America currently has a fulminant heroin/opioid epidemic and there are at least ten reasons for this; which I will discuss in a series of articles in Sober World Magazine. The reasons include:
1. War in Afghanistan
2. Injudicious Prescribing by MD’s
3. Patient Expectations
4. Internet Sale of Pain Pills
5. OxyContin Reconstitution
7. Supply & Demand – “War on Drugs”
8. Physician Training and Biases
9. Mental Health Treatment
10. Public Officials
Yes, there is plenty of blame attributing to the heroin/opiate epidemic and the changing demographics of today’s heroin user, which has migrated outside of our major cities to suburban and rural America. But before we engage in a detailed explanation of who/what to blame and to better understand the complexity of the issue, let’s review the biological, psychological and sociological aspects of the disease of addiction. Then, we can better understand the reasons why this scourge to society has spread so widely and present some viable solutions.
What is heroin? Heroin is actually diacetylmorphine which was synthesized by C.R. Wright in 1874 by adding two acetyl groups to the molecule morphine, which is found naturally in the opium poppy. This alteration of the morphine molecule makes heroin two to four times more potent than morphine with a faster onset of action. In 1898 Bayer Pharmaceutical of Germany marketed diacetylmorphine under the name of heroin. Illicit forms of heroin can be injected, snorted or smoked. Purity has increased so much over the past decade one no longer needs to inject heroin to get the rapid euphoria (“high”). Snorting the drug works quite well!
To understand the biological aspect of the disease of addiction, let’s look at it from the viewpoint of genetic predisposition. Years ago, Scandinavian studies demonstrated that your biological parents are the predominant factor whether you would develop the disease of addiction. The study followed identical (monozygotic) twins who were adopted into different families. The results demonstrated that the children most likely to develop addictive behavior were those from birth parents with the disease of addiction. Although environmental factors were also shown to be important, the predominant factor on whether determining who would develop the disease of addiction was most highly correlated with parents and genetic predisposition.
Metabolism is another example of a biological component that influences addiction. There
is a segment of the Japanese population that rarely drinks alcohol and they also commonly
lack an enzyme called alcohol dehydrogenase. In most of us, alcohol dehydrogenase is
the predominant substance that breaks down alcohol in to metabolites, which are
then excreted by the body. A small amount of alcohol is metabolized by an alternative
pathway. However, if one lacks the enzyme alcohol dehydrogenase, the majority of alcohol
is metabolized by the alternative pathway. The alternative pathway produces a toxic metabolite which can make one extremely ill.
he symptoms and effects of the toxic metabolite can range from mild nausea and dizziness to losing consciousness from low blood pressure, seizures, heart attacks or other significant consequences. Individuals who lack the enzyme alcohol dehydrogenase typically avoid these unpleasant effects by not drinking alcohol. In fact, the medication called disulfiram (Antabuse) is prescribed to some patients who wish to stop drinking. Antabuse blocks the enzyme alcohol dehydrogenase forcing alcohol to be metabolized by the alternative pathway, thus producing toxic byproducts. This type of aversion therapy using medication and recommended counseling can be effective albeit it does carry a risk if patients are not compliant.
Many substance users consume alcohol or drugs in order to eliminate or minimize feelings, fears, or symptoms. Unfortunately, medical services are not easily obtainable for many people suffering from mental health related illnesses, and they may self-medicate with alcohol or illicit drugs. In addition, people commonly fear the effects of withdrawal and this
psychological response continues to drive addictive behavior. There seems to be a relationship between anxiety disorders and alcohol; depression and cocaine or other stimulants; bipolar illness and opiates; and ADHD and marijuana. Treating underlying mental illness is an important component to curb inappropriate substance use. There have been reports that as many as 50% of patients with substance use disorders have underlying mental illness.
Where we live and how we live makes a difference in our choices. If we live in an environment where there is no alcohol or drugs then we are unlikely develop a substance use disorder, even if we have genetic predisposition or underlying mental illness. If we reside where drugs and alcohol are readily available and dependency is developed and then we wish to stop using, it is more difficult to refrain if we return each and every day to this same neighborhood with the same sociological cues. This is a major factor why Vietnam war veterans who became addicted to heroin abroad tended to do much better in recovery when they returned home, having left sociological cues behind in Vietnam; and why it is more difficult for a drug user to change his/her habits if living with another user of alcohol or drugs.
In a recent article published in the New York Times on April 17, 2015 entitled, Serving All Your Heroin Needs (http://nyti.ms/1Th5jDX), two quotes are extremely revealing:
“… selling heroin across the United States resembles pizza delivery.”
“… a new home for heroin is in rural and suburban Middle America …”
To better understand why pizza delivery of heroin works and how it found its way into suburban and rural America, there are three related terms that are essential to understand:
Tolerance refers to not getting as much bang for the buck. In medical terms, it is the body’s adapting to a drug which then necessitates consuming more of the drug to achieve the same effect.
Dependency refers to the state of having symptoms in the absence of the drug. Examples
of withdrawal symptoms are the “shakes” after a heavy drinker stops drinking; or the chills, nausea, vomiting, abdominal cramping, etc. when a heroin addict is deprived of his/her next “fix”.
Addiction is the drug seeking behavior of an individual. However, a person who is dependent may not necessarily be addicted. Since the aspects, a person may become dependent but not have the components of addiction.
For example, if sweet Aunt Tillie ends up in the hospital with severe intractable pain from a tumor pressing on her spinal column, she may be given an opiate such as morphine to reduce her pain until the tumor size can be minimized by radiation or chemotherapy or surgically removed. A few weeks of medication may be needed and during that time Aunt Tillie develops tolerance and dependency to morphine. After the tumor size is reduced and the pressure on the spinal nerves is diminished, the frequency and amount of morphine
is gradually decreased to avoid withdrawal symptoms. After a week or so, Aunt Tillie will no longer require an opiate to eliminate her pain and will be showing no signs of withdrawal. After she is discharged home, she is happy taking an occasional non-narcotic pain medication like Tylenol or Ibuprofen. But how about the person who goes home and has some bio, psycho and/or social components of the disease of addiction. He/she may very well start looking for that euphoric “high” and start seeking drugs. That is the essential difference between dependency and addiction.
How the War in Afghanistan fueled the heroin epidemic in America.
Before the war, the Taliban subsidized Afghan farmers to grow food crops rather than opium. Opium poppy is the plant from which heroin is made. When the Taliban fled or went into hiding, the farmers lost their financial support to grow food, and returned to growing heroin, a crop that thrives in regions of Afghanistan. The increased amount of heroin production flooded the European markets. As a result, the heroin being produced in South America and Mexico was no longer needed in Europe and the excess supply flooded the United States.
Following the principles of economics, supply went up, price went down and in some cities heroin now sells for as little as $4/bag. But we must think of drug cartels as big businesses. In order to become more profitable with a surplus of product, heroin distribution expanded
its market and started finding its way to suburbs and rural areas. Also, because the purity of heroin has increased as much as 60%, it is not necessary to inject (“shoot up”) the drug. Snorting heroin can now give the same “rush” that in the past was only possible by using needles. No needles has resulted in more people willing to try it, contributing to the heroin epidemic and its wide spread use.
There are so many misperceptions that encourage the inappropriate classification of some drug addictions as “bad” (heroin or cocaine) and some as “tolerable” (alcohol or nicotine). In actuality, there are no “good” drug addictions. In order to demystify and destigmatize addiction, we must educate our neighbors, our politicians and our family members and we must find “novel” approaches to reach them. That is why I wrote Addiction on Trial and why I hope you will help to spread the word that the disease of addiction, like diabetes and other chronic illnesses, may not have a cure but can be put into remission, allowing many to live productive lives.
Dr. Kassels has been Board Certified in both Addiction Medicine and Emergency Medicine. He serves as the Medical Director of Community Substance Abuse Centers. He is the author of “Addiction on Trial”, written as a murder mystery/legal thriller to reach and educate a wide range of readers. The book has recently been entered into medical school curriculum to help decrease physician bias. The book is available at: Amazon www.amazon.com/Addiction-Trial-Tragedy-Downeast-Maine/dp/1491825316) and free author book club presentations and educational meetings (in person or using Skype) can be arranged at: www.addictionontrial.com/author-events/