The Opioid Epidemic’s Untold Story

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Last year, more Americans died of opioid overdoses than of many cancers, gunshot wounds, or even car crashes. In fact, by at least one metric, the epidemic is more dire for Americans than was the Vietnam War: while an average of 11 Americans died per day during the 14 years the U.S. was involved in Vietnam, nearly 120 Americans died per day of opioid overdoses in 2018 alone.

As families write obituaries, death notices are printed, and flowers are delivered to grieving loved ones, an important part of the story has gone largely untold. At some point, if they survive, most opioid abusers end up in court. Perhaps they have been arrested for stealing to feed their habits or perhaps an agency has deemed them unfit parents. Whatever the reason, one fact remains: the state court justice system is now the primary referral source for addiction treatment in the country.

This reality has put enormous strain on our nation’s state courts, many of which have been overwhelmed by growing dockets and shrinking resources. In a recent survey of chief justices and state court administrators, 55 percent ranked the opioid epidemic’s impact on the courts as severe. The survey results are unsurprising, given the complexity of opioid cases: it takes an enormous amount of time to figure out what’s best for people who are addicted, how to care for their children, and what resources are available for them. And those who are placed in a treatment program with court oversight may remain involved with the court for years.

While Congress has responded with appropriation increases in targeted funding for the states, almost none of it has been directed to the court system. Court leaders quickly realized the stress this epidemic brought to the courts as a “crisis within a crisis.”

This led to the establishment of the National Judicial Opioid Task Force in 2017 by the Conference of Chief Justices and the Conference of State Court Administrators to examine current efforts and to find solutions to address the epidemic. The task force started by developing five principles for state courts to use as a point of reference in addressing the crisis:

  • The justice system is in the middle of this crisis and should lead the way in delivering solutions.
  • Judges should use their positions to bring together leaders of government agencies and other groups to address the epidemic.
  • Courts should ensure that opioid abusers get the treatment they need.
  • Interventions should be comprehensive and should include initial proper treatment, recovery services, and appropriate placement of children.
  • The courts should use data whenever possible to help them make good decisions.

With these principles in place, the task force has developed—and will continue to develop—practical information, tools, and best practice recommendations for state court judges and court administrators. It recently released a comprehensive resource center to provide information to help courts understand the unique aspects of opioid-use disorder and to handle opioid-related cases more effectively.

To be sure, this isn’t just a serious problem where we live in Indiana and Tennessee. Opioid addiction has rocked states throughout the country. In nine states, the number of prescriptions exceeds the number of residents. And a 2017 White House report estimated that the opioid crisis resulted in economic costs exceeding $504 billion in the U.S. in a single year.

But there are examples of hope. The task force is working with court leaders across the country to identify promising state and local court programs that address the crisis. For example, a New York state court judge has developed an opioid intervention court that, within hours of arrest, links participants with treatment services. Kentucky has created treatment and recovery teams that combine best practices in courts, child welfare, treatment, and peer recovery. In Indiana, the Supreme Court hosted a statewide opioid summit bringing together almost 1000 community stakeholders from every one of the state’s counties. Montana judges are using new technologies to address the complications of providing services in remote communities. And courts in Tennessee are focusing on the needs of pregnant women with addiction and have already seen a reduction in the number of babies born with neonatal abstinence syndrome.

Much work remains. But the National Judicial Opioid Task Force is dedicated to building on the successes of other courts and working collaboratively with local, state, and federal partners to craft the responses and solutions that are required to combat this serious and complicated epidemic.

What Are the Current Drug Trends Among Teens and Young Adults?

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Drug trends among teens and young adults today are “not your father’s Oldsmobile,” so to speak. The whole scene has changed. We continue to have problems with commonly-used mind-altering substances that have been around for a long time such as opiates, marijuana and hallucinogens. Today, however, we add to this list increasingly bizarre practices such as consuming embalming fluid, along with numerous synthetic drugs and organic drugs that are unstudied and often untraceable. Here is an overview of the major drug trends we are seeing nationwide.

Kratom

Today, Kratom has become a hotly-debated drug, often touted as an organic pain-reliever and recently classified as an opioid by the Food and Drug Administration. Despite its widespread use and ease of online ordering, little clinical research has been conducted on this drug making it a risky substance, especially as it becomes increasingly popular with teen and young adults. Though this drug was officially made illegal in Alabama, Arkansas, Indiana, Tennessee, Vermont, and Wisconsin in 2016, Kratom is still legal in many states. Its effects can be severe with more severe side effects including respiratory depression and psychosis. It is also highly addictive.

Synthetic Drugs

Synthetic drugs have become increasingly popular with younger people, and the effects of these drugs can be deadly.

Synthetic drugs include synthetic cannabinoids such as Spice and K2. These drugs are manufactured chemicals that are often sprayed on dried plant material. This allows them to be smoked in a method similar to marijuana. Synthetic cannabinoids are also sold as liquids which can be vaporized in e-cigarettes. Often, these products are labeled as incense and do not come up on standard drug tests, thereby making them dubious to many parents. Common street names include Spice, K2, Genie, Red Magic and Fake Weed.

Synthetic cathinones, commonly referred to as “bath salts,” are similar in that they are manufactured substances and are often labeled as “not for human consumption” despite their widespread use as a drug. These mind-altering substances are unregulated stimulants often used as a substitute for cocaine or amphetamines. They can be swallowed, snorted, smoked, or injected and remain popular among teens young adults. Common names include Flakka, Ivory Wave, Stardust, Cloud Nine, Meow Meow, Vanilla Sky, and White Knight or White Lightning.

Since synthetic drugs are largely unregulated and can be highly dangerous and unpredictable, it is imperative that parents familiarize themselves with these substances, which are often mistaken for benign incenses and can be purchased at many local gas stations and paraphernalia shops.

Hallucinogens

In recent years, we have seen a resurgence of hallucinogens among young people. These include more commonly known substances such as lysergic acid diethylamide (LSD). LSD is often taken as a tablet or “blotter.” Its effects may be intense and include both visual and auditory hallucinations, altered perceptions, delusions and time distortions. Psilocybin, also known as “Magic Mushrooms,” is a naturally-produced psychedelic compound found in species of mushrooms. Dried or fresh mushrooms are often ingested, prepared as a tea or consumed with other foods. Other substances include marijuana cigarettes, which are dipped in solutions to enhance the hallucinogenic effects of THC, with embalming fluid is among the substances used. As one might imagine, this solution can produce disastrous effects, such as decreased lung function and an increased risk of cancer when used recreationally.

Opioids

Opioids continue to be popular among all age groups, including young adults. Young adults consume more prescription medications recreationally than any other age group, sometimes in combination with alcohol, placing them at increased risk for respiratory failure. They are also at high risk for addiction and dependence. Often, physicians find these drugs were illegally and unknowingly obtained from a family member or friend. These addictive substances can lead to heroin and fentanyl use. Opioid use can cause permanent neuropathy among people who overdose or become unconscious from opioids. In a residential treatment setting, it is unfortunately common to see at least one or two patients at any given time with a permanent disability as a result of an overdose.

The Role of the Internet in Drug Use

Today, the internet continues to be a primary source of information about drugs from many young people, with entire sites devoted to explaining drug use. Additionally, young people often report obtaining drugs from site on the “Dark Web,” a part of the internet that requires special software or authorization to access and is not found on regular search engines, making them largely untraceable. These drugs are sent via mail, sometimes to a P.O. Box where they can be received without a parent’s knowledge. Cryptocurrencies like Bitcoin may also be a source of payment, creating a largely anonymous purchase experience.

What Can Parents Do?

  • Pay attention to unexplained changes in your child’s behavior including school/work performance, general mood, sleeping patterns, etc. These changes may be signs of substance use.
  • Pay attention to what is happening on computers in your home. Check browsing history regularly and do not ignore unexplained software on your computer. Check for deleted browsing histories and ask questions.
  • If you discover your child is experimenting with drugs, consider consulting a professional as opposed to trying to figure out the problem yourself.
  • The most significant thing a parent can do to help kids is to spend time with them. This is just as true with adolescents and young adults as it is for young children. Communicating with your kids and being clear about expectations are a parent’s best tools for guiding kids to make healthier choices.

Family Involvement Key to Success of Teen Substance Use Treatment

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Family involvement is a key component to success in treatment for teen substance use disorder, according to a review of recent research by an expert at the Center on Addiction.

“Our review has shown that programs that involve families are the most effective,” said Aaron Hogue, Ph.D., Director of Adolescent and Family Research at the Center on Addiction. He recently spoke about treatment for adolescent substance use at the National Academy of Sciences, Engineering, and Medicine in Washington, D.C.

As the opioid epidemic grows, there is great demand for treatment for opioid use disorder for teens and young adults, Hogue noted. “We know the most effective treatment is medication-assisted treatment, which combines medications with behavioral interventions,” he said. “This review helps treatment providers know which types of behavioral interventions will have the greatest impact.”

He noted that more than 90 percent of teens who meet diagnostic criteria for a substance use disorder do not receive appropriate treatment.

Hogue conducted a cumulative review of experimental studies on outpatient behavioral treatment adolescent substance use. He reported in the Journal of Clinical Child and Adolescent Psychology that ecological family-based treatment is the most effective. This type of treatment targets multiple systems—family, school, peers, juvenile justice—within which teens develop.

As with other types of family therapy, ecological family-based treatment engages teens and families to make long-term changes, addresses individual, family, peer and community-level influences, and reduces problem behaviors.

The ecological model of family therapy aims to change relationships, Hogue explained. “It looks to change the meanings in how behaviors are interpreted. For instance, if a teen were to say, ‘My mom doesn’t trust me – she’s always asking me where I’m going,’ a therapist might reframe it by saying, ‘It sounds like your mom cares about what you’re doing and is worried about you hanging out with the people or going places that will lead to negative outcomes.’ It helps shift how the teen understands the behavior, from being inappropriately controlling to being worried and showing concern.” This doesn’t mean one interpretation is truer than another, but it broadens the understanding of meanings and relationships, Hogue said.

Other types of treatment that were found to be effective included individual cognitive-behavioral therapy and group cognitive-behavioral therapy. These types of therapy help identify, recognize and avoid thought processes, behaviors and situations associated of alcohol or other drugs, and develop better problem-solving and coping skills.

The review found behavioral family-based treatment was “probably” effective. This type of therapy works to improve communication and support and reduces conflict between families that have a member with addiction. Behavioral-based family treatment is focused on increasing the communication and coping skills of family members, Hogue said.

Motivational interviewing was also found to be “probably” effective. This approach bolsters motivation to change substance use behaviors and encourages planning for change and then making and maintaining changes in behavior.

Families looking for therapy should ask how much family involvement there is, Hogue advised. “Am I expected to attend a few sessions at the beginning or end of treatment? Should I be in the building for every session and come in periodically for review and updates? Or am I expected to attend most or all sessions because the focus in on the entire family as a team?” he said. “One approach isn’t necessarily preferable to another, but whichever approach you take, you need to be fully committed to it in order to maximize its effectiveness.”

For more information on types of addiction therapy, read the Center on Addiction’s “Guide to Finding Quality Addiction Treatment.”

Brain Damage from Alcohol Continues After Abstinence

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Damage to the brain caused by alcohol continues during the first few weeks of abstinence, a finding that refutes the notion that the brain begins to normalize immediately after individuals stop drinking.

“Until now, nobody could believe that in the absence of alcohol the damage in the brain would progress,” study investigator Santiago Canals, PhD, of the Institute of Neuroscience of Alicante, Consejo Superior de Investigaciones Científicas–Universidad Miguel Hernández, Spain, said in a news release.

The study was published online April 3 in JAMA Psychiatry.

A Look Inside the Brain

Using diffusion tensor imaging, the researchers assessed microstructural alterations in white matter after long-term alcohol exposure and during early abstinence in 91 men (mean age, 46) who had alcohol use disorder (AUD).

The men were hospitalized and were undergoing detoxification treatment, which guaranteed that they did not drink alcohol. Thirty-six healthy men of similar age who did not have AUD served as control persons.

The researchers found diffuse microstructural changes in white matter in the men with AUD compared with the control persons. These changes primarily affected the right hemisphere and the frontal region of the brain. These changes progressed during 2 to 6 weeks of abstinence.

“The study was not designed to look further in time, also due to the fact that our results were unexpected,” study coinvestigator Wolfgang Sommer, MD, PhD, of the University of Heidelberg, Germany, said.

“Other studies looked at a longer time horizon and typically found signs of recovery, both of the brain structure and its function. Nevertheless, we need more research to understand what is going on here and what are the temporal aspects of the underlying phenomena,” said Sommer.

The researchers replicated their observations in an established rat model of excessive alcohol consumption.

“The fact that the findings in humans mirror those in rats may establish a relationship between the observed changes and alcohol consumption, which is difficult to verify based on human results only, given the large heterogeneity of the abuse patterns, medication for relief of withdrawal symptoms, and comorbidities among patients with AUD,” the researchers write.

“This result establishes the utility of diffusion imaging for monitoring the brain status as a possible noninvasive biomarker of AUD progression and, potentially, of treatment response,” they add.

Important Translational Study

“These types of translational studies are crucial to help fill in gaps in addiction research,” Marisa Silveri, PhD, director of the Neurodevelopmental Laboratory on Addictions and Mental Health, McLean Hospital, Belmont, Massachusetts, and associate professor of psychiatry at Harvard Medical School, Boston, said.

“The findings do fly a little in the face of what we know, because when people become abstinent, it usually doesn’t take them long for things like brain chemistry and cognition to improve, somewhat after abstinence. But it’s studies like these that uncover some more micro level cellular indicators that tell us that just because you can recover some function, it doesn’t necessarily mean the brain is returned to a healthy state,” said Silveri.

“That’s an important message because people often think that when they no longer feel the acute intoxicating effects of alcohol, that it’s not still having an effect, and we do know from many studies that there are residual effects of alcohol intoxication on neurobiology.

“The brain is a fantastic orchestra of networks, and understanding some of the subtler changes and what they mean is work that is most needed,” she added.

Alcohol and the Electric Atrium: How Drinking Promotes AFIB

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Regular alcohol intake at moderate levels was associated with electrical and structural changes in atrial myocardium in patients who underwent electrophysiologic mapping studies prior to catheter ablation for atrial fibrillation (AF) in a small cross-sectional study.

Moderate alcohol consumption, defined as eight to 21 drinks per week, was an independent predictor of the atrial remodeling, characterized by significantly reduced atrial voltage and conduction velocities and increased atrial dimensions, reported a group January 9 in Heart Rhythm.

The same was not found for mild alcohol intake levels, defined as two to seven drinks per week.

The findings suggest that moderate alcohol intake has “direct effects on atrial substrate” that are consistent with myocardial fibrosis, although the association can’t prove it causes AF, observed senior author Peter M. Kistler, MBBS, PhD, Alfred Hospital, Melbourne, Australia.

However, “this study adds to the growing evidence base that excessive alcohol consumption is implicated in AF pathogenesis and as such is a potentially modifiable risk factor,” Kistler told us by email.

The study enrolled 75 otherwise mostly healthy patients with paroxysmal or persistent AF who were scheduled for catheter ablation at two hospitals from 2016 to 2018.

They included 25 self-reported lifelong nondrinkers, 25 who reported consuming two to seevn drinks per week (mean, 4.5), and 25 reporting intake of eight to 21 drinks per week (mean, 14.1) in the most recent 12 months. As defined, one drink contained 12 g of alcohol.

Excluded were patients with permanent AF or significant structural heart disease, and those meeting the study definition of occasional drinker or binge drinker.

Mean left atrial size was larger in moderate drinkers than in nondrinkers (28.0 vs 22.7 cm²; P = .008).

Before ablation, off antiarrhythmic drugs, and in sinus rhythm (after external cardioversion, if necessary), the patients underwent high-density left-atrial mapping studies using the CARTO (Biosense Webster) three-dimensional electroanatomic mapping system.

Moderate drinkers, compared with nondrinkers, had significantly lower mean global bipolar voltages, slower conduction velocities (CV), and a higher proportion of complex atrial potentials

Results of CARTO Electroanatomic Mapping Studies by Alcohol Intake Level
ParameterModerate DrinkersNondrinkersPValue
Global bipolar voltages (mV)1.531.89.02
Conduction velocities (cm/s)33.541.7.04
Proportion of complex atrial potentials (%)7.84.5.004

Mild drinkers, compared with nondrinkers, showed a larger proportion of complex atrial potentials, a difference that reached marginal significance (6.6% vs 4.5%; P = .047), but no corresponding significant difference in mean global voltage or CV.

AF was seen to recur in 37% of patients at 12-lead electrocardiography and Holter monitoring, performed at prespecified intervals or on development of symptoms, during the postablation follow-up, which averaged 18.7 months.

The 37% included nine moderate drinkers, 11 mild drinkers, and eight nondrinkers, for rates of 40% for moderate and mild drinkers and 32% for nondrinkers. Those numbers are not in the report; Kistler said the study is underpowered to detect differences in AF recurrence rate.

However, significant independent substrate-related predictors of recurrent AF included reduced mean global voltage, greater proportion of low-voltage electrograms, and greater prevalence of complex potentials.

“Our study was primarily focused on alcohol’s effects on the atrium’s electrophysiological properties, but numerous recently published studies have identified excessive alcohol consumption as a significant predictor of postablation recurrence,” Kistler said. “This emphasizes the importance of lifestyle modification in improving AF outcomes postablation.”

Big Alcohol Knocks Back Medical Clout on Drinking

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VIENNA — Alcohol should carry warning labels about health risks, the marketing of alcohol directly to the public should be banned, and it should be more expensive, according to specialists in liver disease.

“Cost is the only way you can reduce alcohol consumption,” said Roger Williams, MD, from the Foundation for Liver Research in London. “Everyone has tried education; nothing works.”

In the fifth report of the Lancet Standing Commission on Liver Disease in the UK, Williams and his coauthors ask the British government for a “reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place.” They also ask for “the introduction of minimum unit pricing in England, targeted at the heaviest drinkers.”

The government has been reluctant to introduce any taxes on alcohol, because the drinks-industry lobby is very powerful. In fact, “it appears the lobby has more sway over government than medical opinion,” Williams said.

The report and its recommendations, along with other strategies to reduce alcohol consumption, will be discussed at the upcoming International Liver Congress (ILC) 2019.

Alcohol is still the biggest contributor to liver disease in Europe, followed by obesity and hepatitis B and C infection, according to the European Association for the Study of the Liver (EASL) HEPAHEALTH project (J Hepatol2018;69:718-735).

Harmful Use of Alcohol Causes 3 Million Deaths Annually

Last September, the World Health Organization reported that alcohol causes 3 million deaths globally every year, which is one death every 10 seconds. To combat alcohol-related health risks, the WHO outlined five high-impact strategies to reduce alcohol consumption: restricting availability, raising taxes, banning advertising, enhancing drunk-driving laws, and facilitating treatment.

The heaviest drinkers are now “the 40- to 50- and 50- to 60-year olds,” Williams said, adding that the number of women who drink heavily is rising.

People in these age groups are also at risk for obesity. “If you’re overweight or obese, alcohol-related liver disease is worse,” he pointed out. “The two are synergistic.”

Fortunately, once government does take the lead, it really can be effective, he said. “Smoking is a good example of how policy can affect change.”

The duty escalator — introduced in the United Kingdom in 2008, but then repealed for beer in 2013 and for wine, cider, and spirits in 2014 — automatically increased alcohol duties by 2% above inflation every year.

The Duty Escalator, Minimum Unit Price

When the duty escalator was in place, rates of mortality related to alcohol consumption improved in Scotland and, to some extent, England, an analysis of the policy showed. Immediately after the repeals, however, rates started climbing.

Just 4% of the population accounts for almost one-quarter of the alcohol industry’s sales, and many of these people drink harmful quantities, according to the Lancet report.

“Then there’s the 5% of those who are poor and in a bad environmental situation and are drinking 100 units a day or more,” said Williams. “These are the ones we have to target with the minimum unit price; it stops them from drinking all those cheap ciders.”

In Scotland, legislation that established a minimum unit price was introduced in 2012, over legal challenges launched by the Scotch Whiskey Association.

Interventions should be targeted at higher-risk groups, said Peter Rice, MD, steering group chair of Scottish Health Action on Alcohol Problems (SHAAP), a project of the Royal College of Physicians of Edinburgh.

In fact, policy interventions that have the greatest effect on populations most in need “may be more useful than the traditional alcohol policy field conceptualizations of whole population and targeted measures,” he writes in a recent review of alcohol policies in Europe.

A minimum unit price specifically targeted at the extreme drinker who develops cirrhosis has a higher likelihood of being effective than tax or duty, Rice explains.

“If we can affect the heaviest drinkers, we can affect the rest of the population,” he said.

Policy is effective, he said. “We need restrictions on price, availability, and marketing; we cannot treat our way out of Scotland’s liver disease.”Clear advice from a physician is a powerful tool.

Rice, who will speak at the congress, said he hopes to inspire advocacy from medical professionals. He said he believes that having doctors get used to having direct conversations with patients about drinking is important.

“Clear advice from a physician is a powerful tool,” he said.

But nothing beats doctors getting involved in campaigning. “We need to get busy to advocate for effective prevention. Physicians have effective voices,” said Rice. Doctors, physiatrists, and hepatologists really made a difference “in our own debates in Scotland.”

He and his colleagues continue to work to ensure that the minimum price keeps up with inflation and market changes. “The government is now committed to reviewing price at a 2-year interval,” he reported.

Next, his team will look at pushing for a ban on alcohol marketing. “We increasingly see how sports sponsorship has an effect on people’s normalization of consumption,” he explained. “We would like to see regulations in sports.”

Today, outcomes for patients treated for liver disease are good. “Those who quit drinking do pretty well, as long as there is good support and treatment for them,” said Rice.

But, he added, “like most things in medicine, prevention is better than a cure.”