Homeland Security Today Executive Editor Kristina Tanasichuk sat down to discuss the opioid crisis and some of its causes with Dr. Paul Christo, one of the world’s leading pain specialists and author of Aches and Gains, A Comprehensive Guide to Overcoming Your Pain. Dr. Christo is an associate professor in the Division of Pain Medicine at the Johns Hopkins University School of Medicine and served as director of the Multidisciplinary Pain Fellowship Program for eight years, and the Blaustein Pain Treatment Center at the Johns Hopkins Hospital for five years. He hosts an award-winning, nationally syndicated SiriusXM radio talk show on overcoming pain called Aches and Gains®.
HSToday: Opiod addiction has truly captured the national interest – even the White House has a page devoted to the crisis on its site under Homeland Security. Thank you for sitting down with us to help our readers understand it better. What do you find are the factors associated with addiction in the opioid crisis?
Dr. Christo: There were over 42,000 overdose deaths involving opioids in 2016. That’s very high and there’s no question that opioid-related deaths have become a serious public health problem. Over the last 20 years, physicians and other healthcare providers have liberalized the use of opioids for chronic pain. This was done in a good-faith attempt to ease pain and suffering. The consequences of increased opioid use lead to patients receiving opioids who probably didn’t need them, and also misuse, abuse, and diversion. And, the non-medical use (e.g., getting “high”, reduce anxiety, get to sleep) of opioids has escalated by patients who don’t use them properly.
The non-medical use of prescription opioids can include combining them with other drugs such as benzodiazepines (e.g, valium) and alcohol. When this happens, the risk of death is higher from mixing opioids with these drugs. We’ve also seen prescription opioids being used by those for whom they are not prescribed. This practice has contributed to the rising number of opioid-related overdoses.
HSToday: What’s the typical “route” to addiction, in your experience? Is there one?
Dr. Christo: Addiction is complicated and not widely understood. It’s a chronic, neurological, and biological disease that has a strong genetic predisposition and is also influenced by environmental factors. Addiction takes hold when a drug with rewarding properties (e.g., opioid, alcohol) is introduced to a vulnerable person at a vulnerable time in life. We see impaired control over drug use, compulsive use, continued use despite harmful consequences, and craving.
The path to addiction may begin with a patient misusing an opioid (using it in a way that isn’t prescribed). This might mean using it five times a day instead of three, or using it to treat depression or anxiety. The misuse then progresses to intentionally using the opioid for a non-medical purpose such as “getting high”. This is now called abuse. Once the abuse spirals out of control, addiction can result.
People use substances to change their mood and these substances have reinforcing properties. In a susceptible and vulnerable person, this use can spiral out of control into the disease of addiction.
HSToday: Why is now different?
Dr. Christo: Today, we’re seeing a large increase in the use of street drugs such as heroin often laced with very powerful opioids called fentanyl and carfentanyl. The addition of these opioids to heroin or other illegal drugs makes the combination even deadlier. Due to the reduction in supply of prescribed opioids, some patients are going to the streets to buy opioids in order to get needed pain relief, or needing street opioids to ease withdrawal from prescribed opioids that were stopped abruptly.
HSToday: What advice do you have for state and local law enforcement? How can state and local governments help?
Dr Christo: Law enforcement can carry an opioid reversal drug called naloxone. This drug is administered intranasally, intramuscularly, or intravenously. If a first responder like a law enforcement official administers naloxone, it can save the life of a person who has overdosed on heroin, or an opioid.
State and local governments can help ensure that policies are in place to make naloxone available to first responders such as EMTs and police officers. They can also support compassionate opioid tapering for patients using opioids. This reduces the discomfort of acute withdrawal, which can be debilitating and lead patients to the streets. Governments can support the safe storage of opioids for legitimate use so that friends and family members don’t have access to them, use them, and overdose accidentally.
HSToday: Do you see illegal opioids contributing to this epidemic?
Dr. Christo: Yes. A good number of opioid overdose deaths are due to their illegal use either from the street, or illegally obtained from family and friends. Remember that we’ve also seen deaths linked to combining opioids with other drugs such as alcohol and benzodiazepines. Together, these drugs depress our ability to breathe, leading to death.
HSToday: Who is the typical “addict”? Or is there one?
Dr. Christo: I think many view addicts as homeless, poor, or jobless. The media has also portrayed patients using opioids therapeutically to control their pain as addicts. Certainly, addiction can afflict people in these categories, but addiction, like pain, has no boundaries. It’s a disease and can strike anybody regardless of race, gender, or socioeconomic status.