Opioids: Killing Ourselves with Pain Relief
You have probably heard about the opioid addiction crisis that is sweeping our country. Recently I have seen lots and lots of television segments, including one I personally watched on the television show 60 Minutes, about the opioid addiction that is affecting several areas of our country.
There is a national crisis with opioid addiction. Pharmaceutical companies have developed synthetic opioids that are incredibly addictive, which get prescribed for pain.
Indiana, the state in which I live, is currently working to address this issue. Indiana University is developing a partnership with the Governor’s office to address opioid addiction and to work toward reducing the number of people who are addicted to opioids. The Indianapolis Star is publishing articles about addiction and the overprescription of painkillers to people who seek care from their physicians or local hospitals. https://www.indystar.com/story/news/2017/10/10/state-has-opioid-crisis-see-what-its-leading-university-pledges-50-million-address-opioid-crisi/747151001/
According to an article published by The Indianapolis Star on October 10, 2017.
“Opiate abuse has spiked across much of the country, but Indiana’s problem is particularly acute. Officials say Indiana is one of four states where overdose deaths have more than quadrupled since 1999.”
An article written by Becky Jacobs and published by The Chicago Tribune on Nov. 1, 2017 addresses Indiana Governor Holcomb’s stance on addiction: http://www.chicagotribune.com/suburbs/post-tribune/news/ct-ptb-indiana-opioid-holcomb-st-1011-20171010-story.html
“Holcomb has asked the federal government for permission to use Medicaid funds made available through former President Barack Obama’s signature health care law for drug abuse treatment. A ruling on that has yet to come, but it could bring upward of $60 million for expanded drug treatment to the state’s Healthy Indiana Plan, commonly called HIP 2.0, which covers more than 400,000 low-income people. Democrats have targeted Holcomb on that front, suggesting there are “two Holcombs.”
One supports directing additional resources to fight the opioid problem. The other, Democrats suggest, backed two of the GOP’s recent failed attempts at gutting Obama’s law, which also would have slashed funding for HIP 2.0, including drug treatment.”
Many blame ‘big Pharma’ for the growth in opioid addiction. Pharmaceutical companies have developed synthetic opioids. One synthetic opioid is called Carfentanil, and the equivalent of 1 grain of salt of Carfentanil can kill a person. This drug is inexpensive, and is being mixed with heroin by people who sell illegal drugs, and it is killing people. This drug was not made for humans; it was intended for something which weighs far more, such as an elephant. I typically hear this opioid referred to as the elephant tranquilizer. https://sobernation.com/deadly-carfentanil/
“Carfentanil is one of the most potent synthetic opioids known to man—even more potent than its analogue, fentanyl. Fentanyl has become a buzzword in the addiction recovery community, well-known for its high potency and, most unfortunately, the high frequency of overdoses associated with it. Carfentanil is approximately 10,000 times more potent than morphine, and 100 times more potent than fentanyl.”
Fentanyl is prescribed for pain in humans. You may have been prescribed it, or at least know someone who has been prescribed Fentanyl. Below is a comparison picture of a lethal dose of heroin compared to a lethal dose of fentanyl.
According to the Center for Disease control: https://www.cdc.gov/drugoverdose/opioids/fentanyl.html
“Pharmaceutical fentanyl is a synthetic opioid pain reliever, approved for treating severe pain, typically advanced cancer pain.1 It is 50 to 100 times more potent than morphine. It is prescribed in the form of transdermal patches or lozenges and can be diverted for misuse and abuse in the United States.”
Someone asked me recently how this happened. Why things are different now than they used to be, prior to this epidemic
I’ve thought about this through the lens of what I see with pain, prescriptions, and my contact with people who are addicted to opioids. I tried to imagine the evolution of the overprescription of painkillers, as well as the current trend toward heroin use. In doing so, I also looked at people with whom I come in contact in my personal life. My guess is that most people reading this article know someone or at least know of someone who is addicted to painkillers or has an addiction to a substance of some sort.
My experiences professionally come primarily from working with people who generally have a lower socio-economic status. Having a lower socio-economic status (SES) means having an income which is lower than the average SES, with the average SES being known as Middle Class. Those with a lower SES tend to have less money saved than someone who has a higher socioeconomic status. Many people who have a lower SES do not save money well, and are relying on their paycheck each week to pay their bills. Some refer to people who are in this group who have employment as the ‘working poor’.
A typical difference between those with a higher and lower SES is their social support and their treatment by law enforcement. Many people who have a higher SES have developed a system of friends or family who support them when they are in times of stress. They may have a friend who can help them with childcare, or someone who is willing to listen to them talk about physical or emotional pain they are experiencing.
Some people who have a lower SES don’t have these natural supports. They may have come from a family who is not a positive influence on them. A person in this situation may be advised from their family member to quit their job because their boss isn’t ‘treating them well’. That advice is most likely not in that person’s best interest. They may not have someone who can help them in a time of need, whether that be financial, emotional, or with tasks related to parenting.
Professionals in the community have historically not treated those with a lower SES the same as those from a higher SES. I have read that teens in wealthier communities are treated differently when they are caught using illegal substances than those in communities with higher rates of poverty.
Another experience I have had is with the education system. I took a class called Social Stratification many years ago as I fulfilled credits for my Sociology Minor. I learned that those with a lower SES tend to value obedience over negotiating. My experience with a more urban and poverty filled school system has supported this notion. I have witnessed very different rules about mobile phones in the two types of schools. The schools with higher rates of poverty have very stringent rules about phone use and phones are taken away if they are used inappropriately. My experience as a parent of children who attended a school where families tend to have higher incomes is that there were very few rules around cell phone use.
Those experiences are not related to the prevalence of teen substance use. I would venture to say that the teens who have more access to funds are in some ways more likely to use and abuse illegal substances because it takes funds to purchase the substances.
People who have fewer social supports are more likely to use/abuse substances. Being more likely to be arrested by law enforcement causes there to be more people in poverty who are arrested, which could lead to an over representation of the number of people in poverty who abuse illegal substances compared to those with a higher income.
I am a Licensed Mental Health Counselor (LMHC). I have worked with people involved with the Department of Child Services (DCS) for most of my professional career, which began in 1995. I am trained as a therapist, with an undergraduate degree in psychology. My courses in psychology taught me a lot about the human brain and motivation. My courses in Community Counseling taught me the mechanics of being a mental health therapist.
I have worked primarily in prevention services, which are intended to help prevent people from abusing or neglecting their children. Those of us who work in prevention services try to help people figure out how to parent without hurting their children physically, and to provide a safe environment for them so that they aren’t neglected. Neglect comes in multiples ways, including supervisory, educational, and medical.
Indiana has valued prevention services for many years. In 1998, Indiana became a national leader in prevention by funding a program in every Indiana county called Healthy Families. Healthy Families is an evidence based program that identifies families who are at risk for abusing or neglecting their children prior to their child turning 90 days old. I worked in that program from 1998-2009 as a supervisor. In 2007, Indiana again funded a statewide prevention program. Community Partners for Child Safety (CPCS) is a program initially created to reach families who did not meet the criteria for Healthy Families. Each county in Indiana currently has CPCS.
Following my experiences with Healthy Families, and after the agency for which I had worked for nearly 14 years downsized my position, I provided Home Based Therapy to families involved with the Department of Child Services (DCS). I met with both parents and children, and worked together with them to set goals to reduce the stress in their lives. The type of services I was providing with home based therapy is referred to as Intervention services. Intervention services are put in place following substantiated abuse or neglect on a child, and are intended to help families reduce their stress, which in turn reduces the likelihood for abuse and neglect to re-occur.
I was able to go to the homes of families who lived in Marion County, which is where Indianapolis is, and provide therapy to children and parents who had become involved in what I refer to as ‘the system’. These families had substantiated abuse or neglect, and were working to complete goals and reduce stress so that DCS was no longer involved in their lives so closely.
From 2011-2013, I was able to work for a small not-for-profit agency named Promising Futures of Central Indiana (formerly known as Hamilton Centers Youth Service Bureau). We had nine programs when I began working there. We were most known in the community for our Pregnant and Parenting Teen program, which was funded by a federal grant. The grant allowed us to provide both a residential home for the 16-18 year old parents to reside beginning when they became pregnant and continuing for up to 18 months or their 18th birthday, whichever came first. We also had a contract with DCS to provide residential care to pregnant or parenting youth who were involved with DCS or probation for some reason. Most of the women who participated in that program had experienced abuse or neglect of some sort from their families of origin.
We utilized other parts of the funds awarded to that program to pay the rent and a portion of utilities for women between the ages of 18-21 who were pregnant or parenting. We provided case management and therapy to these women, in hopes that their stable housing and increased support would prevent them from abusing or neglecting their children.
In 2013, our grant was up for renewal, which we did not receive. The grant ended at the end of February, 2013, and in March of 2013 we closed the house, broke the leases of our apartments we had rented for the women who lived there, helped all of the women find other housing as best we could, and closed the program. As you can imagine, this was very difficult for all involved in the process.
Following this, our small agency merged with a much larger not-for-profit agency in Indiana named the Children’s Bureau. The Children’s Bureau was able to provide some of the infrastructure we had not been able to due to our loss of funding. I remain employed at the Children’s Bureau at this time.
During my experiences between 1995 and 2014, I worked with families in different capacities. Common stressors were environmental neglect (unclean homes, head lice), medical neglect, educational neglect, and physical abuse. Although there were families dealing with substance abuse, primarily the reasons for referral were not regarding substance abuse, and when substance abuse was an issue, it was typically marijuana use, methamphetamine use, and alcohol abuse.
In 2014, I returned to Prevention Services. This time, I am in a different capacity as the Director of a program referred to as Community Partners for Child Safety (CPCS). I also provide both individual and group clinical supervision to the Home Based Therapists who provide Intervention services in Region 11. Region 11 includes Hamilton, Hancock, Madison, and Tipton Counties. I provide individual and group supervision to the Liaisons who provide the voluntary program CPCS
At this point I will fast forward to 2017, where nearly every family that I staff clinically in our Intervention program is touched by substance abuse in some way. Many families in CPCS are also being affected by substance abuse. Many are grandparents who are caring for their grandchildren due to the substance abuse of the child’s parent.
Personally, I live in the wealthiest county in Indiana, which also happens to be one of the wealthiest counties in the country. Cities in the county in which I live frequently are found on the “best places to live” lists. There are people both inside and outside of the county who view the county as one without problems.
There are lots and lots of people in this county, so as you can imagine there are of course lots of people with problems. In addition, people with a higher income, and therefore a higher SES are certainly not immune to having problems. In the photo below, you can see the information specific to Hamilton County. There are over 300,000 people in the county. In the photo, you can see that there were a total of 46,606 youth under the age of 18 in Hamilton County in 2015. With 5.2% of those children living in poverty, that works out to almost 2500 children living in poverty. In addition, the northern part of Hamilton County is primarily rural, with the larger cities in the southern part of the county. https://www.iyi.org/index.php/data-library/data-services/county-snapshots/hamilton-county-1
In addition to the work I do for my employment, I, like anyone reading this article, lived through the most recent recession. During that recession, I personally experienced a loss of income, both through my husband’s employer’s inability to pay for work completed, and with my experience working for two separate small not-for-profit agencies that did not survive the recession and are no longer in business. This lack of stability has certainly affected both the parents and the children who survived this time period. I know my own children went from being children of parents who easily paid their bills each month to children of parents who had to budget very carefully to pay all of our bills. My children experienced parents who then became very aware that any income currently coming in could disappear at any time, so saving funds for ‘a rainy day’ has become even more important.
Experiences like this cannot be without affect.
My experience with pain is different than I might expect in a time when painkillers are being over prescribed. My experiences may be different due to the doctors I choose to utilize, so I can’t determine from my own experience whether this is a trend or just my own experience. Approximately 10-15 years ago, I would be prescribed an opioid if I stated to my doctor that I was in pain.
In 2005 I was prescribed cough medicine with hydrocodone without realizing that there was a narcotic in it.
In 2000 I was prescribed Vicodin following sinus surgery, and encouraged to “stay ahead of the pain” and to keep taking it. My personal side effect from narcotics is nausea, so on a follow up visit I described my symptoms. I was prescribed Percocet for breakthrough pain, which interestingly also made me nauseous.
In around 2004, someone I know became addicted to prescription painkillers and attended an inpatient rehabilitation treatment center located in the Chicago area. She is a physician, and she prescribed painkillers to herself. Due to my contact with her, I learned that a physician prescribing narcotics to oneself is a felony.
I also learned that narcotics are made very similarly to heroin, so they are very addictive. In 2005 I first heard prescription painkillers referred to as ‘white collar heroin’. At the time, I had rarely heard of heroin use or overdoses related to heroin.
Looking back, things I learned during my contact with pain, prescription painkillers, and the cost of narcotics turned out to be prophetic.
My experience has been that addiction crosses all socioeconomic statuses. Although most of my professional interactions with people who are addicted to opioids have been people who have a lower SES, personally the opposite is true. Personally, I have had co-workers who have family members who are now deceased due to heroin overdoses.
Personally, I know a physician who no longer practices medicine as a way to prevent relapse.
Personally, I have experienced pain and communicated to my physicians that I prefer pain to the side effects of opioids. I have had outpatient surgery and requested to take acetaminophen or ibuprofen for the pain associated with the surgery.
I have experienced co-workers who were ill but did not want to go to an emergency room for fear of being labeled a drug seeker, even though they were experiencing nausea and not pain.
Personally, I have a relative who has been over-prescribed morphine for many years. His daughters and wife have worked to lessen his dosage, but the struggle continues. He was taking 30mg each morning, then 60 mg for breakthrough pain. He was encouraged to take an additional 30mg if needed for his pain.
As you can only imagine, his version of “as needed” continued to increase as the morphine became less effective on his pain over time. He is currently taking 30mg in the am and pm only, which has increased his functionality. He has Alzheimer’s, which may or may not have been affected by his amount of morphine that he was taking as prescribed. My guess is that the morphine has had a detrimental affect on his physical and mental functioning.
I have another relative who was prescribed morphine for pain she is experiencing related to cancer. Since this diagnosis is recent, my hope is that she will avoid becoming addicted to the morphine she is taking for her pain. I am hopeful that she will go into remission with her cancer and that she will no longer need morphine. It is to be noted that she is married to the relative listed in the previous paragraph, and she has the same primary care physician. This physician increased her dosage of morphine that her oncologist had initially prescribed after she reported her symptoms to him.
Professionally, I have learned about addiction and some of the long term affects that it has. Brain mapping will indicate that the frontal lobe changes with addiction. The frontal lobe helps us with impulse control, which certainly affects our ability to keep from utilizing legal and prescribed or illegal or non-prescribed medication.
Addiction changes pathways in the brain that cannot be changed back.
Professionally, I supervise staff who work with parents who either currently are or have been addicted to opioids. Parents struggling with addiction struggle to parent their children effectively, appropriately, and safely. Many times families experiencing addiction become involved with DCS and their children are removed from their care. Children in families with addiction experience trauma when they are removed from their primary parents’ care and live with family members or foster families.
In the Prevention Program, CPCS, we work with a lot of grandparents who are caring for grandchildren due to substance abuse of their own children. The grandparents experience guilt about their own children’s experience with substance use, which can interfere with parenting their grandchildren appropriately.
In CPCS, we work with parents where the other parent is in jail or prison, who is not able to see their child due to crimes committed while utilizing illegal/non-prescribed substances, or for crimes committed to obtain the substances.
Children are suffering due to the increased stress that their caregivers are experiencing due to substance use and abuse.
The heroin epidemic is real. I am hoping to do my part to help figure out how to reduce the number of people addicted to opioids. Ultimately, my goal is to help more children live safely in a safe and stable environment. To increase the chances of this, children will be parented by parents who are not addicted to opioids, who are providing a safe and stable environment for them.
Indiana has been a leader in prevention services for approximately 20 years of which I am aware. As Indiana’s lawmakers and decision makers continue to allocate funds to this area of service, the state government is indicating that we value prevention services. Currently, the Indiana state budget has been difficult to balance. The budget for the the 2017-2018 time period was just finalized, and there were minimal cuts to prevention services. The governor, who was elected in 2016, is working to keep spending from exceeding costs, which is difficult in this field.
The agency I work for is being proactive and looking for ways to diversify our funding to ensure we are still able to provide services to children and families who live in our state. One area that keeps presenting itself is the opioid crisis. During our strategic planning meetings in October/January, our facilitator began by calling local community members to see what their perception was of our agency, the services we provide, and the needs in the community.
Over and over again, she listened as providers and community members talked to her about the opioid crisis and how something needs to be done to stop it or at least slow the speed of the growth of the crisis. She heard people talk about how kids are being removed from their parents’ care because their parents are unable to care for them. She heard about how DCS is continuing to hire more staff to support their structure of ensuring that children are safe from abuse and neglect.
At our brainstorming sessions, participants in the planning discussed what role my agency could have in addressing the crisis. The discussion included thinking about how to train staff already working in our intervention and prevention programs about signs and symptoms of substance abuse, as well as providing evidenced based curriculum about helping staff work with families who have been touched by substance abuse in some ways.
Of course, we talked about whether we wanted to have a drug treatment program as part of the services we provide. This is not an area on which we have expertise, and would be difficult to start. Another barrier to that plan is finding effective treatment programs for substance abuse. Developing an effective treatment plan for substance abuse is a very large need both locally and nationally.
In summary, I ask that you think about what you can do to address opiate addiction and the affect that it has on children and families in your state. This issue took a long time to develop, and will take a long time to address. Thank you for reading my article, and I am confident we can continue to work together to solve this problem.
Terri Parke, LMHC