Our Opioid Opportunity

The Fix
November 12, 2019

Perhaps everything that is terrible is,
in the deepest sense, something
that wants our love.

Rilke

The overdose epidemic in the U.S. has been called “the greatest public health crisis of our time.” It’s also our greatest opportunity.

The opioid crisis is an identity crisis: it’s a challenge to how we see ourselves. Do we truly believe that we are all in this together? One answer leads us deeper into despair. The other, into a hopeful future.

It’s been said that “doing more things faster is no substitute for doing the right things.” What are the “right things,” the measures that can resolve the crisis, not just postpone it? The right actions come from the right thoughts. Those thoughts come from feelings, and feelings are never right or wrong. But there are some feelings we are born with. They are our birthright. And one of them is love.

The Kindness of Strangers

Hatred never ceases by hatred, but by love alone is healed.

The Buddha

Behind the opioid epidemic is a prevailing lack of compassion, of caring about everyone equally. At the heart (or lack of it) of this societal disease is rampant inequality. The social determinants of health: stress, unemployment, lack of support, poor health care, etc. are major drivers of addiction. Many authors promote this view, including Gabor Mate, Bruce Alexander, Sam Quinones, Robert Putnam, and Harry Nelson.

Our increasing fragmentation affects everyone, poor or rich.

Drug overdose is the leading cause of death for Americans under the age of fifty…

Our material lives may be outwardly prosperous, but our psychological and spiritual lives are in freefall. What is driving us to self-destruction? There are many factors, all with one unifying theme: we are no longer living in community with one another and, consequently, we are lonely.

We all hunger for the same thing. The question is this: do we love our neighbor as ourselves? That’s not just a commandment; it’s a requirement. How do we rebuild community? First, by taking full responsibility for the fallout of not being one.

For Whom the Boom Tolls

Compassion is not a relationship between the healer and the wounded. It’s a relationship between equals. Compassion becomes real when we recognize our shared humanity.

Pema Chodron

I live in Asheville, a city that has recently, like the opioid crisis, exploded. Tourism is at an all-time high, and Asheville has appeared in dozens of destination top ten lists. It has also been ranked second in the country in gentrification.

Blue Ridge Parkway, 8/20/18

Asheville sits in the heart of Appalachia, where the opioid crisis is at its worst. In 2017, North Carolina had the second highest increase in opioid deaths in the country. The Blue Ridge Parkway runs through town and I spend a lot of time there, mostly foraging. That’s where last summer, for the first time, I found not mushrooms but needles.

Despite the crisis, the city just spent six months trying to shut down the local syringe exchange. The same thing is happening in other cities. In Asheville, the exchange had been operating without incident for over two years — until the houseless (a.k.a., homeless) in adjacent areas were kicked out to make way for new development.

Addiction depends on denial. What if development, not heroin, is the real addiction? Will we face up to the dark side of gentrification or just try to make it “go away?”

If a canary dies in a coal mine, you don’t blame the canary. Yet blaming the victim is exactly what we’ve been doing.

License to Ill

A man came to the Rabbi and said, “Rebbe, my son has turned against me. What should I do?” The rabbi said, “love him even more.”

Hasidic story

Most people by now have heard that naloxone (Narcan) can prevent a deadly overdose. So many Americans are dying — often from a mix of drugs, but mainly due to opioids — that naloxone should be as ubiquitous as aspirin. Everyone using a drug that may contain opioids should carry it like an EPI pen. And with the increasing prevalence of fentanyl, a single dose may not be enough. Everyone should know how to tell how much naloxone to give someone in the midst of an overdose. This should be basic, universal knowledge.

But keeping someone alive is just the beginning. In fact, while naloxone may be physically safe, it does have one significant side effect. It’s called precipitated withdrawal. And not helping someone through it is like catching them from falling only to drop them from higher up.

A Devil’s Bargain

Be kind, for everyone you meet is fighting a hard battle.

Ian Maclaren

As one response coordinator describes it, precipitated withdrawal is like “the worst flu you’ve had… times 100.” For some, the feeling is so bad that they find themselves dying, so to speak, to use again.

To the uninformed, it is inconceivable that someone who nearly died from a drug would run out that very same day and buy more of it. Narcan works by binding to opioid receptors, blocking the effect of narcotics like heroin. In drug users with a physical dependency, it also has the effect of causing severe withdrawal symptoms. This all but guarantees that the first thing a user will think of after their overdose is reversed is getting another fix

Naloxone is not just a “bandaid on a bullet hole.” It can feel like ripping open a wound. For “withdrawal is the very situation that [users] are seeking to avoid in the first place.”

“A dose of naloxone,” according to the Chief Medical Officer for a Connecticut health agency, “is a chance. But if it’s not coupled with immediate offers of treatment, it may be a slim chance that leaves the revived individual running back to the same dealer who sold them their last lethal dose.”

Overdose survivors need more than a second (or third) chance: they need a parachute. When you’re in free fall, a little more time isn’t much help.

Back on the Chain Gang

Without forgiveness, our lives are chained, forced to carry the sufferings of the past and repeat them with no release.

Jack Kornfield

“They’re usually very angry when we bring them around,” says one responder. “One kid yelled at me, ‘You think this will make me stop doing drugs?’” Indeed, one substance abuse specialist in Ohio says that 67% of people revived with naloxone in her area use again within 24 hours. NPR reports that “about 30 percent of those revived with Narcan at Boston Medical Center have been revived there more than once… and about 10 percent of patients more than three times. Those statistics are in line with what’s seen in ERs elsewhere, public health officials say.”

According to a former agent for the DEA, one woman in Ohio, within 24 hours of being revived for the the sixth time, was using again. In the first half of 2017, one man in North Carolina was revived fourteen times.

To be clear, I am not saying naloxone provides a safety net that encourages people to take bigger chances. Studies have shown that naloxone does not increase drug use any more than free condoms increase sex. Nor am I saying we should place limits on the number of times we revive people.

What I am saying is that, like heroin, naloxone is no miracle drug. When you “come to,” the problem remains. Overdose survivors are 24 times more likely than the general population to die in the following year. One study found that for those revived with naloxone, nearly one in ten are dead within a year, the majority within the first month. Follow up is critical. But even that is not enough.

Not by Locks Alone

Few things can help an individual more than to place responsibility on him, and to let him know that you trust him.

Booker T. Washington

In June of 2019, New Jersey became the first state to allow paramedics to administer buprenorphine along with naloxone to ease the pain of withdrawal. Buprenorphine is the drug that, like methadone, is used in opioid replacement therapy. But this measure will, according to one expert, “make a meaningful difference only if rescued individuals are linked immediately to ongoing treatment and agree to participate in that treatment.”

“Immediate” is key. And at least one hospital in New Jersey has been making that link, through state-paid recovery coaches, since 2017. A coach might work with someone “for weeks or months.” And the cost to taxpayers of helping people in this way is surely far less than the cost of leaving them on their own.

Unfortunately, however, getting people into treatment is not enough. Not all treatment is good treatment. In fact, much of it is worse than none at all.

Under the Rug

Beware of all enterprises that require new clothes, and not rather a new wearer of clothes.

Thoreau

People usually go to rehab for 28 days, maybe a month and a half. In most cases, the treatment fails, if you regard failure as return to use. A study reported in the Irish Medical Journal found that 91% of people who go through rehab are using again within a year; 80% in the first month.

“Most honest program directors,” says veteran addiction expert Julia Ross, “will admit to 90% relapse rates, and I assume that if they admit to 90%, it’s probably worse.” Drug courts are no better. A national study of seventy-six drug courts found a reduction in the rate of rearrest of only 10 percent.

Moreover, when people come out of abstinence-based rehab, their tolerance has gone way down, so they are more likely to overdose. This is a common reason why fentanyl is killing people: it can be much stronger than they are expecting. Making fentanyl test strips available can help prevent overdose, but that still doesn’t deal with the basic issue of why they’re using in the first place. What pain are they killing?

Zero Tolerance

Winning isn’t everything; it’s the only thing.

Henry “Red” Sanders

I watched my grandmother die a very slow death. At 90 years old, after three cancers, open heart surgery, and several strokes, she still fought tooth and nail. Christopher Ryan, author of Civilized to Death, compares our approach to death to the final minutes of an NBA basketball game. We drag it out. We go for quantity instead of quality. Is that also our approach to addiction? As long as they don’t die, we’re OK. This is similar to abstinence-based approaches to addiction treatment: As long as you don’t use, you’re OK. This amounts to saying, “it’s more important to look good than to feel good.”

To be clear: I’m not saying we should just let our neighbors die. I’m saying we need to do more than just keep people alive; not less. We need to treat the cause, not just the symptom.

Spare the Prod

If you want to be heard, whisper.

author unknown

The overdose crisis is part of a larger epidemic of despair. The facade of America as the “land of opportunity” is failing. Asheville today is “booming.” For whom? Are we saving lives or just saving face?

Fortunately, Asheville has begun to address its weak spots, and we now have three needle exchanges. We all need to look in the mirror and face where we — as a community, as a country — are really at. Because not doing so is killing us. Whether we die quickly from overdose or slowly from alcoholism, cancer, or depression, we are ALL canaries in a coal mine. And you can’t just rake the canary over the coals.

It’s one thing to save lives. But throwing someone into withdrawal without providing detox support or throwing them out of treatment because they’ve relapsed is like hitting a child to make them stop hitting other children. Such heavy-handed measures only perpetuate a cycle of abuse. Even a magic bullet leaves a wound.

Sticks and Phones

Can you love people and lead them
without imposing your will?

…leading and not trying to control:
this is the supreme virtue.

The Tao Te Ching

There’s a reason our greatest leaders practice nonviolence. If all we do is arm people with naloxone, if we fight firearms with firearms, the conflict will only escalate. Stronger opioids are already requiring stronger antidotes.

With this approach, we may win a few battles, but we will lose the war. You can’t win when you see this as a war to begin with. Because you can’t force someone out of addiction any more than you can force them to stay alive. Force is what causes addiction.

In 2015, Victoria Siegel, 18, died of a methodone overdose precipitated by cyberbullying. We worry about bullying in schools. By whom? What about parental bullying — or governmental? Some of us are aware of the alarming incidence of domestic violence. How many of us recognize how our culture is inherently abusive, our very way of life?

Sometimes we forget that we are treating people, not diseases. We are bio-psycho-social beings. We have feelings. If addiction comes from pain, and pain comes from hurt, then we need to reduce hurt, not just harm.

A Dying Shame

You cannot be lonely if you like the person you’re alone with.

Wayne Dyer

We will not end drug abuse until we end human abuse. We will not end human abuse until we end abusive thinking, because violence starts with what you think. A saying often attributed to Martin Luther King Jr. is that “you can have no influence over those for whom you have underlying contempt.” As long as I think, “you’re not good enough; this is all your fault,” or I say that to myself, addiction will be there.

The blame game has no winners. “We’ve lost what it means to just be ourselves and for that to be ok and for that to be enough. So we find ways to self-medicate.” People will use painkillers as long as the pain is killing them, for there are few emotions more agonizing than shame.

We Are Faminy

I don’t remember now how many days we stayed—long enough to hear David sing often and tease us about white people’s music, which, according to him, is only about “love.” He observed that the Hopi have many songs about water, which they consider the rarest and most precious of resources, and then asked, with feigned innocence, if white people sang so often about love because it was equally rare in our world.

Peter Coyote

To many, opioids feel like the opposite of shame. One user describes the feeling as “like being hugged by Jesus.” Indeed, “the very essence of the opiate high,” according to Gabor Mate, is that it feels “like a warm soft hug.” This is the feeling of unconditional acceptance and support, a.k.a., love.

We live in a culture where love is the one thing we sorely lack. Millions of people are starving for just a few drops of it. If only for a few moments, we desperately need to feel like we’re OK, that someone wants us to be here, as we truly are. Like they say, it is rain that grows flowers, not thunder.

Inside, we know we’re not just here to feed The System. We know it should be feeding us. We should not be starving. We should not have to be forced, or force ourselves, to do anything. People need to be supported to decide for themselves what healing looks like for them and to approach it in their own time.

The Emperor in the Room

Opioids are like guns handed out in a suicide ward; they have certainly made the total epidemic much worse, but they are not the cause of the underlying depression.

Anne Case and Angus Deaton

To solve the drug problem, we need to focus on more than drugs. Otherwise, we are shooting the messenger. Drugs are like the emperor’s clothes; it’s time to look at who’s wearing them.

Like Dr. Jeckyll and Mr. Hyde, opioids and their antagonists are two sides of the same coin. Focusing on either is like looking for your keys under the streetlamp when you know you dropped them further up the street. There is an “upstream” issue here. That issue is our domination-based, “have to” culture. If we stick to our guns, if we continue to be violent, inside and out, we will continue to die.

Whether we kill another person, the planet, or ourselves, we are a culture committing suicide. We are overdosing on “progress.” We are addicted to things far more insidious than opioids; you’re looking at one.

Progress isn’t progress when it’s in the wrong direction. The direction we’re going is apart. The direction we need to go is back together.

Only the Lonely

Humanity’s current crisis may not, at its root, be an economic crisis or an environmental crisis. It may well be a crisis of consciousness, a crisis in how see ourselves and the world around.

Peter Russell

If you’re in the right place at the right time, armed with enough naloxone, you can save a life. But what about an hour later, or the next day? You might get someone into treatment, but what about after that? A person that susceptible to overdose can scarcely be left alone. And that aloneness is the real problem. In fact, it’s how addiction starts.

The connection between social isolation and addiction shows up on many levels, from treatment to prevention. The most obvious is that you can get naloxone into the hands of every drug user, but it will do them no good if they overdose alone.

Human beings may be the most social animals on earth. Social isolation can drive us to despair, addiction, and even suicide. Loneliness is self-reinforcing and can lead to shame, for it can mean “I don’t deserve to be loved.” This can be the underlying emotional pain that comes back during withdrawal, whether from an opioid or from someone withholding their affection. And that lack of affection could be the primary cause of addiction.

Fatal Attraction

If one has a friend, what need has one of medicines?

Bhartrihari

There can be no healing without community. “This unique American moment asks not for a call to arms, but for a call to neighborliness.” No amount of “care” can substitute for the watchful eye of loving family, friends, or neighbors. No amount of “treatment” can make up for how we treat each other. It truly takes a village.

Ultimately, it’s not drugs that are killing us; they are just finishing us off. Whether or not we beat the horse, we’re already practically dead. Something has weakened us enough to succumb to drugs. It’s the same thing that allows dealers to intentionally make some of their merchandise deadly, or if it’s naloxone, to jack up their prices.

“Sure glad the hole isn’t at our end.”

The root of all evil isn’t white. What our culture is most addicted to is exploitation. It’s what the system is set up for. It compels us not to care. “The loss of community is not a problem that can be dealt with through psychotherapy,” for what needs rehabilitation is our society. There’s something wrong “with the village.”

The greatest tool I know for rebuilding community is Nonviolent Communication (NVC). The best approach I’ve encountered for addressing the disconnection inherent in addiction is SeekHealing.

We are the Medicine

At the root of the opioid epidemic are deeper questions that we have to ask about society. What kind of society do we want to live in? Do we want to live in a society where we believe every life truly matters? Do we want to live in a society where we all chip in, recognizing that we are vulnerable in some way, whether it’s to addiction or loneliness or other conditions, and that we are stronger when we come together, when we recognize our interdependence, and when we help each other?

As tragic as the opioid epidemic is, if it can move us in a direction of shared understanding about our interdependence, if it can help us address these deeper social roots of disease, then I believe that we will have used it ultimately to improve ourselves to become stronger as a country.

Vivek Murthy

To make it out of this crisis, we need to look at the big picture. As writer David Dobbs puts it, “trying to understand mental illness without accounting for the power of social connection is like studying planetary motion without accounting for gravity.” If we only look at addiction on an individual level, we are missing the forest for the trees. If you don’t heal the forest, it gets harder and harder to heal each tree.

It’s especially hard to heal when you’re continually cut down. In this culture of mutual exploitation, we treat each other like truffula trees. We factory-farm humans and clear-cut them for fuel. We do it to each other and we do it to ourselves. All to feed the machine, the matrix. To race into space, we’re melting our wings.

Saving lives, then, is only the beginning. It’s the tip of the iceberg. Because it is we, not “they,” who have an addiction. This isn’t about how we use drugs; it’s about how we use each other. Because ultimately, there are no others. We are not just a bunch of individuals. We are one, interdependent whole. Our greatest public health crisis is that we’ve forgotten who we are.

The Opposite of Addiction

Sometimes out of really horrible things come really beautiful things.

Anthony Kiedis

This crisis is an opportunity, a wake-up call. If we take responsibility for it, there’s no limit to what we can do. It’s said that anything is possible if it doesn’t matter who gets credit for it. The same is true of blame.

We are all in this together. That’s the bottom line. There is but one answer to this crisis, and we each carry it at the bottom of our heart.

Alan Muskat serves on the board of SeekHealing. He is the author of Coming Home.