as a hidden contributor to the opioid crisis and the role
that primary care and emergency medicine play in addressing
Efforts to Prevent and Combat Opioid Overmedication - Watch
opioid overdose deaths ranked by county,
The Controversial Link Between Antidepressants and Suicidality Risks in Adults: Data From a Naturalistic Study on a Large Sample of In-Patients With a Major Depressive Episode
2016-17 Overdose Map
FDA: More opioids,
Involving Prescription Opioids
The most common drugs involved in prescription opioid overdose deaths include:
For people who died from prescription opioid overdose in 2017:
The highest overdose death rates from prescription opioids were in West Virginia, Maryland, Kentucky, and Utah.1
Statistically significant changes in drug overdose death* rates involving prescription opioids§ by select states,¶ United States, 2016 to 2017.** Note: Rate comparisons between states should not be made due to variations in reporting across states.
*Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD10). Drug overdose deaths are identified using underlying cause-of-death codes X40X44, X60X64, X85, and Y10Y14.
Rates shown are for the number of deaths per 100,000 population. Age-adjusted death rates were calculated using the direct method and the 2000 standard population.
§ Drug overdose deaths, as defined, that have natural and semi-synthetic opioids (T40.2) and methadone (T40.3) as contributing causes.
¶ Analyses were limited to states meeting the following criteria: For states with very good to excellent reporting, =90% of drug overdose deaths mention at least one specific drug in 2016, with the change in drug overdose deaths mentions of at least one specific drug differing by no more than 10 percentage points (pp) between 2016 and 2017. States with good reporting had 80% <90% of drug overdose deaths mention of at least one specific drug in 2016, with the change in the percentage of drug overdose deaths mentioning at least one specific drug differing by no more than 10 percentage points between 2016 and 2017. States included also were required to have stable rate estimates, based on =20 deaths, in at least two drug categories (i.e., opioids, prescription opioids, synthetic opioids other than methadone, heroin).
**Absolute rate change is the difference between 2016 and 2017 rates. Percent change is the absolute rate change divided by the 2016 rate, multiplied by 100. Statistically significant at p<0.05 level. Nonoverlapping confidence intervals based on the gamma method were used if the number of deaths was <100 in 2016 or 2017, and z-tests were used if the number of deaths was =100 in both 2016 and 2017. Note that the method of comparing confidence intervals is a conservative method for statistical significance; caution should be observed when interpreting a nonsignificant difference when the lower and upper limits being compared overlap only slightly.
Source: CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2018. https://wonder.cdc.gov/.
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths United States, 2013-2017. Morb Mortal Wkly Rep. ePub: 21 December 2018
Hedegaard H, Bastian BA, Trinidad JP,
Spencer M, Warner M. Drugs most frequently involved in drug
overdose deaths: United States, 20112016. National
Vital Statistics Reports; vol 67 no 9. Hyattsville, MD:
National Center for Health Statistics. 2018.
Addiction vs. A Daughters Addiction: Gender
Differences In Drug Use and Recovery
Today, we know that there are a number of biological differences between men and women that impact the development of addiction. Women develop alcohol-related dependence faster and with a lower amount than men do. This is because women generally have more body fat and lower volume of body water to dilute alcohol. Women also develop health-related problems, such as breast cancer and nerve damage, due to substance use faster than men do.
Psychologically speaking, women are more likely than men to have co-occurring substance use and mental health conditions. Women more often meet diagnostic criteria for mood disorders, depression, agoraphobia, PTSD, anxiety and eating disorders. They are also more likely to have been sexually or physically abused or experienced interpersonal violence. Rates for sexual abuse in childhood and adulthood are reportedly higher in women than for men. These experiences can have a large impact on the what types of services they require during their recovery. This includes clinically-sound, trauma-informed programming that treats addiction alongside other mental health conditions. Trauma-specific intervention programs generally recognize the interrelation between trauma and symptoms of trauma, such as substance use, eating disorders, depression and anxiety.
Perhaps most importantly, we know that women are more stigmatized for their substance use conditions. They report higher feelings of guilt and shame surrounding their substance use. These feelings are often related to the gender-specific roles, often associated with caregiving. Many women also tend to have one parent who has abused substances, which may factor into the development of addiction.
If youre looking for treatment for your daughter, niece, granddaughter or another young woman in your life, and as a result of the significant differences in the way in which substance use conditions present for women, consider services that are tailored to womens needs and obstacles they experience. Services for women in substance abuse treatment should include women-only programming (due to trauma history and other issues), strong female leaders and providers, peer support and cultural training and programming that addresses the unique needs of women in treatment.
Regardless of age or race, men use alcohol and drugs more frequently and in greater quantities than women. They often start using alcohol and other drugs for different reasons than women. For many young men, male institutions and social rites of passage (sports, fraternities, etc.) encourage the use of alcohol. Men generally start binge drinking at an earlier age than women. Binge drinking is also more prevalent in men and is more likely to result in alcohol-related problems. Due to higher frequency and quantities as well as binge drinking habits, men are five times more likely to develop a substance use disorder.
Though we know that although men are less likely to be forthcoming, many have significant histories of childhood physical and sexual abuse or current victimization by domestic partners. They are more likely to die from suicide, despite being less likely to attempt suicide. They often feel excessive amounts of shame when dealing with emotional and substance abuse problems, making it less likely that they will seek out medical or behavioral health counseling for their problems. Once in treatment, men often struggle with talking about their emotions and how to deal with them appropriately.
If you are looking for treatment for your son, nephew, grandson or another young man in your life, consider programming that addresses effective communication training, sexual identity issues and skills for managing difficult emotions. Also look for mental health services that address sexual issues, PTSD and anger management. Like with women, all-male group therapy has proven to be highly effective and structured activities with other men can provide the necessary peer support. Individual therapy with a positive male role model as well as female clinicians who model appropriate female-male relationships are also beneficial in the recovery process.
Why Gender-Specific Programming Works
There is a significant disparity in substance use disorders rates between men and women. These differences range from greater access and opportunity for use to increased social pressure and possibly a greater genetic disposition to use substances. Men and women may find that they benefit, in critical ways, from having gender-specific programs available to them. Men and women do better in treatment and continued care when they have treatment customized to meet their particular needs.
If your child is transgender or identifies in another way, its especially important to find programming that is LGBTQI-sensitive and trauma-informed.
Recovery and positive clinical
outcomes are possible with more specialized care.
Opioid Pain Relievers Are Prescribed For Your Child: What
You Should Know
This overview is intended to help you know what questions to ask when a healthcare provider recommends or prescribes a pain reliever for your child, and how to be sure that your child takes the medication as prescribed without misusing the medication or sharing it with others.
What are some common opioid pain relievers?
There are also non-opioid pain relievers (gabapentin, for example) that also have a potential for misuse and abuse, but much lower than that of opioids.
Why is the Misuse of Prescription Pain Relievers So Dangerous?
Opioid pain relievers are powerful drugs very similar to heroin in their chemical makeup, and habit-forming by their very nature. This is why the U.S. Centers for Disease Control (CDC) strongly recommends against the prescribing of opioids for long-term treatment of chronic pain. Even for treatment of acute (short term) pain, opioid pain relievers should only be prescribed and taken sparingly.
The risk of addiction is particularly concerning when the patient is a teen or young adult because their brains are still developing and therefore biologically predisposed to experimentation. So if your teen or young adult is prescribed opioid pain relievers,you or your childs caregiver should control the medication, dispense it only as prescribed and monitor their children closely for signs of misuse or growing dependence.
In addition to the danger of dependence, misuse of opioids can cause dramatic increases in blood pressure and heart rate, organ damage, difficulty breathing, seizures and even death.
Why Would a Young Person be Prescribed an Opioid Pain Reliever?
Opioid pain relievers are most often prescribed following surgery or to treat cancer pain - so many young people will not be in a position to be prescribed opioids. But opioids may be prescribed for young peoplein the event of accidental injury - a sports-related injury, for example, or a biking accident in which a fracture or even a severe sprain occurs. Another reason for which opioids are often prescribed to young people is oral surgery to remove wisdom teeth. Additionally, there are other ailments - sickle cell disease or other pediatric chronic pain conditions - for which opioids may be recommended.
What Questions Should You Ask Your Childs Healthcare Provider When an Opioid Pain Reliever is Recommended or Prescribed?
What Should You Do if an Opioid Pain Reliever Has Been Prescribed for Your Child?
What Signs of Misuse or Dependence Should a Parent Be Alert For?
If you are concerned that your child may be dependent on pain medication, consult the prescriber (who may in turn consult with a pain specialist), and they should also consider having a substance use counselor complete an assessment. An assessment should include a thorough look at the extent of your childs drug and alcohol use, his/her mental and physical health as well as personal, medical and family history.
Download our Opioids eBook
Get a comprehensive overview of the
opioid epidemic how opioids affect the body, the
risks involved and how you can help your family stay safe.
FENTANYL & OTHER OPIOIDS A Comprehensive Resource for
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Use (52 page PDF)
Governments Solution To The Opioid Crisis Feels Like A
War To Pain Patients
ay Lawrence, an energetic truck driver in his late 30s, was driving a semitrailer across a bridge when the brakes failed. To avoid plowing into the car in front of him, he swerved sideways and slammed the truck into a wall, fracturing his back. For more than 25 years, he struggled with the resulting pain. But for most of that time, he managed to avoid opioid painkillers.
In 2006, his legs suddenly collapsed beneath him, due to a complex web of neurological factors related to his spinal cord injury. He underwent multiple surgeries and tried many medications to alleviate his pain.
The next year, he began to experience some semblance of relief when his doctor prescribed morphine, one of a class of opioid drugs. By 2012, he was taking 120 milligrams per day.
But this isnt a story about opioid addiction. Lawrence managed a relatively productive, happy life on the medication for the better part of 10 years.
This isnt the life I thought Id have, he told his wife, Meredith Lawrence, in December 2016. But Im all right.
Living on disability payments, he could still walk around their two-bedroom trailer home using his cane, take a shower on his own and, on his good days, even help his wife make breakfast.
Then, in early 2017, the pain clinic where he was a patient adopted a strict new policy, part of a wide-ranging national effort to respond to the increase in opioid overdose deaths.
Citing 2016 guidelines from the U.S. Centers for Disease Control and Prevention, her husbands doctor abruptly cut his daily dose by roughly 25 percent to 90 mg, Meredith Lawrence said. That was the maximum dose the CDC recommends, though does not mandate, for first-time opioid patients.
The doctor also told Jay Lawrence that the plan was to lower his dose to 45 mg over the next two months, a cutback of more than 60 percent from what he had been taking.
At the end of that traumatic visit, his wife said, Jay Lawrences doctor dismissed their concerns and shared his own fear about losing his license if he continued to prescribe high doses of opioids. (When HuffPost followed up, the doctor declined to comment on the case, citing patient privacy.)
For a month, Lawrence suffered on the 90 mg dose. At times, his pain was so bad that he needed help to get out of the recliner, and when his wife looked over, she sometimes saw tears streaming down his face. He dreaded his next appointment when his dose would be slashed to 60 mg. In the weeks before that scheduled visit on March 2, 2017, Lawrence came up with a plan.
On the day of his appointment, on the same bench in the Hendersonville, Tennessee, park where the Lawrences had recently renewed their wedding vows, the 58-year-old man gripped his wifes hand and killed himself with a gun.
There are at least nine million chronic pain patients in the United States who take opioid painkillers on a long-term basis. As law enforcement and medical regulatory bodies try to curb the explosion in opioid deaths and the rise in illegal opioid use, they have focused on reducing the overall opioid supply, whether or not the drugs are provided by prescription.
Theres mounting evidence this wont work ? that curbing patient access to legal prescription opioids does not stem the rate of overdoses caused primarily by illegal drugs ? and that patients are being denied desperately needed relief. There are also troubling indicators that cutting back on opioids increases the risk of suicide among those with chronic pain.
Some chronic pain patients and advocates have even begun compiling lists of individuals they know who have died by suicide after they were no longer able to treat their pain with opioid medication.
There is no doubt in my mind that forcibly stopping opioids can destabilize some of the most vulnerable people in America, said Dr. Stefan Kertesz, a professor of medicine and an addiction researcher at the University of Alabama at Birmingham. And the outcomes for those folks include suicide, overdose and falling apart medically.
For a decade or so, government officials in the U.S. have sought to drive down the opioid supply through a range of tactics ? from increased seizures of diverted opioid medications to state crackdowns on pill mills. The Trump administration has embraced the hard-line approach.
In late January, Attorney General Jeff Sessions announced a surge in Drug Enforcement Administration activity targeting pharmacies and physicians that, in the agencys view, oversupply opioids. In February, the Justice Department doubled down with the announcement of a new task force that would focus on manufacturers and distributors of opioids. In March, President Donald Trump unveiled a plan to lower opioid prescriptions by a third within three years. And in late June, the federal government arrested 600 people, including 165 medical professionals, for allegedly participating in $2 billion worth of fraud schemes involving opioids.
The Trump administrations efforts are dramatic even within the context of the CDCs opioid dose guidelines. The guidelines were originally intended to advise primary care physicians treating chronic pain patients and other pain sufferers. They were urged to exercise caution in prescribing opioids, to use alternatives whenever possible and to prescribe daily doses of no more than 90 morphine milligram equivalents (MME) for new opioid users.
For pain patients like Jay Lawrence who had already been on opioids for years, however, the guidelines simply recommended regularly assessing the harms and benefits of the dosage. They didnt advise either mandatory cutoffs or any set limits. (The Tennessee Department of Healths guidelines would also have allowed Lawrence to stay at 120 mg of morphine when prescribed by a pain specialist.)
But the CDC guidelines have been weaponized, said Kertesz. The ramped-up enforcement by the DEA and state regulators has led some doctors to choose caution and to overcorrect in their prescribing, lest they lose their ability to practice medicine at all. Kertesz decried these policies as simplistic in a definitive new article published last week in the journal Addiction.
In February, Sessions struck a particularly harsh tone by suggesting that the fate of chronic pain patients was not high on his list of concerns. I am operating on the assumption that this country prescribes too many opioids, the attorney general said. I mean, people need to take some aspirin sometimes and tough it out a little.
Attitudes like that are based on a series of mistaken assumptions about pain, according to Dr. Thomas Kline, a North Carolina-based family practitioner and former Harvard Medical School program administrator. Kline regularly updates a list of pain patients, published on Medium, whove killed themselves in the wake of draconian restrictions on pain medication.
I ask people to imagine the very worst pain theyve ever experienced in their lives, Kline said. And then that theyre denied relief by a doctor with the one medicine proven effective for pain control for 50 centuries. (Historical records show that people in ancient Mesopotamia cultivated the poppy plant for medical use.)
The governments aggressive focus on doctors and patients is unlikely to address the very real menace of opioid-use disorders and sharply escalating overdose deaths. Fraud ? driven by pharmaceutical company policies - and diversion - the phenomenon of prescription medications being sold as street drugs - initially spurred a wave of opioid abuse in the late 1990s, as some doctors turned their practices into pill mills. But new reports by the CDC and a drug data firm, the IQVIA Institute for Human Data Science, suggest that prescription drugs play a much smaller role in todays crisis.
The reports show that total opioid prescriptions dropped 10 percent in 2017 - the sharpest annual decline in such prescribing in 25 years. While opioid prescriptions peaked back in 2010, the studies found that growth rates in opioid-linked deaths, overwhelmingly due to illegal fentanyl and heroin, have skyrocketed in the last seven years.
Indeed, although two-thirds of the 64,000 overall drug overdose fatalities were linked to opioids in 2016 - the most recent year for which there is data - more than 80 percent of those opioid drug deaths came from illegal street drugs such as heroin and fentanyl. Prescription opioid drug deaths alone - excluding methadone - amounted to less than 15 percent of all drug overdose deaths, or about 9,500 fatalities.
Still, the CDCs guidelines have triggered restrictive laws in at least 23 states that mandate ceilings on opioid dosage. (Oregon, in fact, is moving to taper dosages down to zero for all Medicaid chronic patients over a year.) That makes relief less attainable for pain patients and threatens the practices of doctors who treat them. These laws have been augmented by the growth of state prescription monitoring programs that use the software NarxCare, which is designed to flag addiction but can also rope in pain patients based on their prescription history and use of multiple doctors.
The side effects of the current enforcement efforts are disturbing enough, from patients denied relief to drug shortages to suicides.
No health agency has kept track of all pain-related suicides that may be linked to doctors cutting back on prescriptions. But some preliminary findings from Department of Veterans Affairs researchers indicate that VA pain patients deprived of opioids were two to four times more likely to die by suicide in the first three months after they were cut off, compared to those who remained on their pain medications.
That study isnt without flaws. Veterans die by suicide at higher rates than average ? currently accounting for 20 suicide deaths a day ? so they are not a nationally representative sample. And the VA study, which was released at a national opioid summit in early April, has not yet been submitted for peer review.
But another study, published last year in the peer-reviewed journal General Hospital Psychiatry, looked at nearly 600 veterans who in 2012 were cut off from dosages after long-term opioid use and found similar results. Twelve percent of the vets showed suicidal ideation or took violent action to harm themselves ? a rate nearly 300 percent higher than the overall veterans community.
To protect people, you have to take care of the patient, not the pill count, said Kertesz, who worked on the VAs April 2017 study but spoke to HuffPost only as an independent researcher. The findings suggest that the discontinuation of opioids doesnt necessarily assure a safer patient.
Even terminally ill cancer patients are increasingly getting less relief, and there are growing shortages of injectable opioids at local hospitals and hospices, spurred in part by DEA-ordered reductions in opioid manufacturing quotas.
Leah Ilten, a 53-year-old physical therapist who lives in Kennewick, Washington, told HuffPost that as her 86-year-old father lay dying of pancreatic cancer in a hospice, the medical staff ignored her pleas to provide appropriate opioid pain relief, even cutting his dosage in half on the last day of his life. A few days earlier, when he was in the hospital, one nurse explained to her that opioids could lead to an overdose or could potentially cause the man, who lay moaning in pain, to get addicted.
I was horrified, Ilten said.
In mid-April, the DEA responded to the injectable opioid shortage by lifting production quotas. An agency spokesman told HuffPost that it was a manufacturers problem, not the quotas, while asserting that progress is being made.
There have been production issues, including Pfizers foul-ups with a plant in Kansas. But the DEAs delay in taking action - shortfalls were flagged in February in a letter from the American Society of Anesthesiologists and other health groups - definitely contributed to the shortage, according to Dr. James Grant, president of the ASA. He told HuffPost that quotas were among the factors creating the crisis.
Im not willing to go back to the state I was in before I started treatment. - Anne Fuqua
Faced with the hardline national crackdown on opioid prescriptions, people with chronic pain are trying to raise awareness of the suffering caused by the loss of medications. Some are gathering the names of those patients who ended up taking their own lives, both as a memorial to those who died and as a protest against the health establishment that has seemingly abandoned them. Others are seeking comfort from each other on social media.
Lelena Peacock, who declined to name her southeastern city of residence for fear of retaliation from doctors, is struggling with how to treat the pain associated with fibromyalgia. The 45-year-old found that her social media posts drew other pain patients who turned to her for help.
By her own count, Peacock has thus far convinced more than 70 chronic pain patients to call 911 or suicide prevention hotlines instead of killing themselves.
For Anne Fuqua, a 37-year-old former nurse from Birmingham, Alabama, the motivation for compiling a list of chronic pain-related suicides is to track the damage done by what she sees as policies that have left people like her behind.
Theres so many people who have died, she said. We have to remember them.
Fuqua has an incurable neurological illness known as primary generalized dystonia that causes Parkinsons-like involuntary movements and painful muscle spasms. She started taking about 60 mg of Oxycontin a day in 2000. Her doctor began to limit her access to high doses of opioids in 2014, the same year she started chronicling those friends who had killed themselves or otherwise died after being denied pain medications. Her informal list is now up to roughly 150 people, augmented by lists that other pain patient advocates have compiled.
On July 9, Fuqua joined other chronic pain patients at a meeting at the Food and Drug Administration campus in Maryland to express their fears and outrage at the cutbacks. Sitting in the front row in her wheelchair, she told FDA officials about that list and declared, Im not willing to go back to the state I was in before I started treatment.
Fuquas own difficulties are compounded by the fact that her body does not respond to even large doses of opioids the way others do ? she suffers from severe malabsorption that hampers her ability to benefit from everything from opioids to vitamin D. Since 2012, she has relied on a strikingly high daily regimen of 1,000 MME of opioids, including fentanyl patches, to manage her pain.
But her physician, Dr. Forrest Tennant, was driven to retire this year after a DEA raid and investigation. The Los Angeles-area physician mailed her a final series of prescriptions, which will run out at the end of July.
Its terrifying, she said looking at her future. If these were people who had asthma or diabetes and werent stigmatized because of opioids, this wouldnt be allowed to happen.
Another doctor has quietly stepped forward to continue treatment for Tennants remaining patients, Fuqua said, although theres no assurance that this physician wont also be investigated in the future.
If these were people who had asthma or diabetes and werent stigmatized because of opioids, this wouldnt be allowed to happen. - Anne Fuqua
The raid on Tennants home and office last November illustrates the hard-line regulatory and enforcement approach that critics say doesnt distinguish between pill-mill doctors who deserve to be shut down and legitimate pain doctors who use high-dosage opioids. The wide-ranging search warrant served to Tennant essentially accused him of drug trafficking even though hed earned a national reputation for deft treatment of - and research about ? pain patients.
Hes highly respected and prominent in pain management, said Jeffrey Fudin, a clinical pharmacy specialist who heads the pain pharmacy program at the Albany Stratton VA Medical Center in Albany, New York, and serves as an associate professor at the Albany College of Pharmacy and Health Sciences. Most of his patients had no other options, and they came from around the country to see him.
Tennant was known for taking on difficult-to-treat patients, including those suffering from pain as a result of botched surgeries and other forms of malpractice. His research included innovations in the use of hormones to alleviate pain and lower opioid use up to 40 percent, as well as work on genetic testing for enzyme system defects that lead to opioid malabsorption.
The DEA can trigger an investigation every time they misapply the CDC guidelines without paying attention to the population the physician treats or issues of medical necessity, said Terri Lewis, a patient advocate and a Ph.D. clinical rehabilitation specialist with Southern Illinois University who trains clinicians on how to manage seriously ill patients with incurable pain.
Special Agent Timothy Massino, a spokesperson for the DEAs Los Angeles division, declined to comment on the agencys approach to Tennant. Its an ongoing investigation, he noted.
Tennants isnt alone. Physicians must now balance their prescribing obligations to their patients with legitimate fear for their livelihoods.
DEA enforcement actions against doctors have risen some 500 percent in recent years ? from 88 in 2011 to 449 last year, according to an analysis of the comprehensive National Practitioners Data Bank by Tony Yang, a professor of health policy at George Washington University. Even though thats a relatively small number of arrests compared to the roughly one million physicians in the country, such arrests can have an outsized impact.
They make big news, and they serve as a deterrent for physicians whose specialties require them to use a lot of pain medications, Yang said. It makes them think twice before prescribing opioids.
Meredith Lawrence shows the tattoo she got after her husbands death. The bluejay represents her husband, Jay; a cup of coffee is the way she loves to start her day; and the quote is Sail away with me, what will be will be.
Dr. Mark Ibsen of Helena, Montana, found himself in a five-year battle against the state licensing board thats still not over - even though a judge last month reversed the boards decision to suspend his license because of due process violations. The court has remanded the case back to the licensing board for potential further investigation of his opioid prescriptions, but Ibsen has decided he wont resume his medical practice.
Thats bad news for Montana, which has the highest rate of suicide in the country, according to the CDC. Whats more, chronic pain-related illnesses account for 35 percent of all the states suicides, as a recent state health department study found.
In the course of his fight with the medical board, the 63-year-old doctor said three of his former chronic pain patients have killed themselves after he and other doctors stopped prescribing opioids. The first of those patients died shortly after attending a hearing to show his support for Ibsen.
The deaths of pain patients haunt those who treated them and loved them. Meredith Lawrence, who sat with her husband to the very end, said, It was as horrifying as anything you can imagine.
But I had the choice to help him or find him dead someday when I came home, she added.
Lawrence was arrested and sentenced to a years probation for assisting a suicide. Now her goal is to fight restrictions on opioid prescriptions.
If we dont stand up, more people will die like my husband.
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text SOS to 741-741 for free, 24-hour support from the Crisis Text Line. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.
Art Levine is the author of Mental
Health, Inc: How Corruption, Lax Oversight, and Failed
Reforms Endanger Our Most Vulnerable Citizens.
Any Alternatives When A Physician Offers My Child Opioids
While opioid medications may be effective for treating pain in the short-term, they have an extremely high propensity for addiction and do nothing to address its underlying cause.
The good news is that there are many alternatives to opioids that can help alleviate your son or daughters pain. Weve helped to spell them out for you and have provided guidance on how to ask your doctor about these alternatives:
What Are Some Alternative Medications for Pain That Can Replace Opioids
When My Son or Daughter Goes Through Opioid Withdrawal?
I wouldnt wish it on my worst enemy, said Mike, a 24-year-old Naltrexone (Vivitrol) patient committed to recovery. Its the worst thing you could think of.
Because of learned responses in your loved ones brain that come from opioid use, once he or she has detoxed meaning that the body is free of the drug he or she is still highly susceptible to relapse.
In the video below, experts Alicia Murray, DO, a Board Certified Addiction Psychiatrist, and Adam Bisaga, MD, a Professor of Psychiatry at Columbia University, describe what opioid withdrawal is really like and how use of medications in a treatment plan can help ease (or alleviate) the brains learned responses and aid in your son or daughters recovery:
Cant My Kid Stop Using Opioids?
Watch experts Adam Bisaga, MD, a Professor of Psychiatry at Columbia University, and Alicia Murray, DO, a Board Certified Addiction Psychiatrist, discuss the changes that occur in the brain when heroin, prescription pain pills or other opioids are used, and how they can make your child think only about the drug:
What drugs are
the most commonly abused?
problem of opioid addiction
The principle behind the program
In 2009, our physicians looked at the most frequently prescribed drugs for Kaiser Permanente members in Southern California. They were surprised to find that drugs for hypertension and diabetes were not at the top of that list. Instead, opioid medicines and highly addictive narcotics were the most common. In addition, people were getting prescriptions at higher doses than we had previously seen.
Around the same time, new research was being published on the hazards and ineffectiveness of opioids for the management of chronic pain. Given all this evidence, we decided we needed to break the cycle and find alternatives. Rather than risk patients being addicted and overdosing, we would seize the opportunity to improve the quality and safety of drug prescribing at Kaiser Permanente.
Starting in 2010, we launched the Safe and Appropriate Opioid Prescribing Program, a comprehensive initiative to transform the way that chronic pain was viewed and treated. We implemented several efforts to reduce opioid prescriptions, including prescribing and dispensing policies, monitoring and follow-up processes, and clinical coordination through our electronic health record system.
Changing prescribing patterns
Through this program, weve effectively and appropriately reduced:
Results continue to demonstrate that the program is reducing overprescription of opioids and reducing the risk of overdose and death in our members.
Beyond protecting our members, Kaiser Permanentes focus on prescribing the lowest effective dose and supply has helped reduce the risk of opioids getting to the street. We know that unused medications in the medicine cabinet can find their way into our communities.
Caring for chronic pain
According to current clinical evidence and the Centers for Disease Control and Prevention (CDC) guidelines, opioids are not effective in treating chronic pain. Therefore, Kaiser Permanente has turned to a more multidisciplinary approach. We focus on making sure patients get the most effective treatments based on current evidence. This could include non-opioid medications, physical therapy, acupuncture, exercise, injections, cognitive behavioral therapy, and other methods.
After implementing the Safe and Appropriate Opioid Prescribing Program across Southern California, patients themselves reported feeling generally positive about our new approach to pain management. Many are, in the end, feeling better once they are off the very large doses of opioids they were on in the past.
Replicating this program across the country
As a result of a systematic and
comprehensive set of strategies and tactics over several
years, were seeing similar results in other states
where Kaiser Permanente operates. Were encouraged for
the long term because other health care systems could
implement this program, too.
Opioid prescriptions dropped in most Oregon counties between 2010 and 2015, according to new federal data.
But there were four outliers: Malheur, Morrow, Union and Wallowa counties, where providers handed out more opioids per capita in 2015 compared with five years prior, according to data obtained by The Oregonian/OregonLive from the U.S. Centers for Disease Control and Prevention. The top 10 prescribing counties on a per capita basis were in rural parts of the state.
Though prescribing is dropping, the dips are not the same across the board. Oregon leads the country in seniors who are hospitalized for opioid abuse, dependence, overdose and adverse effects.
No. 1 Curry County is the top opioid prescriber in Oregon: 1,800 morphine milligram equivalents per person.
No. 2 Baker County ranked No. 2 on the CDC list, with 1,612 morphine milligram equivalents prescribed per person in 2015.
No. 3 Malheur County came in third, with nearly 1,600 morphine milligram equivalents prescribed per capita in 2015.
No. 4 Union County came in fourth in the CDC rankings, prescribing just over 1,560 morphine milligram equivalents per capita in 2015.
No. 5 Tillamook County providers handed out about 1,550 morphine milligram equivalents per capita in 2015, making it No. 5 on the list of opioid prescriptions per county in Oregon.
No. 6 Lincoln County In the CDC data, Lincoln County ranks No. 6 in Oregon, with about 1,540 morphine milligram equivalents prescribed per capita in 2015.
No. 7 Coos County came in seventh in the CDC data, with nearly 1,480 morphine milligram equivalents prescribed per capital in 2015.
No. 8 Josephine County came in as No. 8 in the CDC data, with about 1,420 morphine milligram equivalents prescribed per capita in 2015.
No. 9 Clatsop County came in ninth in the CDC data. Prescribers gave out nearly 1,410 morphine milligram equivalents per capita in 2015.
No. 10 Jackson County Rounding
out the list of the top 10 counties in terms of opioid
prescriptions is Jackson County. Prescribers there handed
out about 1,340 morphine milligram equivalents per capita in
U.S. in seniors hospitalized for opioids
Oregonians age 65 and up are landing in the hospital for opioid overdoses, abuse, dependence and adverse effects at a greater rate than any other state, federal figures show.
A dozen other states including Washington and California also show seniors with high hospitalization rates for opioids, including Vicodin, OxyContin and Percocet.
But Oregon's rate has nearly tripled in the past decade. The state has outpaced the country for three straight years climbing to a peak of 700 hospitalizations per 100,000 elderly patients in 2015. That translates to 4,500 people.
Addiction specialists didn't anticipate such stark results from data collected by the U.S. Agency for Healthcare Research and Quality and are calling for deeper study to figure out why.
"This is not something we can blow off," said Dr. Shorin Nemeth, regional medical director for palliative care at Providence Health and Services. "This is a vulnerable population."
Nemeth had no idea about the problem until contacted by The Oregonian/OregonLive. Startled to see the statistics, he talked to peers outside Providence. They had no clue either, he said.
Public health officials in Oregon are aware of opioid abuse among older people, but they haven't taken a step back to look at what's driving the phenomenon or told providers what to do about it. They're focused instead on curbing opioid use overall.
"It appears that we are moving in the right direction but we're not there yet," said Dr. Katrina Hedberg, the state epidemiologist and health officer. "We're hoping that prescribing fewer opioids will lead to fewer people who are hospitalized."
Two factors might make Oregon stand out: Doctors have continued to prescribe more opioids to older people and the state has been a national leader in encouraging more liberal use of medication for pain.
It's also possible that old age and the kinds of drugs prescribed to seniors are contributing to the spike. Some opioids are more powerful than others. Some linger longer in the body. Dose is important, too. As is the health condition of the patient.
"Anytime we see increased rates among certain populations or increased rates over time, that's something that needs to be looked at closer," said Gery Guy, a health economist and opioid specialist at the U.S. Centers for Disease Control and Prevention. "It is very concerning."
*This rate does not incllude emergency room visits
''Worst pain" in my life
Jerry Hall took 100 milligrams a day at the height of his opioid addiction five times the normal amount.
Like many people, he started relying on prescription medication for chronic pain but slowly slid into addiction.
Now 60 and living in Southwest Portland, Hall first developed back pain three decades ago when a ram charged at him on a farm in Newberg and threw him 40 feet into the mud.
"I didn't know where I was for a few minutes," Hall said.
Sometimes his pain was so severe that he couldn't work for days as a truck driver. His doctors prescribed Vicodin, he said, but he didn't get addicted.
That changed after a hernia surgery in 2010 and subsequent pain in his left hand. He suspects it was related to a misplaced intravenous line.
"It was the worst pain I'd had in my whole life," Hall said. "It felt like it had its own heart beat."
The agony didn't go away. His doctors gave him oxycodone, a common opioid.
The drug helped dull the persistent throbbing but his hand didn't heal.
The prescriptions kept coming.
Opioids pushed for pain
Oregon has been at the forefront of a movement to control people's pain, including an early emphasis on palliative care and hospice services.
When Hall first got injured, opioids were becoming more widely used as pain treatment in Oregon and nationwide.
In 1995, Oregon passed a pain treatment act, which protected doctors from discipline when they prescribed opioids for severe pain, provided they followed the law. The following year, the American Pain Society launched a nationwide campaign that called on doctors and nurses to ask people about their level of pain. This has become a routine medical practice.
State medical groups, accrediting bodies and even federal drug regulators encouraged the use of opioids for pain.
A national epidemic
The drugs mask symptoms by attaching to receptors in the brain. They block pain, slow breathing and have a calming effect.
"Those of us who were doing medical training in the '90s got a heavy dose of it," said Dr. Todd Korthuis, an addiction treatment specialist at Oregon Health & Science University.
Oregon doctors, often on the leading edge of palliative care, were generous in prescribing.
"We were all awash with it when I started here in 2002," Korthuis said. "Over half of my clinic patients were prescribed opioids."
He suspects the current rates stem from Oregon's liberal prescribing practices years ago. Providers, with a push from medical leaders and drug companies, didn't question how many pills they were prescribing. They were focused on treating pain.
"It was all about compassionately taking the best possible care of the patient as the field understood it," Korthuis said.
Opioid prescriptions in Oregon have dropped but not across the board.
An analysis by The Oregonian/OregonLive shows that the raw number of prescriptions for seniors rose slightly in 2016 compared with 2015. But the older population grew overall, pushing down the per-capita prescription rate by 4 percent.
For people 45 to 64, opioid prescriptions per capita dropped 7 percent among a population that stayed steady. That signals the efforts to stem prescriptions for this group are taking hold.
In 2012, Oregon providers handed out nearly 820,000 opioid prescriptions to those 65 and older. That jumped to 1.1 million in 2016, or 1.6 prescriptions per senior, according to the analysis of U.S. Census and state data.
Snagged for cheating
Jerry Hall's doctors became concerned about his continued opioid use around 2012, the same year he went on disability because of various health issues.
They put him on a monitoring program, made him sign an agreement to take only prescribed pills and introduced random urine testing to ensure he wasn't downing other narcotics.
They prescribed 20 milligrams of oxycodone a day, he said. He emptied the bottle in a couple of weeks. To fill the gap, he said he snagged pills from family, friends and neighbors. Some were free. Others cost up to $10 each.
Eventually, he got caught cheating.
In 2013, during a random urine test, doctors found unprescribed methadone in his system and they stopped his prescriptions.
Hall went into severe withdrawal.
"First you're freezing, then you're burning up," he said. "I couldn't have anything touch me. I couldn't lay down. I couldn't sleep."
He couldn't even hold his beloved cats.
He tried to quit but the symptoms raged, sometimes for four days at a time. With no idea how long they would last, he devoted his life to getting more pills.
He paid his rent and fed his cats. He spent all the rest on opioids, even eating from food pantries.
Hall's experience is far from unique, said Dr. Bryan Dixon, an addiction psychiatrist at Cedar Hills Hospital, a behavioral health treatment center in Portland.
"It doesn't matter if you're 18 or 80," Dixon said. "Once you're dependent, opiates are incredibly difficult to stop."
Hall knew he was addicted but he didn't tell his family, friends or acquaintances. He was too ashamed.
Providers curtail prescriptions
Federal and state health officials have been slowly tackling the overuse of opioids.
In Oregon, the focus on prescription drug abuse has centered on young people. In 2010, a summit including then-Gov. Ted Kulongoski revealed the state's 18- to 25- year-olds had the highest rate of prescription abuse in the country.
The state set up a prescription monitoring program the next year and in late 2015 issued a well-publicized public warning to announce that large medical groups in the Portland area had agreed to curtail opioid prescriptions for chronic pain.
The Centers for Disease Control and Prevention followed in a few months with extensive guidelines advising providers to limit the use of opioids. One section warns about the risk of seniors taking opioids. They can fall, become confused or experience a bad reaction if they take a cocktail of medications.
The Oregon Health Authority issued supplemental guidelines last year that call for the use of alternative treatments or the lowest effective dose of opioids, but the guidelines don't address age groups. Washington state has its own guidelines as well, including a section on seniors.
Hedberg, the state's top medical officer, said the state is trying to curtail opioid prescriptions for everyone, not just one age group.
It stands to reason that seniors with opioid problems would end up in the hospital more often than the general population, she added. Older people simply have more ailments, she said.
But so do seniors in other states that have much lower rates for those 65 and older, like Florida and New York.
It could be that Oregon has a higher rate of seniors with an opioid abuse problem or that state providers are more likely to hospitalize them for treatment, Hedberg said.
Public health officials have no plans to dive into this issue: They've adopted an overall strategy of curtailing prescriptions, tracking trends and trying to get more people with dependency issues on treatment.
This year, Oregon is getting an extra $7 million from the federal Health and Human Services Department to fight opioid addiction and overdoses.
The state plans to use the money to increase access to medication-assisted care. It will target Oregon tribes and rural areas, which lack treatment centers, Hedberg said.
There's no plan to focus on seniors.
Risk factors abound
The Oregonian/OregonLive interviewed pharmacy experts, primary care doctors, pain specialists and addiction experts in the Portland area about why Oregon has such a high rate.
None had a definitive answer.
Many people who started taking the pills a decade or two ago likely stayed on them or resumed treatment as they aged and experienced arthritis or had hip or knee replacements, said Dennis McCarty, a substance abuse treatment specialist at OHSU.
Doctors might overlook risks for substance abuse in older people because they consider addiction a problem of younger people, they're often focused on younger patients with addiction problems, said Dr. Steven Stanos, medical director of pain services at Swedish Hospital in Seattle and president of the American Academy of Pain Medicine.
Or they might associate symptoms such as falls, delirium and memory loss, with aging instead of opioids.
Seniors also may wind up in the hospital more often because they don't metabolize medications as well as younger people, and many take several medications, which can increase health risks.
Yet steering seniors away from opioids in some cases isn't always a good idea. The drugs aren't considered to be a problem for hospice patients or to treat pain associated with cancer.
"It's a challenge in these older patients because many times they have severe pain," Stanos said. "That keeps them from functioning."
Many pain medications that doctors might prescribe to avoid opioids can cause problems in seniors.
Amitriptyline and gabapentin, both used for nerve pain and depression, can cause delirium. Some anti-inflammatories, like ibuprofen, affect kidney function and can trigger stomach ulcers.
Oregon and other states with such high rates of senior hospitalizations should take the problem to doctors and insurers to investigate, specialists said.
"The data should be analyzed in terms of what is the cause of this," said Cynthia Reilly, a Pew Charitable Trusts specialist on substance abuse. "It's something they should take a closer look at."
New drug helps
Jerry Hall increasingly feared his addiction would kill him.
So in early 2015, he saw Dr. Brinton Clark, medical director of Providence Medical Group Northeast. She started him on Suboxone, a medication used to treat opiate dependence.
"That was the day that changed my life," Hall said.
Suboxone contains two elements, naloxone, which is used to treat a narcotic overdose, and buprenorphine, which treats pain but isn't as addictive as many other opioids.
It can still cause withdrawals.
Clark has tapered Hall's dose, starting with a moderately high dose of 20 milligrams a day. He's now down 3 milligrams.
"He's a star patient," Clark said. "He's close to being off."
Hall said if he had known opioids would take over his life and how difficult it would be to get off them, he never would have taken the drugs.
"I would have taken an aspirin," he
In 2000, nearly 58 people died of opioid-related causes statewide, according to the Oregon Health Authority. In 2011, that rose to 292 fatalities.
Overdoses from prescription painkillers have been a big cause.
In 2011, 216 people died from the painkillers in Oregon, compared with 122 heroin deaths.
The outlook has improved, with deaths from prescription painkillers and heroin falling by 2015 when pills killed 180 people and heroin accounted for 91 fatalities.
The following bar charts show death rates for all opioids heroin, prescription pills, methadone, even psychotropics -- over half-decade periods from 2001 to 2015.
Source: Source: Oregon Health Authority ; data are derived from death certificates that include heroin as cause or contributor to death. Known suicides are excluded.
Oregon has one
of the highest rates of prescription opioid misuse in the
Partners across Oregon are working to reduce this epidemic. We have made recent progress, but there is more work to be done.
Talk to your health care provider or visit the links below for treatment resources.
Pain management resources
Addressing the opioid epidemic involves many local, state and national partners. In Oregon, our Opioid Initiative Partnership includes the following groups:
Why do people become addicted to opioids?
Opioids can make your brain and body believe the drug is necessary for survival. As you learn to tolerate the dose youve been prescribed, you may find that you need even more medication to relieve the pain or achieve well-being, which can lead to dependency. Addiction takes hold of our brains in several ways and is far more complex and less forgiving than many people realize.
How can you avoid addiction to opioids?
If you or a loved one is considering taking opioids to manage pain, it is vital to talk to a physician anesthesiologist or other pain medicine specialist about using them safely and exploring alternative options if needed. Learn how to work with your physician anesthesiologist or another physician to use opioids more wisely and safely and explore what pain management alternatives might work for you.
People addicted to drugs may change their behavior. Possible signs include:
What should you do if you or someone you know is addicted?
If you or a loved one is ready to seek help for an addiction, the first step is to find a physician or other health professional who can help. Ask your physician for a referral to a medical professional in addiction medicine. Or search the American Society of Addiction Medicines website for addiction specialists in your area. The American Academy of Addiction Psychiatry also has a Patient Referral Program.
Another resource is the Substance Abuse and Mental Health Services Administration (SAMHSA) toll-free help line to find drug treatment near you: 1-800-662-HELP (4357). Or you can visit SAHMSAs Behavioral Health Treatment Services Locator. Theres also a State Agencies webpage that helps you find state agencies that might have special programs for you or a loved one.
"If you or a loved one is ready to seek assistance for an addiction, the first step is to find a physician or other health professional who can help."
If you are supporting a friend or loved one in overcoming addiction, the National Institute on Drug Abuse offers the following advice: Assure your friend or loved one that addiction can be managed successfully, but acknowledge that it may take several attempts at treatment to find the best approach. If your friend or loved one refuses to seek help, a confrontational intervention is not recommended. These encounters can escalate into violence or backfire in other ways. Try to convince the person to consult with a physician.
What are opioid withdrawal symptoms and how can you alleviate them?
Opioid withdrawal symptoms can but wont necessarily include some of the following:
Opioid withdrawal symptoms generally last between three and five days, although they can last up to 10 days, according to the American Society of Addiction Medicine (ASAM).
Withdrawal from opioids can be difficult and even dangerous. Trying to quit cold turkey is not recommended, ASAM advises, because it can lead to stronger cravings and continued use. The safest way to alleviate opioid withdrawal symptoms is through medically supervised treatment that generally includes medicines, counseling and support. Some medications used to relieve withdrawal symptoms are methadone and buprenorphine (Subutex). These medications also can be used as long-term maintenance medicine for opioid dependence. In addition, a medication called clonidine can be used during withdrawal to help reduce anxiety, agitation, muscle aches, sweating, runny nose and cramping. It does not help reduce cravings. The addiction medicine physician may also prescribe medication to treat vomiting and diarrhea and help with insomnia.
What are the symptoms of an opioid overdose?
Signs of an overdose include:
How should you respond to an opioid overdose?
If you think someone may be experiencing an opioid overdose, take the following actions immediately:
If You Get Little or No Response
If lightly tapping, shaking and shouting at the person or rubbing your knuckles on the persons breastbone do not elicit a response (per Step 1 above), take the following actions:
1. Call 911. If you have naloxone, a medication that can rapidly reverse the effects of an overdose, administer it according to the instructions on the package (in addition to calling 911).
What is naloxone and how can it help with an overdose?
Available as an injection or nasal spray, naloxone (also sold under the brand name Narcan) is a lifesaving medication that can rapidly reverse the effects of an opioid overdose. If you happen to have naloxone when responding to an overdose, call 911 and administer the medication according to the package instructions.
Access to naloxone is expanding on a state-by-state basis. It can be prescribed by a physician, is often carried by police officers and emergency medical responders and is increasingly available over the counter at some pharmacies.
How should you store and dispose of opioids to protect family members?
If you are taking opioids, you are not the only one in your household who is in danger of misuse, addiction and overdose. Other members of your household, including children, also are vulnerable. Heres how to protect them:
If you have leftover or expired prescription medications, follow these drug disposal tips:
Some meta-analyses of randomized
placebo-controlled trials on antidepressants conclude that
there might be an increased risk for suicidal behaviour,
especially in children and adolescents but also in adults.
Placebo-controlled trials exclude patients with serious
suicidality and might therefore underestimate the risk of
respective adverse events. The change of suicidal ideation
and the prevalence of suicides and non-fatal suicide
attempts were therefore analysed in a large naturalistic
prospective multicentre study of depressed in-patients.
Additionally, specific risk factors for new emergence of
suicidal ideation were investigated. The naturalistic
prospective study was performed in 12 psychiatric hospitals
of the German research network on depression and suicidality
(seven psychiatric university hospitals and five district
hospitals) in Germany. All patients (n=1014) were
hospitalized and had to meet DSM-IV criteria for major
depressive disorder. Six events were defined for the
purposes of statistical analysis: 'emergence', 'extended
emergence', 'improvement' and 'worsening of suicidal
ideation', 'suicide attempts' and 'suicides'. Logistic
regression analysis and classification and regression trees
(CART) analyses were conducted to determine specific risk
factors for new emergence of suicidal ideation. The mean
HAMD total score decreased from 24.8 at baseline to 10 after
10 wk. An effect on suicidality was evident by week 2 in the
sense of a decrease of the mean HAMD item-3 score.
Emergence, worsening and improvement of suicidal ideation
occurred in 3.2%, 14.74% and 90.79% of patients,
respectively. A total of 10 suicide attempts and two
suicides were reported. The rate of suicides (13.44/1000
patient-years) was rather low and comparable to the rate
observed in randomized controlled antidepressant trials.
Five risk factors for emergence of suicidal ideation were
determined with two independent statistical methods: age
(with higher risk at age <45 yr), treatment resistance,
number of hospitalizations, presence of akathisia and
comorbid personality disorder. Age <45 yr as one of five
risk factors for the emergence of suicidal ideation is in
line with the meta-analysis performed for the recent US Food
& Drug Administration (FDA) memorandum; although the
naturalistic study design does not permit definite
conclusions to be made about certain compounds. The rate of
suicides was comparable to that seen in randomized
controlled trials, as were the rates of emergence and
worsening of suicidal ideation, but more improvement was
found. Thus, in-patient treatment in a psychiatric care
setting, including daily assessments of suicidality by
trained psychiatrists adhering to the rules of good clinical
practice (e.g. use of specific co-medications, supportive
psychotherapy and continuous medical attendance by nursing
staff) might be beneficial.