a focus should be placed on reducing large scale drug trafficking.

Controls at the borders should be increased, with a specific focus on Mexico, which

leads in drug imports to the US (Drug Enforcement Administration). Special

emphasis should also be placed on imports from China, since China is nearly at the

same level of Mexico as an exporter of opioids to the US. Ninth, consideration

should be given to a “maximum” amount of treatments that will be used to save

individuals who repeatedly overdose.

Finally, we should know that reduced use of pain medication might result in

not giving medicine to patients who legitimately need them and are at a low risk of

addiction.
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Conclusion

As shown in this research, opioid addiction is a serious disease that needs to

be treated seriously. Actions can be taken—in our hospitals, schools, and within the

law enforcement community—to reduce patient access to unnecessary prescription

drugs and to illicit drugs. No single solution will prevent people from falling down

one of the pathways to addiction but specific actions may reduce the chances of

someone becoming an addict. It is clear that, with an improved understanding of

addiction, addicts, and pathways to addiction, many practical solutions may be

implemented to fight the opioid crisis and reduce the chances of a family following

the disastrous path John Brown led his wife Jan and son Michael down.

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Works Cited

Adams, J. et al. "Are Pain Management Questions in Patient Satisfaction Surveys

Driving the Opioid Epidemic?" American Journal of Public Health 2017: 985-

6.

Basen, Ryan. "Experts: Opioid Problem Difficult but Solvable." 26 February 2018.

Medpage Today. 2 March 2018

<https://www.medpagetoday.com/painmanagement/opioids/71375>.

Bellum, Sara. Real Teens Ask: Is Addiction Hereditary? 18 February 2011. National

Institutes of Health. 24 March 2018

<https://teens.drugabuse.gov/blog/post/real-teens-ask-addiction-

hereditary>.

Bloomberg, Joshua. Drug Dealers Give Free Samples to Customers. Prod. The

Baltimore Sun. Baltimore, 9 March 1997.

CDC. U.S. Department of Health and Human Services: Centers for Disease Control

and Prevention. 2 March 2018 <https://www.cdc.gov>.

Drug Enforcement Administration. "(U) National Heroin Threat Assessment

Summary - Updated." US Department of Justice, June 2016.

—. "2016 National Drug Threat Assessment Summary." US DEpartment of Justice,

2016.
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Fagerman, Ken RPh, MM. "Recent Pharmacy Robbery Statistics." Pharmacy Times:

Practical Information for Today's Pharmacist 21 April 2018.

Garbe, Will. "Across Ohio, Children are Calling 911 to Report Overdoses." 27 March

2017. 1 March 2018

<https://www.daytondailynews.com/news/local/across-ohio-children-are-

calling-911-report-overdoses/qNsaNTxzbDCHKs79mE3RAN/>.

Genetic Science Learning Center. Genes and Addiction. 24 March 2018

<http://learn.genetics.utah.edu/content/addiction/genes/>.

Gordon, Serena. "The Opioid Crisis' Hidden Victims: Children in Foster Care." 8

January 2018. Health Day: News for Healthier Living. 2 March 2018

<https://consumer.healthday.com/general-health-information-16/drug-

abuse-news-210/the-opioid-crisis-hidden-victims-children-in-foster-care-

729966.html>.

J.J. Personal Interview with a Heroin Addict Elen Rossi. Dayton, 11 November 2018.

Lewis, Sharon L, et al. Medical-Surgical Nursing: Assessment and Management of

Clinical Problems. St. Louis: Elsevier, 2018.

Mendez, Emly, M.S., Ed. S. A Guide to Addiction and Recovery for White-Collar

Americans. 15 November 2017. 25 March 2018

<https://www.recovery.org/topics/white-collar/>.

Nachtwey, James. The Opioid Diaries. March 2018. Time Magazine. 26 February

2018 <http://time.com/opioid-addiction-epidemic-in-america>.

Narcotics Anonymous. Narcotics Anonymous. NA World Services Inc. 1 March 2018

<https://na.org/>.
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National Institute of Health. Opioids: Brief Description. Ed. National Institute of

Health. 2018. Department of Health and Human Services. 24 March 2018

<https://www.drugabuse.gov/drugs-abuse/opioids>.

Premier Health. Opioid Assist. 3 March 2018 <https://www.opioidassist.com/>.

U.S. Department of Health and Human Services Substance Abuse and Mental Health

Services Administration. Substance Abuse and Mental Health Services

Administration. 2 March 2018 <https://www.samhas.gov/>.

United States, Office of the President. "President Donald J. Trump is Combatting the

Opioid Crisis." 1 March 2018. 3 March 2018

<https://www.whitehouse.gov/briefings-statements/president-donald-j-

trump-combatting-opioid-

crisis/?utm_source=ods&utm_medium=web&utm_campaign=1600d>.

WHIO. Dayton No. 1 in Nation for Drug Overdoses. 24 May 2016. 25 March 2018

<http://www.whio.com/news/crime--law/dayton-nation-for-drug-

overdoses/y5TbZ36ygEHKXhtrmQNrIN/>.

WKYC Staff. Ohio Report: Dealers Giving Other Drugs Away with Heroin. WKYC.

Cleveland: WKYC, 2016.

Woodard, David and Van Demark, Robert E. "The Opioid Epidemic in 2017: Are We

Making Progress?" South Dakota Medicine: The Journal of the South Dakota

State Medical Association 70 (2017): 467-471.