August Monthly Mosaic: Prescription Opioids & the War on Drugs
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—– In response to current discussions and misconceptions surrounding opioid prescription use, and because International Overdose Awareness Day is just around the corner on August 31st, the Diversity Awareness Reflection and Education (DARE) committee thought it pertinent to dedicate August’s Monthly Mosaic to Prescription Opioids & the War on Drugs. There is a lot of animosity toward pharmaceuticals, especially opioids. Common opioids include schedule II substances such as morphine, fentanyl, hydrocodone, and oxycodone; and heroin, which is a Schedule I substance. Opioids are commonly prescribed to treat pain, but they may be used by individuals for a variety of reasons. As a reaction to the increases in opioid overdoses, misconceptions are being spread about prescription painkillers leading to opioid use disorder. These misconceptions are further skewed to paint those who develop an opioid use disorder as “chasing highs” until it destroys or ends their lives. It is understandable that people want to react strongly to the opioid crisis — between the years of 2000 and 2014, the United States experienced a 200% rise in the rate of opioid overdose deaths. However, much of the current discussion is not in line with evidence, and spreading this misinformation only further harms both those who need access to opioids for pain management and people who struggle with problematic opioid use. This issue deserves more nuanced discussion and evidence-based solutions. In recent years, the conversations around people who use drugs has shifted. Although our laws are slow to reflect it, many people now understand problematic drug use as a public health issue instead of a criminal one. While this is certainly a good step toward respecting people who use drugs, it is important to note that it is not a coincidence that our understanding and compassion for people who struggle with drug use has improved as the faces of those people changed. The drug crisis in white communities today dwarfs the crack epidemic that decimated communities of color in the 80s, but the media does not blame “white culture” for this crisis, and police departments do not target whites when enforcing drug laws. This is not to say that we should stop progressing now — rather we acknowledge the role race plays in public perception of people who use drugs.
—– MEDICAL VERSUS NONMEDICAL USE From a more medical perspective, a few things are considered when determining medical vs non-medical use (note – this is not necessarily OUR perception, rather how it may be perceived by those not as sensitive to the issues). The first common determinant is intent — whether the drug is used to treat a medical problem, or to “get high” or “self-medicate.” The effect of the drug is also considered — whether the drug helps the person in question live a better life or negatively impacts their quality of life. Another determinant is control — whether the drug use is controlled by the physician or the person taking the drug. Legality is also considered — is the person in question taking the drug as it is prescribed to them, or are they taking a drug prescribed to another person or an unprescribed substance? Finally, the pattern of drug use is considered — is the person in question using the drug at a moderate dose and as prescribed, or are they taking it in social settings and/or mixed with other drugs? During the 2015 NSDUH survey, participants were asked why they use prescription drugs non-medically, and their responses included to relieve physical pain, relax or relieve tension, help with sleep, help with feelings or emotions, experiment or see what it is like, feel good or get high, increase or decrease effects of other drugs, ‘because I am hooked or have to have it,’ help lose weight, help concentrate, help be alert or stay awake, help study, or some other reason. The first few of these results especially suggest there exists a false dichotomy between medical and non-medical use; indeed, many who by these standards are taking a drug non-medically are using it to treat medical problems. For the sake of simplicity, we shall differentiate between medical and non-medical use based on whether or not someone is taking a drug as it is prescribed to them, but we acknowledge that non-medical use can be beneficial as well.
—– OPIOIDS AND SUBSTANCE USE DISORDER It is a popular belief that if you are prescribed an opioid, you will develop an opioid use disorder. In contrast, prescribing painkillers did not cause the opioid epidemic, and painkillers do not have as high an addiction potential as one might think. Rates of carefully diagnosed substance use disorder average less than 8% among people taking prescribed opioids long-term, and rates of opioid use disorder among people who take opioids as prescribed short-term are even lower, averaging less than 1%. It is also important to keep in mind that much of the long-term use we see would not qualify as a substance use disorder, and is considered pain management. People can develop problematic relationships with opioids for a variety of reasons, but the narrative of short-term pain patients getting hooked on their medications represents a very small minority. Plenty of those who use opioids, medically or non-medically, manage regular use without a problem. In fact, most people who use drugs never develop a substance use disorder. For those who do struggle with opioid use disorder, we might be thinking incorrectly about what that means. It was already mentioned above that attitudes toward problematic drug use have shifted from a moral failing to a public health issue, with many now asserting that addiction is a disease. However, new research suggests it may be even more accurately described as a learning disorder. In this description, developing a substance use disorder starts with the person learning that the drug helps relieve some other problem they are experiencing, such as anxiety or depression. Regardless of what causes people to develop problematic relationships to opioids, recovery looks different for everybody. For some people who struggle with their opioid use, abstinence may be the only way they are able to feel in control of their lives. For others, recovery looks like less chaotic, but continued, opioid use. Whatever recovery looks like for each individual, there are evidence-based treatments available for people who struggle with opioid use and seek recovery; and while 12-step, abstinence-only programs may work for some, they are not the only option, and may not the best option. Medication Assisted Therapy (MAT) is a treatment that involves providing people seeking treatment with substances such as methadone and suboxone that bind to the same receptors as heroin and prescription painkillers. Ibogaine and other psychedelics have shown effectiveness in treating addictions, although people usually have to seek such treatments underground due to the drug’s legal status, and those trying to quit using opioids may need MAT as well to ease withdrawal symptoms. Harm reduction is an invaluable tool for combatting the opioid crisis. The basic principle of harm reduction is that while we cannot eradicate drug use, we can reduce the harm associated with consuming drugs. Examples of harm reduction as it relates to opioid use include syringe exchanges, access to naloxone, and safe consumption/injection facilities (SIF/SCFs). Unfortunately, these options can be very difficult to access due to prohibition. Many of the risks associated with opioid use are the result of prohibition. Due to fear of both punishment and the social stigma that comes with using drugs, prohibition drives people to consume alone and in more dangerous environments, to share needles, and to not seek help. Because of prohibition, young people are only taught to not to use drugs and are not given the necessary information on how to reduce risks should one decide to take drugs. Harm reduction resources like SIFs are largely unavailable under prohibition because they provide a space for people to consume illegal substances. Solving the opioid crisis involves considering alternatives to prohibition.
—– THE IGNORED EXPERIENCES OF CHRONIC PAIN PATIENTS It is vital to consider the lived experiences of people who use opioids when discussing how to solve the opioid crisis — from people who struggle with problematic non-medical use to those who need prescription opioids for a decent quality of life. Neglecting the voices of people who take and have personal experience using opioids makes the problem more difficult to solve. People who live with severe and chronic pain are often left out of the discussion and mischaracterized by those who speak over them. Without daily opioid treatment, many people with disabilities and chronic pain are unable to live comfortably. It is all too common to hear people who have no experience with chronic pain negatively discussing someone with severe and chronic pain’s dependency on opioids, and faulting doctors for prescribing the medication. Much of this attitude comes from conflating “addiction” and “dependence” as well as from not understanding the types of conditions for which opioids are simply the best option. Physical dependence can occur without addiction. Most people with chronic pain who use opioids are physically dependent; they require opioids to manage pain and prevent withdrawal. However, as long as they take their medication, they do not experience the loss of control and compulsive behaviors that are associated with substance use disorder. And yes, doctors who prescribe these medications know that their patients will become dependent on them. Long-term opioid treatment is simply the best option for many people dealing with severe chronic pain, especially for conditions that have no known cure. Because of the harsh backlash against prescription painkillers, many doctors have been forced to restrict pain patients’ access to opioids. Restricting medications for people who depend on opioids for a decent quality of life is horribly inhumane. Also, these restrictions drive those who are using prescription opioids non-medically to seek riskier alternatives, putting them in danger of ingesting counterfeit pills or adulterated heroin. It is time to stop pinning pain patients and people who struggle with opioid use against each other. Limiting prescriptions to combat substance use disorder hurts people with chronic and severe pain, and it does not solve the problem of substance use disorder. Likewise, demonizing those who struggle with opioid use disorder in contrast to those who take opioids as prescribed only harms those who struggle with their use. Decisionmakers and drug policy reform activists need to consider the perspectives and experiences of those most affected in order to successfully combat the opioid crisis. So many of us have been personally affected by overdose and addiction, and the discussions around this topic are highly emotional, but we must be careful not to react with backlash that does more harm than good. Additionally, we must continue fighting to end the War on Drugs that has created this problem.
—– ADDITIONAL RESOURCES Interested in learning more about these issues? These links are great resources to get you started… Living With An Opioid User: A Guide To Keeping Safe “Part of what drives opioid users into the darkness is stigma. It’s lack of acceptance. That makes people use alone, use risky and get fucking dead. It’s not acceptable. People are killed by the lack of compassion, or even outright aggression of others. Every time my partner has been told they can’t do it, they can’t stop, they’re just a waste of life, it has pushed them further into the dark. I don’t support that approach, it never helped me, and I don’t think it genuinely helps anyone. Tough Love is a lie the lazy and uncaring tell themselves to excuse their own abuse of the marginalized.” Opioid Overdose Basics “This section outlines the basics of opioid/depressant overdose prevention, recognition and response” Harm Reduction Fact Sheet “Harm reduction is a set of practical strategies and ideas aimed at reducing the public health risks associated with drug use. Harm Reduction calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs, and the communities in which they live, in order to assist them in reducing harm. Harm Reduction is not the opposite of Recovery, it is just the more patient and sustainable route.” How to Administer Naloxone
—– DRUG WAR NEWS FROM AROUND THE WORLD The War on Drugs is an international travesty. This section of the Monthly Mosaic, co-sponsored by SSDP’s International Outreach Committee, will highlight some of the top drug policy reform news from around the world. Canada British Columbia looks to Portugal to combat opioid crisis “Canadian health-care experts, including British Columbia’s provincial health officer, want the federal government to strongly consider Portugal’s approach to drug policy, including the decriminalization of personal possession.” China Video: Harm Reduction in China “In recent years, harm reduction services in China have made great progress. Innovative strategies and policies around it have been put into practice. This video clip is edited from media reports on harm reduction strategies and approaches on June 26, 2017. Opinions of stakeholders at different levels are also shared. Colombia Colombia’s Coca Farmers in Legal Dilemma That May Jeopardize New Drug Policy “Colombia’s government is intent on passing a law that will grant a one-year judicial immunity for small-scale coca farmers who agree to abandon their illegal cultivations, which is a provision of the government’s peace deal with the FARC. Without guaranteeing that farmers will not be jailed in the short term, there is little hope that they will voluntarily switch to alternative crops as part of the government’s new substitution program.” European Union The EU Adopts Its Most Progressive Drug Action Plan Ever “The three-year Action Plan translates the goals of the seven-year EU Drug Strategy (2013-20)into concrete actions with clear responsibilities and performance indicators. This is the second action plan relating to the current drug strategy, the previous one (2013-16) having been evaluated by external evaluators, RAND and EY in 2016.” Georgia Georgia: Constitutional Court’s judgement on sowing, growing and cultivation of cannabis “The Constitutional Court’s judgements in shaping the drug policy of Georgia is significant at a time when parliament, in this Fall, is also considering the review of the draft package in changing the law for decriminalization of all drugs, which has been submitted to parliament by National Drug Policy Platform.” India Indian Minister Calls for Medical Cannabis Legalisation: Could It Help Reduce the Heroin Crisis? “Maneka Gandhi, Minister for Women and Child Development, declared that “marijuana should be legalised for medical purposes, especially as it serves a purpose in [treating] cancer”. Indonesia The Butterfly Community: A Movement of Women who Use Drugs in Indonesia “Working as a peer educator, Risma met women who had used drugs and faced debilitating stigma. Unwilling to accept this marginalisation for herself or her peers, Risma set up phone support and counselling to assist women in standing up to fight for their health and rights. “I realised there were many of us.” Iran Iranian Parliament Receive Law Meant to Spare 5,000 Drug Smugglers “As soon as the new drug law is passed, the death sentence of more than 5,000 prisoners could be converted into prison sentences,” said Hassan Norouzi, a spokesman for parliament.” New Zealand Why cannabis reform needs to be done with Māori, for Māori “It’s a stat the needs to be repeated: although making up just 15% of New Zealand’s populace, Māori are 51% of the prison population, and 40% of those are incarcerated for drug offences. While politicians avoid drug law reform, the police have effectively been given a mandate to decriminalise cannabis in practice. But the current arrangement isn’t close to working for New Zealand’s indigenous population, who face racial discrimination in the police’s subjective application of the law.” Philippines Philippines’ ongoing war on drugs shatters hopes of peace for a generation “The “war on drugs” may seem distinct from longer-running security issues, but it isn’t. The crackdown is contributing to a culture of unchecked violence, which is increasingly accepted as a necessary measure. If this normalisation continues, lasting peace will never be achieved.” Scotland (UK) Scotland’s Drug Strategy to be Refreshed “The moves were announced by Public Health Minister Aileen Campbell at the ‘Drug Policy Through a Health Lens’ conference in Glasgow on the 26th of July and come as a report revealed rising inequality in the 1980s put men from Scotland’s poorer areas who were born between 1960 and 1980 at increased risk of drug overdose deaths.” Serbia Without shift: Harm reduction after the Global Fund in Serbia “As of 3 years ago, Serbia stopped being eligible for funding from the Global Fund, which resulted in the closure of harm reduction programs around the country. Our movie gives you a glimpse of the desperate situation faced by injecting drug users in Serbia, and also explores the consequences of the closure of needle exchange programs in Belgrade, whilst trying to assess the current situation in the country.” United Kingdom Number of drug-related deaths in England and Wales rises to highest on record, Government must declare public health emergency “Office for National Statistics (ONS) data released today shows 3,744 drug-related deaths registered in 2016 in England and Wales and a 44% increase on 2012 figures. It is the fourth year in a row that the ONS has registered an increase. 2016 is now the year with the highest number of registered drug-related deaths since records began.” Uruguay Uruguay pharmacies start selling cannabis “In all, 16 pharmacies have been authorized to sell marijuana under state controls, barely enough to cover a country of 3.5 million people.”
GET INVOLVED CONTRIBUTIONS Each Monthly Mosaic is edited by Elise Szabo and Kat Murti. This issue also features contributions by Vilmarie Narloch, Psy.D. Each month, SSDP’s Diversity, Awareness, Reflection and Education (DARE) committee publishes the Monthly Mosaic, a newsletter dedicated to exploring intersectionality and the War on Drugs. Previous issues have covered topics such as domestic violence, trans awareness, Black Lives Matter, and women’s unique experiences with the drug war. The DARE Committee strives to promote inclusivity within the SSDP network, and facilitate collaboration and engagement with presently underrepresented perspectives, individuals, and movements. In order to ensure that the Monthly Mosaic more intentionally and meaningfully reflects these values, the DARE committee is pleased to invite members of our student and alumni network to submit ideas for upcoming issues. If you have any questions, please contact Elise at firstname.lastname@example.org. We look forward to reading your submissions!