Note: This article was created as a quick explainer of the opioid crisis and the Port Gamble S'Klallam Tribe's newspaper, Syecem. It appeared in the November 2017 edition.
Hardly a day goes by without news about America’s opioid problem. It has become this country’s worst and most deadly drug crisis.
According to data from the Centers for Disease Control (CDC) and compiled by The New York Times, drug overdose deaths in 2016 topped 59,000—a 19% increase over 2015. The 2016 overdose death toll is greater than the number of people who died in that year in car crashes (38,000) or from gun violence (36,000). It is even greater than the number of deaths at the peak of the HIV/AIDS crisis (43,000) or U.S. casualties in the Vietnam War (58,200).
Drug overdoses are now the leading cause of death among Americans under the age of 50.
Opioids are a class of drugs that can be used to treat pain. They include brand names such OxyContin®, Vicodin®, codeine, and morphine—all of which are only legal when obtained with a valid prescription. Also included under the classification are heroin and Fentanyl, a synthetic opioid that is often illegally produced and mixed with other drugs, increasing the risk of overdose. Opioids are so named because they are synthetic derivatives of opium.
Opioids work by mimicking neurotransmitters that activate brain receptors to block pain. This abnormal stimulation also floods the brain with the naturally-occurring “pleasure center” compound, dopamine, which can produce euphoria in the user.
Prescribed opioids can be safe for pain relief if they are taken for a short period of time, but, because of the feelings of pleasure they induce, they are also highly addictive, even when taken under the supervision of a doctor.
According to the American Society of Addictive Medicine, over 2.5 million Americans aged 12 and older are addicted to opioids.
The History of the Crisis
Before the 1990s, doctors were hesitant to prescribe opioids for anything other than severe pain, such as in patients with end-stage cancer, over worries about misuse and addiction.
In the early part of the decade, concerns began to increase over the number of Americans suffering from chronic pain. Doctors were, rightfully, encouraged to find solutions to this serious medical issue, which, according to the Institute of Medicine, impacts 100 million Americans, or about a quarter of the U.S. population. Chronic pain affects more people than heart disease, diabetes, and cancer combined.
Pharmaceutical companies seized the opportunity, marketing opioids to skeptical doctors. One such drug, OxyContin, was released by Purdue Pharma in 1995, and was promoted as something of a medical miracle: a time-release narcotic that could safely treat moderate to severe pain without fear of addiction.
According to a recent New Yorker article, “The Family That Built an Empire of Pain”, which explores the role OxyContin has played in the current drug epidemic, “Purdue launched OxyContin with a marketing campaign that attempted to counter (fears of addiction) and change the prescribing habits of doctors. The company funded research and paid doctors to make the case that concerns about opioid addiction were overblown, and that OxyContin could safely treat an ever-wider range of maladies. Sales representatives marketed OxyContin as a product ‘to start and stay with.’ Millions of patients found the drug to be a vital salve for excruciating pain. But many others grew so hooked on it that, between doses, they experienced debilitating withdrawal.”
It is estimated that Purdue has made over $35 billion in revenue from the sale of OxyContin.
While drug trials soon found that Purdue’s claim of 12-hour pain relief from OxyContin was, at best, exaggerated, prescriptions of the drug and other opiates increased. It’s not hard to understand why when you consider that that cost of chronic pain—in treatment, lost wages, and other lifestyle impacts—is more than $600 billion a year. Opioids were an easy solution to a very difficult and expensive problem.
Over the last decade, heroin use has increased five-fold. According to the CDC, this staggering jump is being led by middle-aged women and men aged 25-44. The study states that this rise can be attributed to many factors, but especially prescription opioid addiction and a need to find cheaper alternatives when a legal prescription is not possible.
A 2014 Journal of the American Medical Association Psychiatry found that 75% of heroin users in treatment began their addiction with painkiller abuse.
The U.S. Government Response
Throughout the 2016 Presidential campaign, both the Democratic and Republican candidates stressed that the federal government needed to aggressively respond to the opioid crisis. This was as more and more media reports began to tell the stories of everyday Americans trying to conquer—or, at the least, live with—their addictions.
On October 26, President Donald J. Trump directed the Department of Health and Human Services to declare the opioid crisis a “public health emergency,” which is different than a “national emergency”. The distinction is in how the designations are funded and the power they give the federal government to act upon initiatives.
While the administration has not put forth a plan to deal with the issue, during a statement announcing the directive, President Trump said one idea is for the government to produce an advertising campaign to help steer kids away from using drugs in the first place.
“This was an idea that I had, where if we can teach young people not to take drugs, it’s really, really easy not to take them,” said President Trump.
This approach harkens back to former First Lady Nancy Regan and the “Just Say NO” campaign of the 1980s. Unfortunately, studies of that program and ones like it show they are marginally effective, at best.
There’s also the question of how any program proposed by the administration will be funded. Public health emergencies must come out of the Public Health Emergency Fund, which, currently, has a balance of $56,000. The federal government estimates that the cost to treat opioid addiction could be as high as $75 billion a year.
President Trump has admitted this shortfall, and has said he is trying to negotiate funding with Congress as a part of his budget plan.
Despite the fact that it’s unclear what impact, if any, the President’s directive will have on the opioid crisis, Dr. Luke McDaniel, Medical Director of the Port Gamble S’Klallam Tribal Health Center, is optimistic.
“We remain hopeful that the President’s declaration will, one day, lead to substantive action,” said Dr. McDaniel.
Treating the Crisis in Indian Country
The National Institutes for Health estimate that Native Americans are at least twice as likely to become addicted to drugs or alcohol. In Washington state, indigenous people die of drug overdoses at a rate 2.5 times that of the white population. Lack of access to medical care and mental health and addiction services compound the problem
But there is good news: Tribes like PGST, who are trying to turn this trend around.
The PGST government has developed its own response plan to the opioid crisis. Called THOR (“Tribal Healing Opioid Response), the program has three broad goals: prevent opioid misuse and abuse; expand access to opiate use disorder treatment, and prevent deaths from overdose.
(Read more about THOR on page 1.)
Dr. McDaniel believes that the nature of tribal communities make holistic programs like THOR more likely to succeed. “For reasons of family, culture, and history, I think native communities are exceptionally tight,” he said. “No one is thrown away. Addicts remain family and problems are not ignored. Hope for redemption always endures. The community always comes together to keep on working.”
In addition, the health department has started a needle exchange program to reduce the risk of infection from shared needles.
Health department, police, and Natural Resource Enforcement staff are trained in the administration of Naloxone Hydrochloride Injection (NARCAN), which can reverse an overdose if given immediately. Recently, 120 Tribal members were trained in how to administer NARCAN.
The Behavioral Health department offers access to suboxone, a drug used to treat opiate addiction in adults. This is in addition to chemical dependency and mental health counseling.
A document prepared by the PGST Health Services Department to explain the response to the opioid crisis talks about the Tribe’s thoughtful, holistic approach to the problem: “A strength of our approach is the collaboration between departments. No one department ‘owns’ the opioid response, each has a role.”