The Ugly Truth: Why Everyone is Dying From Heroin (Hint: It’s Not Because of Fentanyl)

It’s an ugly truth.
Give an addict heroin and there is a chance they will die. Not because of fentanyl. But because they are an addict that is doing heroin.

Just an update, Philip Seymour Hoffman’s bag of dope didn’t have fentanyl in it. It wasn’t even too much. He was just an addict on a day that ended with the letter ‘y’. That is why he died.

37 deaths in Maryland. An abnormally large amount of deaths in Pittsburgh. Deaths in South Florida. People dying all the time from “drug overdose.” And it all has been chalked up to heroin, not just heroin though, heroin cut with fentanyl. A special potent mixture that leads to overdose and death.

We have heard so much about heroin cut with fentanyl, not only is it kind of getting obnoxious, but we all seem to have forgotten that heroin in and of itself is kind of problem. Hello!!

Forget the shit labeled Theraflu. Forget the marked baggies. Forget the relapse and tolerance crap. Just in case anyone has forgotten, heroin, all by its pretty little china white, beige or brown self, can cause you to draw in and out your last breaths on this awesome planet. All it has to be is that extra .1 or .2 (or maybe you ball hard and do a whole extra 1.0) and that does the trick.

Or maybe, just maybe, here is the kicker; It doesn’t even have to be extra at all, it could just be the next shot for no reason other than the fact that you are doing heroin. YOU ARE DOING HEROIN! And quite possibly can’t stop even if you want to. People die all the time from just good ‘ol heroin in its regular uncut form, merely because they were doing a drug that can potentially kill you. You just don’t hear about it because its usually some average guy or girl, not a celebrity, who dies alone, without 36 other deaths to make their passing newsworthy.

Heroin, in and of itself, without being too much, without needing fentanyl, without a low tolerance, IS DANGEROUS. Heroin is going to keep killing people as long as there are people doing heroin. No one has to overdose and do too much, they just have to use the stuff. This is the truth, especially for addicts. Anyone, absolutely anyone, who is using heroin runs the risk of dying, regardless of tolerance, regardless of what it is or isn’t cut with, and regardless of how experienced they are. People die because they are addicted to a drug and the risk of dying from it is there every time they decide they want to feel better, numb out, get high, whatever. The thought of death either never enters their mind, is immediately pushed out by the desire to get high, or is ignored with an invincibility idea that you get when you haven’t overdosed yet (“It can’t happen to me.”) Maybe the idea that they could die does enter their mind, but it means nothing when you are an addict. The facts are, that death from heroin can happen just because you’re a human being that did heroin. Forget the overdose part of it all together.

But how?

Heroin is a potent opiate analgesic. And the disease of addiction is one that will screw with you until you’re in your grave, jail, or have decided to change your life and get sober (and even then there needs to be constant progress.) Put that combo together and you don’t need the term overdose. You might not even need the term addiction in all reality. All you really need, to die, is heroin.

Heroin not only blocks your brain from being able to register pain, it also suppresses things like your breathing while slowing your heart rate. It is a depressant. Think slow, think sloth, think sleepy. That is what heroin does. It numbs you out and slows you down, get a little too slow, and you might just stop. The heart can slowly stop beating. The lungs can slowly stop inflating and deflating. It is really simple. And it doesn’t have to be a cocktail of crap mixed with heroin to cause it. Heroin does this by itself, even in small amounts. Every time an addict uses heroin this is what happens, and the next time they decide they want to get high, could be the time their body decides to stop instead of keep on keeping on. There doesn’t need to be a bigger reason or explanation behind it. Heroin is dangerous every single time you do it just because it’s heroin. People are NOT going to stop dying. Because people are still using heroin. And the majority of people are still using heroin because their addiction tells them need to. That my friend, is the ugly truth.

Our Friends in Russia are drowning; AA is Struggling to change their Culture

The norm usually looks likes this: Where there is a big drinking or drug problem, there is also a pretty decent sized recovery movement. However: this isn’t so everywhere. Russia’s dry, not of alcohol but of AA. And well, you would think Russia is a place where they need it most. Yet drinking in Russia, is the equivalent of drinking water. That coupled with a country where opening up can be a bit hard. AA just can’t get a foothold in the place.

Walk down the streets of Russia at one point in time, and you were bound to see a couple men, drunk and slippery holding 3 fingers in the air. Why? Well a bottle of vodka cost 3 rubles, and that meant if there were three of you, it was an easy, cheap share and split. The three fingers was a universal sign for investing in a bottle and a drunken day.

Today, vodka cost a bit more in Russia, but that doesn’t mean anyone has slowed down on their drinking. A 2011 report from the World Health Organization estimated that Russians were drinking an average of about 4 gallons of pure alcohol per year. To put that into perspective, that is 70% more than we Americans do. In 2009, the British medical journal The Lancet estimated that more than half of all Russians dying between the ages of 15 and 54 were dying from excessive drinking. And half the children in Russian orphanages suffer from fetal alcohol syndrome. The alcohol problem in Russia is equivalent to the prescription/heroin problem in the states.

And all Russia’s leaders think to do is to make vodka harder to buy. But that has not worked. And nothing else really has either. Alcoholism has been declared a “national disaster.” And from our perspective the thing it looks like Russia is lacking is AA. They have no recovery movement built. In the United States, the recovery movement has become almost synonymous to AA. And the 80 year old movement has had a lot of success. But in Russia, AA is struggling to catch on. Only about 40 groups have formed throughout the entire country. Which is minuscule amount considering the size of the country, and absolutely nothing when compared to us here. There is twelve times that in just the Cincinnati area alone.

So why hasn’t AA caught on in Russia? Some of the reasons are medical, some of them are religious, some of them are cultural. The difficulties that AA has to deal with in Russia point to the fundamental idea that trying to transplant ideas across borders, may not always work. That some ideas are not as universal as we like to think.

So what is it really? Why not AA?

Well, Russians have a special relationship with their booze. We always laugh when we are told that the word “vodka” translates literally to “water.” And stuff like the recent news that Kremlin officials were only just getting around to formally recognizing beer as a form of alcohol. But it all just confirms an enduring and undying stereotype about Russian people: that they can, and do, drink in quantities that would startle people in most other nations. The roots of Russia’s special relationship with alcohol have been the subject of widespread speculation, with some chalking it up to genetic predisposition and others pointing to the supposedly essential melancholy of the Russian soul.

The Russian states official stance toward alcohol is lax at best. With a number of the country’s leaders trying to curb excessive drinking, they don’t attack the issue at the root. Svetlana Moseeva, who operates a free alcohol recovery center outside of St. Petersburg, compared her country’s record of dealing with alcoholism to that of a drunk man who decides one morning to kick his habit and finally dry out, only to pick it back up the next day. “They think, ‘OK, we did something, we put a check mark next to the problem, and now we can calm down,’” Moseeva said.

Oh and the Russian government is trying to keep the drinking culture in tact. Here is an example having to do with an 1859 uprising of peasants who decided to protest the state’s liquor taxes by going sober. A British journalist who witnessed the state’s crackdown on the teetotalers reported seeing peasants getting liquor “poured into their mouths through funnels” before being “hauled off to prison as rebels.”

A further obstacle to AA’s growth in Russia is something more philosophical: At a basic level, its premise of sobriety through mutual support just doesn’t make sense to a lot of Russians. In the past, this has taken the form of anti-Western suspicion—“What are the Americans trying to get out of this?” is a question Moseeva used to hear regularly. But more fundamentally, the group-therapy dynamic collides with a skepticism about the possibility of ordinary people curing each other of anything. “The idea that another drunk can help you is asinine to most Russians,” said Alexandre Laudet, a social psychologist who has researched Russian alcoholism.

Then there’s the problem of opening up to strangers.The AA method works in part through trust in people you’ve never met before, and coming clean to them about one’s most shameful secrets.“It is much harder for a Russian person to talk about himself than it is for an American,” said a Russian AA member named Mikhail. “And there are a lot of reasons why, including that the generation of my parents—and my own, I’m 55 and couldn’t speak the truth at all, because it was possible to get arrested for it.” Today, according to Moseeva, Russians are reluctant to admit in public they have a problem with alcohol because, while drinking is not considered shameful, doing it because you have some kind of psychological problem very much is.

Meanwhile, AA’s advocates note that the new Russia is still young. Less than 25 years ago, the country was ruled by a totalitarian regime, and its post-Soviet culture is still, in many ways, a work in progress.

Robin Williams Death Highlights Increasing Suicide Rate among Adults 45-64

U.S. health officials say Robin Williams’ death highlights the increasing rate of suicide among American adults ages 45 to 64, News media reported Williams, 63, died in an apparent suicide in August 2014.

Suicide risk increases in people who are struggling with drug and alcohol use and depression. Williams had dealt with all of these, according to The New York Times. After a period of cocaine use early in his career, Williams quit in the mid-80s. He sought treatment for alcohol abuse in 2006, and had recently been treated for severe depression.

According to the Centers for Disease Control and Prevention (CDC), suicide rates for adults ages 45 to 64 increased 40 percent from 1999 to 2011. Jill Harkavy-Friedman, Vice President of Research at the American Foundation for Suicide Prevention, says the suicide rate for people in middle age to late middle age is higher than any other group. “We don’t hear about middle-age or older people who kill themselves unless they’re a star like Robin Williams,” she said. “Because it’s so shocking when a younger person dies, there’s a tendency of re-reporting and romanticizing.”

Possible reasons for the increased suicide rate in this age group could include economic pressures, health problems and the increased use and abuse of prescription drugs, Julie Phillips, Associate Professor of Sociology at Rutgers University, told the newspaper. She noted social isolation may also play a role.

Efforts to prevent suicide have largely focused on young people and the elderly, according to Alex Crosby of the CDC. “Middle-aged adults got kind of left out in the thinking of where to focus to resources for suicide prevention,” he said. “It’s important for us to examine more closely and put more resources into that population.”

Too Much Alcohol: Making Screening and Counseling Routine

At least 38 million adults in the United States drink too much alcohol, leading to a wide range of negative consequences, including heart disease, breast cancer, sexually transmitted diseases, fetal alcohol spectrum disorders, motor vehicle crashes, and violence. Drinking too much includes binge drinking or high per-occasion use (5 or more drinks on an occasion for men and 4 or more for women), high weekly use, and any alcohol use by pregnant women or those under age 21.
Drinking too much alcohol accounts for about 88,000 deaths in the United States each year and is the fourth leading preventable cause of death. In 2006, it cost the United States about $224 billion. And although this may be a surprise, most people who drink too much are not alcoholics.
More than 30 years of research has shown that alcohol screening and brief counseling is effective at reducing risky drinking. However, this month’s Vital Signs reports that only 1 in 6 adults — and only 1 in 4 binge drinkers — say that a healthcare professional has ever talked about alcohol use with them. We need to work toward making alcohol screening and brief counseling routine.
How many US adults drink too much?
An estimated 30% of adults misuse alcohol, with most engaging in high daily, weekly, or per-occasion use which results in the increased risk for health consequences. However, only about 4% of the US population is alcohol dependent. Drinking too much is dangerous and is associated with many health and social problems, including heart disease, breast cancer, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, sudden infant death syndrome, motor vehicle crashes, and violence.
Is it realistic to expect health professionals to do anything about this problem?
Absolutely. Health professionals are already asking screening questions on an array of risk factors and may even have information about alcohol use on patient history forms. It’s simple to add alcohol screening questions to these forms. The counseling interventions are also brief (6-15 minutes), involve the patient’s active participation, and do not have to be provided by a physician, but can be provided by other health professionals, including nurses, social workers, and psychologists.
Screening and counseling can also be provided electronically to save staff time.
There are many resources for clinicians and public health practitioners with tips on brief counseling with patients who are drinking too much. In addition, the Affordable Care Act requires new health insurance plans to cover alcohol screening and brief counseling without a copayment.

What are the latest guidelines on screening and counseling in healthcare settings? What is the evidence about how well they work?

There are a number of validated screening tools to assess alcohol use, including the AUDIT, AUDIT-C, and a single-question screen for number of days in a year of binge-level alcohol use. Counseling or a brief conversation with those who drink too much can then inform the patient about health problems that could occur as a result of their drinking, and set goals and a plan for reducing drinking if the patient wants to do so. Patients who agree to reduce their drinking are then followed to assess their success.
Counseling interventions are brief (6-15 minutes) screening sessions that can help:

• Reduce average alcohol use by over 3 drinks per week;

• Reduce episodes of binge-level alcohol use by 12%; and

• Improve adherence to recommended drinking limits.

These effects can last for years and can also lead to reduced healthcare utilization, including fewer hospital days and lower costs. A very small percentage of those who are screened will have indications of alcoholism or a severe alcohol use disorder. These patients can be referred for specialized treatment.

What is an ideal screening and counseling intervention in, for example, a primary care outpatient setting, perhaps during an office visit?

Alcohol screening can be done using a set of validated questions, such as the AUDIT, AUDIT-C, or even a single question about days of binge-level alcohol use in the past year. These questions can be worked into an existing patient questionnaire or asked of patients during other clinical activities. Scoring the screening questions typically takes no more than a few seconds. Only patients who screen positive will require counseling.
Alcohol screening and counseling is similar to smoking cessation interventions, with the use of motivational interviewing and the 5 A’s of behavioral change intervention (ask, advise, assess, assist, and arrange). The clinician works with the patient to come up with a plan for reducing their drinking that takes into consideration their specific health issues as well as problems with functioning at home or work, and legal problems. Follow-up occurs in future visits to determine whether the patient’s drinking and associated problems are improving.

In what settings and in what age groups should health professionals consider screening? Which health professionals might carry out the screening and counseling most effectively — physicians, NPs or PAs, RNs, or others.
Alcohol screening and brief counseling can occur in primary care settings, trauma care settings, emergency departments, and many other health and social service settings. It can be delivered by social workers, nurses, psychologists, and others. Delivering alcohol screening and counseling by phone, computer, or mobile devices can also reduce the demand on staff time for delivering this service.

Are there some successful or innovative programs that have used these guidelines in practice?

One example of successful integration of alcohol screening and brief counseling into routine clinical care is Kaiser Permanente of Northern California. It has recently integrated this service into its primary care practices, covering 3.4 million members. During a 4-month period (July-November 2013) there were 230,000 brief interventions or referrals. Staff supported this implementation, in part because the screening process was built into their electronic health record (EHR) system.

What are the ways that alcohol screening and brief counseling can be integrated into EHRs?

There are a variety of e-tools, including prompts and other reminder systems, that can be used to help clinicians integrate alcohol screening and brief counseling into their practices. The Community Preventive Services Task Force has also recommended the use of electronic methods (eg, use of computers, telephones, or mobile devices) to deliver components of alcohol screening and brief intervention. In addition, alcohol screening and brief counseling are being considered for inclusion as a meaningful use measure in EHRs, which could also help support the use of this service in clinical settings.

What should clinicians do differently tomorrow to start to improve this situation?
Doctors, nurses, and other health professionals can take 3 key actions:

• Screen all adult patients for alcohol use as part of their regular services by using clinical intervention guidelines and overall implementation guidelines;

• Counsel those who drink too much to drink less, using specific techniques such as motivational interviewing to establish a plan, and then reassess their success in future visits; and

• Advise pregnant women and underage youth not to drink at all.

They can also train staff to support the routine delivery of this intervention and make changes in the healthcare delivery system to ensure the success of alcohol screening and counseling activities.

It snuck up on us

FEDS PLEDGING FULL ATTENTION TO HEROIN EPIDEMIC

U.S. Attorney General Eric Holder recently acknowledged the epidemic “snuck up on us” at a national law enforcement summit on heroin in April. But, he also used the summit to pledge renewed attention to what he called “an urgent public health crisis.”
Holder cited a rise in investigations and heroin seizures by the DEA over the past three years and the Justice Department’s commitment to specialty drug courts that let addicts get treatment “and return to their communities before incarceration.”
Last year, the DEA seized more than 2,100 kilos, or about 2.3 tons, of heroin at the Mexican border. That’s more than triple the amount seized in 2008. But DEA officials say they weren’t specifically targeting heroin. There’s just more heroin crossing the border.
At the summit, Holder acknowledged more needs to be done. “Addressing this … will require a combination of rigorous enforcement and robust treatment.”
At the same time, the explosion of heroin users, addicts and overdose deaths has some critics asking why it took so long and whether a faster response by public officials — at all levels — could have slowed or prevented heroin’s resurgence. Much of the criticism is aimed at the Food and Drug Administration’s handling of the approval the original opioid pain pills for wide use.
“This did not sneak up on us,” said Kolodny, who is also chief medical officer for Phoenix House, a New York-based drug treatment non-profit organization. “The opioid epidemic began in the late 1990s, and very early on we saw people who were addicted to opioids move over to heroin. Had the FDA been doing its job, I don’t think we would have an epidemic today.”
I never understood the concept of letting an addict crash and burn before you intervene. This is a public health crisis. Addiction is a chronic disease.

CHARLOTTE WETHINGTON, MOTHER OF A HEROIN VICTIM AND ADVOCATE FOR TREATMENT

Wethington, the anti-drug activist, said the fervor with which government officials are acting is encouraging, but much delayed.
“I was trying to sound the warning bell and nobody was listening,” said Wethington, who now works as an addiction and recovery counselor.
Unable to find local help from doctors, law enforcement or treatment centers during and after her son’s overdose, Wethington pushed for changes to Kentucky law to allow families to petition courts to intervene and order addiction and rehab services for drug addicts — even if they had no criminal record.
“I never understood the concept of letting an addict crash and burn before you intervene,” she said. “This is a public health crisis. Addiction is a chronic disease.”
Kentucky adopted the Matthew Casey Wethington Act for Substance Abuse Intervention in 2004 — modeled after an existing Florida law. Ohio adopted a variation of Casey’s law in 2012. Advocates in at least 11 other states, including Indiana, Arizona, New York and Florida, are working to do the same.
“I get calls from people all over the country who ask me how can I get Casey’s law in my state. It’s bittersweet because we couldn’t save our own son.”

A Snapshot of Annual High-Risk College Drinking Consequences

The consequences of excessive and underage drinking affect virtually all college campuses, college communities, and college students, whether they choose to drink or not.

Death: 1,825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor vehicle crashes (Hingson et al., 2009).

Injury: 599,000 students between the ages of 18 and 24 are unintentionally injured under the influence of alcohol (Hingson et al., 2009).

Assault: 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking (Hingson et al., 2009).

Sexual Abuse: 97,000 students between the ages of 18 and 24 are victims of alcohol-related sexual assault or date rape (Hingson et al., 2009).

Unsafe Sex: 400,000 students between the ages of 18 and 24 had unprotected sex and more than 100,000 students between the ages of 18 and 24 report having been too intoxicated to know if they consented to having sex (Hingson et al., 2002).

Academic Problems: About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall (Engs et al., 1996; Presley et al., 1996a, 1996b; Wechsler et al., 2002).

Health Problems/Suicide Attempts: More than 150,000 students develop an alcohol-related health problem (Hingson et al., 2002), and between 1.2 and 1.5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use (Presley et al., 1998).

Drunk Driving: 3,360,000 students between the ages of 18 and 24 drive under the influence of alcohol (Hingson et al., 2009).

Vandalism: About 11 percent of college student drinkers report that they have damaged property while under the influence of alcohol (Wechsler et al., 2002).

Property Damage: More than 25 percent of administrators from schools with relatively low drinking levels and over 50 percent from schools with high drinking levels say their campuses have a “moderate” or “major” problem with alcohol-related property damage (Wechsler et al., 1995).

Police Involvement: About 5 percent of 4-year college students are involved with the police or campus security as a result of their drinking (Wechsler et al., 2002), and 110,000 students between the ages of 18 and 24 are arrested for an alcohol-related violation such as public drunkenness or driving under the influence (Hingson et al., 2002).

Alcohol Abuse and Dependence: 31 percent of college students met criteria for a diagnosis of alcohol abuse and 6 percent for a diagnosis of alcohol dependence in the past 12 months, according to questionnaire-based self-reports about their drinking (Knight et al., 2002).