The Opioid Crisis- Getting Vulnerable
I gave an academic talk the other day where I shared some personal experience with the opioid crisis. I don’t normally open up this way because my anecdote can bias my research, however my story can also bring my work to life in some meaningful ways. Thus, I am selective about what I share in certain non-recovery settings. I told the story of my friend Brad who I grew up who was my first close friend to die from an overdose, in 2005. I had lost a few other friends prior to that, but Brad’s death really struck me because I had gotten high with him shortly before it happened. I shared that since getting sober in 2006 I have lost about 20 friends to drug-related overdose. I shared that my brain has started to block those memories out and I probably couldn’t even list off the names. At some point I stopped going to memorials. And at some point, I even stopped making friends. People were shocked. Was this true? I did say it. In reflection I have realized that it takes a while for me to become close to someone these days, particularly if they are in recovery. I have wounds. And complex trauma wounds can be so subtle that we sometimes don’t even know we have them. And the truth is, I have been to many memorials, just not all of them.
Why Are So Many People Dying?
I’m a big city kid. I live in West Los Angeles. But the opioid crisis has swept the entire nation. Overdose is more common in rural areas compared with urban settings1with higher prevalence among whites compared to nonwhites2and is a growing risk among adolescents.3Prescription opioid injection misuse is higher among males4but some data suggests that non-medical opioid use is higher among female adolescents.5Female adolescents? There is something going on here. This is about more than just “peer pressure” or growing up in socially disadvantaged settings. Of course, environment factors matter. Of course, it has to do with the pharmaceutical industry and with irresponsible prescribers, but where does all the pain come from in the first place? Why do these opioids feel so darn good? Why are so many people dying? This fentanyl thing is out of hand. The opioid crisis has gone too far.
Pain management is the medical specialty that treats a variety of conditions including cancer, traumatic pain, postsurgical pain, and end of life issues. By far the most common opioid analgesics are codeine, hydrocodone, oxycodone, morphine, and fentanyl. OxyContin sales went from $48 million in 1996 to $1.1 billion in 2000. I am guessing you have seen the news about Purdue Pharma and the Sackler family. It’s quite disheartening but also exciting to see shifts happening. There are lots of new policies and procedures for opioid prescribing, as well as efforts to move patients toward non-opioid approaches to pain management, such as yoga, acupuncture, etc. Meanwhile, adoption and implementation of new policies and procedures in emergency departments (e.g. better screening) have been slow and not without administrative challenges.6
A Veterans Health Administration study found high opioid prescription rates among veterans with unexplained gastrointestinal (GI) symptoms (e.g. irritable bowel syndrome) where opioids have no clear role.7The authors identified psychiatric comorbidity as a mediator of unexplained GI symptoms, potentially driving opioid misuse. While opioids may provide some short-term relief of GI-related issues, these benefits are likely to fade as tolerance increases, and can leave patients with opioid-induced bowel dysfunction. Mental health screening before prescribing has also been recognized as an important risk mitigation strategy during the crisis8but has not been widely implemented. As a nutritionist, I am very much interested in the link between opioids and gastrointestinal function. I do think there will be some exciting findings in the next few years. However, nutrition never gets the attention it deserves on the medical stage, and sometimes I am even offended by the idea that nutrition is “alternative medicine.” It makes a big difference- it is just slow and therefore difficult to measure. But it matters. Nutrition matters.
The Biopsychosocial Perspective
In order to truly understand the opioid crisis, it is critical to examine it from all perspectives, including social and environmental factors, psychosocial factors such as stress, trauma/PTSD, and childhood adversity. And biological factors: genetics, epigenetics, microbiome, nutrition, etc. A biopsychosocial approach looks at all possibilities and more importantly at the interactions between influencing forces, from the microscopic to the planetary level. Some experts believe that the biopsychosocial approach lacks foundation and does not identify specific quantifiable mechanisms that demonstrate a causal chain of events.9The biopsychosocial model has also been criticized as being anti-medicine, but it has also been argued that it may improve psychiatric intervention.10
In my opinion, this perspective is exactly what we need to combat the opioid crisis, as reductionistic approaches such as new medications to treat opioid addiction can only address parts of the issue. We need a systems approach. For example, a biopsychosocial perspective on pain suggests an interaction with psychological factors such as depression and anxiety which lead to psychosocial interventions (e.g. behavioral and cognitive therapies) based on an individual assessment in addition to psychopharmacology.11
Furthermore, the “nature vs. nurture” controversy related to addiction has decreased in the past two decades given strong evidence for both, as well as the emerging field of epigenetics representing convergence between genetic and environmental factors. There is so much new information related to the intersection of social and biological factors, and we need to embrace multidisciplinary efforts in order to fully understand them. Multi-modal = multiple modalities.
The role of trauma and chronic stress have been identified as important vulnerability factors in the development of addiction. In some cases, a trauma history may serve as a proxy measure for addiction severity. The self-medication hypothesis describes one’s tendency to find ways to anesthetize unresolved pain. This perspective of underlying risk factors for opioid use disorder can include negative childhood experiences that are psychological/emotional (e.g. leading to depressive symptoms) or physical (e.g. pain). Advocates of this theory suggest that individuals self-medicate in response to physical and psychological experiences of pain, such as victimization.12Adverse Childhood Experiences, also known as ACE scores, are a major part of my current work and research. I can’t wait to share more about this with you soon. The original ACE study showed that individuals who had 4 or more ACEs were at a 12-fold increase in risk of drug addiction.13We need to start screening for ACEs and intervening early on.
Policy and Environmental Interventions
The environmental theory of the opioid epidemic is impossible to deny. Legal action against Purdue Pharma have implicated the role of the pharmaceutical industry in disseminating misleading claims about the addictive potential of OxyContin. Irresponsible prescribing is another important part of the supply side theory, as countless “pill mills” have been raided in the last ten years across the US. Finally, increased accessibility of illicit opioids such as heroin have continued to plague communities across the nation. Policy interventions targeting all three of these problems are essential. Environmental enrichment has shown promise in reducing opioid administration.14But we obviously need to go much further. Where to?
Painful life experiences increase vulnerability to addiction. It is well established that early life adversity can compromise adult mental health through multiple stress-related pathways,15including transmission of atypical HPA axis regulation.16The psychosocial theory describes the stress, trauma, and ACEs that are often influenced by socioeconomic status, and which appear to modify reward pathways in the brain. One solution is trauma-informed mental health services, and the other is to improve the social factors in susceptible populations. So much work that needs to be done here. Trauma-informed therapy is the key. But sadly, only those with financial resources are likely to access this. We need high quality trauma-informed care in underserved communities.
YES. This is where my current efforts are headed. I don’t want to spill the beans, but I do want to get you excited about work that is being done. My recent book chapter can be found HERE and I assure you a very exciting publication is coming soon.
There is a need for more research on how stress, trauma, and ACEs impact reward functioning in the brain. Given what is known about the link between psychosocial factors and the opioid crisis, it would be helpful to further elucidate the neurobiological underpinnings. This direction has recently been described as a “syndemic” approach, examining the pathways from socioenvironmental conditions to biological states, and the drivers behind disease clustering,17which has been observed in the opioid crisis. Given that opioid use disorder is also prevalent in socially advantaged groups, it may be useful to examine how socioeconomic status impacts treatment outcomes in all directions. There is a vast array of social issues that still need to be resolved, particularly on the supply-side of the opioid demand, where new prescribing policies are underway. And there is so much we need to know about opioids and the microbiome, particularly how opioid use can affect mental health through the gut-brain axis. Stay tuned!
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