Addiction treatment shrinks during the pandemic, leaving people with nowhere to turn

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Josh Ledesma displays safe injection supplies with outreach specialist Rachel Bolton outside the Access Drug User Health Program drop-in center in Cambridge, Massachusetts on March 31, 2020. Craig F. Walker/The Boston Globe via Getty Images

Elizabeth Chiarello, Saint Louis University

COVID-19 has overshadowed the U.S. opioid crisis, but that doesn’t mean opioid addiction has gone away. During the COVID-19 pandemic, the opioid crisis has gotten worse. Drug overdose death rates rose 13% in the first half of 2020. COVID-19 threatens to dismantle an already frayed addiction treatment system, creating a crisis on top of a crisis.

The opioid crisis, or, more aptly, the overdose crisis, has plagued the U.S. for two decades. Drug overdose is the leading cause of accidental death, claiming 70,000 American lives each year. Opioids contribute to 130 deaths daily, enough people to fill a commercial airliner.

As a medical sociologist who has researched the opioid crisis for the last decade, I have seen the havoc it has wrought. Here is how I see COVID-19 making it worse.

A glimmer of hope, dashed

A road sign advertises help for addiction in West Virginia, one of the states hit hardest by the opioid crisis.
In the city of Logan, West Virginia, a road sign advertises help for addiction. Andrew Lichtenstein/Corbis via Getty Images

Overdose deaths increased steadily each year since 1999 until they declined 4.1% in 2018, largely due to fewer deaths involving prescription opioids. Experts suggest that lower opioid prescribing rates, expanded treatment access and increased naloxone access help explain the decline.

That brief downturn gave way to steeply rising overdose death rates in 2019 and 2020 as deaths involving other drugs like cocaine and methamphetamine rose.

Not only are numbers going up, but the drugs that contribute to overdose have changed.

Many overdose deaths involve multiple drugs. Prescription drugs now play a less prominent role than heroin, cocaine and methamphetamine. Synthetic fentanyl – a potent illegal opioid manufactured in labs – poses the biggest threat. It contributes to twice as many overdose deaths as prescription opioids.

Inadequate addiction treatment

The overdose death rate – 20.7 deaths per 100,000 people – comes as no surprise to people familiar with U.S. addiction treatment.

Only 17% of people with addiction get treatment.

And addiction treatment is notoriously fragmented and underfunded. Cordoned off from mainstream health care, the addiction treatment industry receives scant regulation. Quality varies. Only one-third of facilities provide medications for addiction treatment, evidence-based care that reduces overdose risk.

In the face of inadequate addiction treatment, harm reduction strategies are effective. Harm reductionists encourage people who use drugs to use strategies that protect them from overdose, infectious disease and abscesses from sharing or reusing syringes.

Programs that reduce harm include naloxone programs that distribute naloxone throughout communities and syringe services programs that distribute clean syringes to people who inject drugs. These programs, while effective, receive tepid support, largely due to stigma. Naloxone distribution programs and syringe services programs operate on shoestring budgets with limited hours that have only become more restricted during the pandemic.

COVID-19's emergence has further complicated the opioid crisis.
A medical assistant in Charlestown, Massachusetts takes a swab sample from from a patient. Matt Stone/MediaNews Group/Boston Herald via Getty Images

Clash of the crises

When the COVID-19 pandemic began, the federal government took measures to lessen the pandemic’s impact on the opioid crisis.

The government lowered barriers to medications for addiction treatment by allowing methadone clinics to give patients medication to take home and by allowing physicians to provide buprenorphine, another drug used in recovery, through telemedicine. These measures reduced in-person contact.

But people dealing with the disorder still face challenges. For one, they cannot attend in-person support groups. Social isolation increases the likelihood of drug use and overdose. While figures are not yet available, much anecdotal evidence suggests that coping with the pandemic increases stress and anxiety while disrupting routines that are important for recovery.

And, COVID-19 has made the illegal drug supply more dangerous. In the illicit market, drugs contain various substances. A person who purchases heroin might end up with a mix of heroin, fentanyl and oxycodone, drugs of varying strengths. People who use drugs typically get them from a known supplier, so they know what they are getting and how much to take.

COVID-19 interrupted the illicit drug trade, so there were fewer drugs coming into the country. When supply runs low, people do not stop using drugs; they get drugs of unknown composition from new suppliers. If someone buys heroin but unknowingly receives much stronger fentanyl, the overdose risk skyrockets. People die because they do not know what drug they are taking.

Crisis compounded

In addition, COVID-19 exacerbates the trauma that leads to overdose. Addiction is a “disease of despair,” meaning it is more common among people with poor social and economic prospects. Mental health conditions, job loss and housing instability all contribute to drug use.

COVID-19 makes treatment less available. Treatment centers struggling to stay open are reducing hours and furloughing staff. Syringe service program site closures and stalled naloxone programs undermine harm reduction efforts.

Strategies to expand treatment have been of some help. However, only physicians who already have an X Waiver – a special dispensation to prescribe opioids for addiction – can provide telemedicine for buprenorphine. The federal government’s actions have moved care online, but only minimally increased treatment capacity.

A systemic solution

Things are dire, but leaders can deploy effective strategies now. In the short term, leaders can double down on harm reduction. They can blanket communities with naloxone, putting it in every library, gas station, pharmacy and vending machine, making it as commonplace as a fire extinguisher. They can invest in syringe services programs and encourage people to use drug test strips to test for fentanyl.

They can expand medications for addiction treatment by eliminating the X waiver, letting all licensed physicians provide them, and by allowing pharmacists to provide buprenorphine, an approach showing favorable results in Rhode Island. They can expand Medicaid, which requires insurers to cover treatment for addiction. These measures could save lives.

Leaders also need a long-term strategy that tackles the root causes of addiction. As COVID-19 makes clear, disrupting the drug supply does not make addiction disappear – it puts people with addiction at greater risk. The rise in cocaine overdose deaths is especially worrying, because while medications for addiction treatment work for opioid use disorders, they do not work for cocaine use disorders.

In the last 20 years, the U.S. has cycled through overdose spikes due to prescription opioids, then heroin, then fentanyl. Now cocaine and methamphetamine pose looming threats.

Investing in healthy communities is the best line of defense against overdose. A stronger social safety net would improve problems that lie at the root of addiction such as unemployment, homelessness and mental health conditions. Building infrastructure to prevent and treat addiction will equip our communities to weather storms like COVID-19.

[Deep knowledge, daily. Sign up for The Conversation’s newsletter.]

Elizabeth Chiarello, Associate Professor of Sociology, Saint Louis University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

A Crisis Collision: Will COVID-19 Disrupt Efforts to Address the Opioid Epidemic?

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Prior to the advent of the coronavirus disease 2019 (COVID-19) pandemic, the opioid epidemic had been sweeping through the United State. An opinion piece recently published in the Annals of Internal Medicine highlights growing concerns among medical professionals about the exacerbating effects the pandemic may have among people with opioid use disorder (OUD).

Job loss, food insecurity, and overall morbidity have disproportionately affected marginalized communities, including people with medical and psychiatric comorbidities. This has left the medical community with concerns about the potential rise in substance use disorders and opioid overdose. In the published opinion piece, William C. Becker, MD and David A. Fiellin, MD, explore the importance of uninterrupted access to methadone and buprenorphine for patients with OUD.

For quarantined patients, mobile teams were suggested as a way to deliver methadone, considering physical examination requirements have been relaxed and extended supply of the medication for stable patients has been allowed. The authors also encouraged the use of settlement funds from a buprenorphine manufacturer to address limited access to the drug due to financial constraints. The safer pharmacologic properties of buprenorphine allow it to be dosed less frequently, and in-home initiation of the drug is now supported by new dose titration protocols.

Currently, first year clinicians are required to limit the number of patients they treat concurrently; however, authors suggest this restriction be temporarily lifted in order to compensate for the limited number of physicians available due to the COVID-19 crisis, and support networks should be funded from local, state and federal governments to address patient needs.

In addition to highlighting the importance of uninterrupted access, the authors also implore the federal government to maintain funding for opioid-related projects, as the race for a COVID-19 vaccine threatens to halt strides in research on OUD treatment.

Finally, medical professionals are concerned that COVID-19 may delay remunerations for families affected by the opioid crisis. Financial insecurity due to the crisis makes it increasingly important to facilitate the acceleration of cases nearing resolution, because the postponement of court hearings in the era of social distancing may delay the compensation of victims of opioid manufacturers’ malfeasance.

“The response to COVID-19 and the speed with which regulatory barriers are being reconsidered and removed should be translated to opioid-related clinical, research, and legal policy”, the opinion authors noted. “In the absence of such efforts, we risk more catastrophic effects from these colliding epidemics.”

Alcohol Deaths Double in the US.

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The following article is a reprint from our friends at the Pain News Network

By Pat Anson, PNN Editor

Alcohol related deaths in the U.S. have doubled in the past two decades, according to a new study that highlights an under-reported aspect of the overdose crisis: while deaths involving prescription opioids are declining, alcohol abuse appears to be increasing.

Researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) found the number of death certificates mentioning alcohol more than doubled from 35,914 in 1999 to 72,558 in 2017.

By comparison, 17,029 deaths in 2017 involved a prescription opioid, according to CDC estimates.

“The current findings suggest that alcohol-related deaths involving injuries, overdoses and chronic diseases are increasing across a wide swath of the population. The report is a wakeup call to the growing threat alcohol poses to public health,” said NIAAA Director Dr. George Koob.

Nearly 1 million alcohol-related deaths were recorded between 1999-2017. About half the deaths resulted from chronic liver disease or overdoses on alcohol alone or with other drugs.

Researchers noted that alcohol-related deaths were increasing among people in almost every age, race and ethnic group. Their study is published in Alcoholism: Clinical & Experimental Research.

“Taken together, the findings of this study and others suggests that alcohol-related harms are increasing at multiple levels – from ED visits and hospitalizations to deaths. We know that the contribution of alcohol often fails to make it onto death certificates. Better surveillance of alcohol involvement in mortality is essential in order to better understand and address the impact of alcohol on public health,” said Koob.

Other drugs besides alcohol are increasingly involved in overdoses. A recent analysis of over one million urine drug tests conducted by Millennium Health found that positive results for illicit fentanyl rose by 333% since 2013, while positive rates for methamphetamine increased by 486 percent.

That study, published in JAMA Network Open, found that positive rates for heroin and cocaine peaked in 2016 and appear to be declining.

The analysis is similar to a 2019 report from the National Institute on Drug Abuse, which found that drug deaths involving prescription opioids and heroin have plateaued, while overdoses involving methamphetamine, cocaine and benzodiazepines have risen sharply.

Unreliable Data

Just how reliable is the federal data on drug use and overdoses? Not very, according to another study published in Drug and Alcohol Dependence.

Troy Quast, PhD, an associate professor at the University of Florida’s College of Public Health, compared overdose data from the Florida Medical Examiners Commission (FMEC) to drug deaths in a CDC database. Quast found the federal data significantly undercounted overdose deaths in Florida linked to cocaine, benzodiazepines, amphetamines and other drugs.

Florida medical examiners are required by law to wait for complete toxicology results before submitting an official cause of death to FMEC. It often takes weeks or months to identify the exact drug or drugs that cause an overdose. By contrast, the CDC data is based on death certificates filed by coroners and other local authorities, which often don’t include detailed toxicology reports. This causes significant differences between the two databases.

Between 2003 and 2017, roughly one-in-three overdose deaths in Florida involving illicit or prescription opioids were not reported by the federal government. The discrepancy wasn’t limited to opioids. Quast also found that nearly 3,000 deaths in Florida caused by cocaine were not included in the CDC database. Overdose deaths involving benzodiazepines and amphetamines were also significantly under-reported.

“The CDC data are widely reported in the news and referenced by politicians, which is problematic since those estimates significantly undercount the true scope of the epidemic for specific drugs,” said Quast. “The rate of under-reporting for all overdose deaths in Florida is near the national average, so the problem is not to the state.”

This isn’t the first time the reliability of CDC data has been questioned. In 2018, CDC researchers admitted that many overdoses involving illicit fentanyl and other synthetic black market opioids were erroneously counted as prescription drug deaths. As result, federal estimates prior to 2017 “significantly inflate estimates” of prescription opioid deaths.

Even the adjusted estimates are imprecise, because the number of deaths involving diverted prescriptions or counterfeit drugs is unknown and drugs are not identified on 20% of death certificates. When the drugs are listed, many overdoses are counted multiple times by the government because more than one substance is involved.

The federal government is working to improve the collection of overdose data. Over 30 states are now enrolled in the CDC’s Enhanced State Opioid Overdose Surveillance program, which seeks to improve overdose data by including toxicology reports and hospital billing records.

In 2017, the program reported that nearly 59 percent of overdose deaths involved illicit opioids like fentanyl and heroin, while 18.5% had both illicit and prescription opioids. Less than 18% tested positive for prescription opioids only.

A recent study of drug deaths in Massachusetts found that only 1.3% of overdose victims who died from an opioid painkiller had an active prescription for the drug – meaning the medication was probably diverted, stolen or bought on the street.  

I’m a POW in the “War on Drugs”

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Douglas Hughes, Guest Columnist, Pain News Network

If you can hear the muffled sound of champagne being uncorked by lawmakers viewing my image, it’s no mistake. They have ignored my cries for help for a number of years, along with those of millions of other intractable pain sufferers.

I am 69 years old and have lost over forty pounds since August 2018. I am 6’2” and weigh 139 pounds, less than I did in eighth grade.

I cannot get anyone to care for me medically. I eat all the time, something else is wrong.  I had to change my primary care provider just to get a simple eye exam, the kind you do in a hallway. When tested, I could only see the top “E” with one eye. I had rapid-advancing cataracts.  

My picture is reality!  We have been so stigmatized and basic medical treatment denied to us, while the opioid pain therapies which kept us alive were abruptly taken away to profit from our deaths. 

Does my image impart distress? If not, you may hold the fortitude and inhumanity required for public office today. In West Virginia, elected officials still believe the opioid crisis is a due to a single drug — prescription opioids — diverted from a single source: pain clinics.

DOUGLAS HUGHES
DOUGLAS HUGHES

We have done nothing morally or legally wrong to deserve the horrendous lack of basic civility that you would show a wretched animal. I frequently relate my desire to be treated as a dog. Not in humor, but for the compassion that a dog would get if it was suffering like I am. 

The federal government has gone to extraordinary measures to brutalize the functionally disabled for personal enrichment and fiduciary windfall for programs like Medicare, Veterans Affairs, Workers Compensation, Medicaid, private retirements plans and others.

The largest windfall is to health insurance companies, which reap immense savings by curtailing the lingering lives of their most costly beneficiaries, the elderly and disabled. 

You May Be Next

Since the Vietnam War, there have been many advances in emergency medicine. More people are saved each year, yet left in constant pain. In the blink of an eye, you could become one. A car wreck, botched surgery or numerous health conditions can leave you with chronic or intractable pain.  

My image is a warning. I didn’t become the person you see until the government intervened in the pain treatment I was getting for 25 years. This was under the guise of a well-orchestrated effort by many state and federal agencies. 

The Drug Enforcement Administration has been the most prolific in this coordinated, decades-long effort.  In 2005, I witnessed them investigate and close a pain clinic where I was a patient.

My doctor was at the top of his field, a diagnostic virtuoso of complicated pain conditions.  He himself suffered from one pain condition of which I was aware.  No drug seeker could ever pass themselves off as a legitimate pain sufferer in his practice, yet he was harassed and forced to close because of assumptions of opioid overprescribing asserted by medically untrained law enforcement.      

It was my great fortune to have him diagnose the crushing injury in my torso and hips after twelve years of suffering.  He and two other pain specialists said I was “one of the most miserable cases” they had ever seen.

The loss of this and other outstanding professionals has repercussions even today. New doctors being trained are misled to believe the doctor-patient relationship is nonexistent. It was sacrificed to special interest greed and the conflagration of a drug crisis that will never end until that relationship is restored.

How easily has the public been misled to believe all physicians became irresponsible at the same time by treating pain conditions incorrectly with opioids? Now we have law enforcement dictating what pain treatment is appropriate. It is nonsensical at best and unimaginably inhumane at its heart.

My picture is the culmination of this government-standardized pain treatment and its consequences.  If heed is not taken immediately by the medical profession, lawmakers and society at large, you may be next to choose between suicide or emaciation.

Killing functionally disabled intractable pain sufferers like me, or non-responsive elderly in hospitals, will not stop opioid addiction, drug diversion or overdose deaths. It will however leave you a skeleton, praying for help like a prisoner of war.

Only the hearts of tyrants and fools see anything redeeming in that.

Douglas Hughes is a disabled coal miner and retired environmental permit writer in West Virginia. He recently ended his candidacy for governor due to health issues.

Best to Avoid Alcohol Altogether

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In updated cancer prevention guidelines released today, the American Cancer Society (ACS) now recommends that “it is best not to drink alcohol.”

Previously, ACS suggested that for those who consume alcoholic beverages, intake should be no more than 1 drink per day for women or 2 per day for men. That recommendation is still in place, but is now accompanied by this new, stronger directive.

The guidelines, revised for the first time since 2012, also place more emphasis on reducing the consumption of processed and red meat and highly processed foods, and on increasing physical activity.

Asked for independent comment, Steven K. Clinton, MD, PhD, associate director of the Center for Advanced Functional Foods Research and Entrepreneurship at the Ohio State University, Columbus, explained that he didn’t view the change in alcohol as that much of an evolution. “It’s been 8 years since they revised their overall guidelines and during that time frame, there has been an enormous growth in the evidence that has been used by many organizations,” he said.

But importantly, there is also a call for action from public, private, and community organizations to work to together to increase access to affordable, nutritious foods and physical activity.

“Making healthy choices can be challenging for many, and there are strategies included in the guidelines that communities can undertake to help reduce barriers to eating well and physical activity,” said Laura Makaroff, DO, American Cancer Society senior vice president.

The guidelines were published today in CA: A Cancer Journal for Clinicians.

The link between cancer and lifestyle factors has long been established, and for the past 4 decades both government and leading nonprofit health organizations, including the ACS and the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR), have released cancer prevention guidelines and recommendations that focus on managing weight, diet, physical activity, and alcohol consumption.

In 2012 the ACS issued guidelines on diet and physical activity, and their current guideline is largely based on the WCRF/AICR systematic reviews and Continuous Update Project reports, which were last updated in 2018. The ACS guidelines also incorporated systematic reviews conducted by the International Agency on Cancer Research (IARC) and the US Departments of Agriculture and Health and Human Services (USDA/HHS), and other analyses that were published since the WCRF/AICR recommendations were released.

Emphasis on Three Areas

The differences between the old guidelines and the update do not differ dramatically, but Makaroff highlighted a few areas that have increased emphasis.

An area that Makaroff highlighted is alcohol, where the recommendation is to avoid or limit consumption. “The current update says not to drink alcohol, which is in line with the scientific evidence, but for those people who choose to drink alcohol, to limit it to one drink per day for women and two drinks per day for men.”

Thus, the change here is that the previous guideline only recommended limiting alcohol consumption, whereas the update suggests that, optimally, it should be avoided completely.

Time spent being physically active is critical. The recommendation has changed to encourage adults to engage in 150 to 300 minutes (2.5 to 5 hours) of moderate-intensity physical activity, or 75 to 150 minutes (1.25 to 2.5 hours) of vigorous-intensity physical activity, or an equivalent combination, per week. Achieving or exceeding the upper limit of 300 minutes is optimal.

“That is more than what we have recommended in the past, along with the continued message that children and adolescents engage in at least 1 hour of moderate- or vigorous-intensity activity each day,” she told Medscape Medical News.

The ACS has also increased emphasis on reducing the consumption of processed and red meat. “This is part of a healthy eating pattern and making sure that people are eating food that is high in nutrients that help achieve and maintain a healthy body weight,” said Makaroff.

A healthy diet should include a variety of dark green, red, and orange vegetables; fiber-rich legumes; and fruits with a variety of colors and whole grains, according to the guidelines. Sugar-sweetened beverages, highly processed foods and refined grain products should be limited or avoided.

The revised dietary recommendations reflect a shift from a “reductionist or nutrient-centric” approach to one that is more “holistic” and that focuses on dietary patterns. In contrast to a focus on individual nutrients and bioactive compounds, the new approach is more consistent with what and how people actually eat, ACS points out.

The ACS has also called for community involvement to help implement these goals: “Public, private, and community organizations should work collaboratively at national, state, and local levels to develop, advocate for, and implement policy and environmental changes that increase access to affordable, nutritious foods; provide safe, enjoyable, and accessible opportunities for physical activity; and limit alcohol for all individuals.”

No Smoking Guns

Clinton noted that the guidelines are consistent with the whole body of current scientific literature. “It’s very easy to go to the document and look for the ‘smoking gun’ ­— but the smoking gun is really not one thing,” he said. “It’s a pattern, and what dieticians and nutritionists are telling people is that you need to orchestrate a healthy lifestyle and diet, with a diet that has a foundation of fruits, vegetables, whole grains and modest intake of refined grains and meat. You are orchestrating an entire pattern to get the maximum benefit.”

What If the Opioid Crisis Is Worse Than We Think?

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Editor’s Note: The following article is courtesy of the Pain News Network

A recent study in the journal Addiction reports that the opioid crisis in the U.S. may be worse than we’ve been led to believe. The number of overdose deaths linked to legal and illicit opioids over the past two decades could be about 28 percent higher than reported.

Economists Andrew Boslett, Alina Denham and Elaine Hill looked at drug overdose deaths between 1999 and 2016 in the National Center for Health Statistics. Of 632,331 deaths, over one in five had no information on the drugs involved. The researchers estimated that as many as 72% percent of those deaths likely involved opioids. This yields an additional 99,160 deaths involving prescription opioids, heroin, fentanyl and other street drugs that were not counted.

This estimate may or may not be right, but it is definitely not new. Claims like this have been around for years.

In 2017, Business Insider reported on an investigation by CDC field officer Dr. Victoria Hall, who looked at the Minnesota Department of Health’s Unexplained Death (UNEX) system. She found that 1,676 deaths in the state had “some complications due to opioid use,” but were not reported as opioid-related deaths.

A 2018 study at the University of Pittsburgh found that as many as 70,000 overdose deaths were missed because of incomplete reporting.

‘Cooking the Data’

It has long been suspected that the CDC’s opioid overdose death toll is faulty – either too high or too low, depending on your point of view. Public health data in the U.S. is shoddy, the result of a fractured and fragmented system that has little central guidance or administrative oversight. The overdose numbers aren’t as reliable as they should be, which raises suspicion they are being manipulated.

The Atlanticmakes a similar point about the coronavirus outbreak.

“Everyone is cooking the data, one way or another. And yet, even though these inconsistencies are public and plain, people continue to rely on charts showing different numbers, with no indication that they are not all produced with the same rigor or vigor,” wrote Alexis Madrigal. “This is bad. It encourages dangerous behavior such as cutting back testing to bring a country’s numbers down or slow-walking testing to keep a country’s numbers low.”

The implications of under-counting deaths in the overdose crisis require careful consideration. Political campaigns, public policy, state laws and regulations, and clinical practice are built on these numbers. For instance, the Trump administration was recently touting a 4% decline in overdose deaths, but that reduction may not exist.

Similarly, cannabis advocacy groups argue that state legalization has reduced overdose deaths. But again, that reduction may evaporate with better data. State laws and regulations are built on the assumption that trend lines were going in a particular direction. But maybe they aren’t.

Most important, policy groups have argued strenuously that reducing prescription opioid utilization would alleviate the overdose crisis. But if there are vastly more deaths than recognized, where does that leave these groups?

Of course, determining cause of death is a process fraught with difficulties. The New York Timesreports that morgues are overburdened and understaffed, many suspected overdose deaths are not fully evaluated, and reporting on the cause of death is not standardized.

Making a probabilistic assessment is even more fraught. For instance, a recent attempt to use stool samples to measure how many rodents, birds and other wildlife are eaten by domestic cats was undone by the discovery that cat food manufacturers regularly change their ingredients.

In other words, there are many known problems and occasional surprises in public health data, so any estimate has to be treated with caution. But if opioid overdoses are vastly undercounted, then we should reassess the policies and politics of the crisis.

By Roger Chriss, PNN Columnist: Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.