JC’s Recovery Center Blog

Profile of a Drug Overdose Victim

When you think of a drug overdose victim, chances are you think of someone inexperienced with drug use who takes more than they can handle, or a person who unknowingly takes a purer strain of drug than they’re used to. Those assumptions, however, aren’t reflected in current U.S. statistics. So what is an accurate profile of a drug overdose victim?

WHO: Statistics show that the people most at risk of drug overdose are people you wouldn’t necessarily think of as drug addicts — suburban, middle-aged white men, according to a 2014 study. Although many people picture the young being hardest hit, the Centers for Disease Control and Prevention (CDC) reports that in 2015 alone, the highest death rate from drug overdose occurred in people aged 45 to 54.

WHAT: What drugs are people in the highest risk groups taking? In a word, painkillers. Prescription opioids like hydrocodone (Vicodin, Lortab) and oxycodone (OxyContin) were responsible for 24% of drug-related deaths in 2015. According to the Office of the Surgeon General, 44% of Americans say they personally know someone who is or was addicted to prescription painkillers, and 78 Americans die every day from an opioid overdose. Prescriptions for opioid medications have quadrupled since 1999.

But the problem doesn’t stop with prescription painkillers. Heroin is another drug contributing to the alarming rise in overdose deaths. In 2015, heroin was responsible for 25% of drug-related deaths. Heroin overdose deaths tripled between 2010 and 2015. The highest recorded death rate from drug overdose in the U.S. occurred in 2014, when there were 47,055 drug overdose deaths, including 28,647 people who died from an overdose involving either a prescription painkiller or heroin.

Trailing close behind heroin and pain pills, at an 18% overdose death rate, are semisynthetic opioids such as fentanyl. Typically used for sedation during medical procedures and to treat cancer pain when other painkillers have failed to provide relief, fentanyl is 50 times stronger than heroin. For illicit use, fentanyl is regularly mixed into other drugs such as heroin and cocaine, often without the user’s knowledge, making it even more dangerous.

WHEN: Many users don’t realize that once they achieve a period of abstinence, either through a drug rehab program or on their own, they are at greatest risk for drug overdose. When they haven’t been using the drug regularly their tolerance drops. If they relapse (as about half of addicts do) and return to their usual dose of the drug, they are at grave risk of overdose.

There is also a risk of overdose when people mix drugs. For example, if a person takes one form of an opiate (such as a pain pill) and within 24 hours takes another type of opiate (such as heroin), they increase the opiate’s effect in their body and, thus, their risk of overdose.

WHERE: Studies also reveal surprising information about where drug overdoses are most likely to take place. A growing number of drug overdoses are occurring not in low-economy urban areas, but in suburban and non-urban settings, and often in affluent neighborhoods. Some of the states with the highest numbers of drug overdose deaths in recent years are New Hampshire, Ohio, West Virginia and Kentucky.

WHY: Addiction to opioid painkiller medications can develop even when people are using them for legitimate medical reasons. In fact, nearly one in four patients receiving long-term opioid pain therapy in a health care setting struggles with addiction. People who struggle with underlying depression, anxiety, trauma or other issues may find that the medication they take for physical pain also helps them cope with their emotional pain. This can contribute to addiction and lead to further problems. For example, since heroin is cheaper and easier to get than prescription opioids, many painkiller addicts turn to heroin when pain pills become difficult to acquire.

Stemming the Tide of Drug Overdose

In an effort to raise public awareness about opioid addiction, the Surgeon General has launched a “Turn the Tide” campaign advising concerned Americans to take active measures to help people in their communities who are struggling with addiction. Some of these include:

  • Write to local health care providers encouraging them to treat their patients’ pain appropriately
  • Talk to community leaders about the practices that are most effective and the challenges that remain
  • Inform policy makers, educators, law enforcement officers and others to help change how they think about substance use disorders and addiction

These measures can help address the problem at the community level, but it is also important to take action at the individual level. If you are seeking medical assistance to manage your pain, ask your doctor questions before taking an opioid prescription. Also consider alternative pain management approaches as well as medications that carry a lower risk for addiction, such as gabapentin (Neurontin, Gralise) and pregabalin (Lyrica). These are FDA-approved for pain and can be combined with other therapies for long-term use.

Finally, if you or someone you know is struggling with opiate addiction, get treatment before you become a statistic, and learn about the powerful anti-overdose tools available to you. Naloxone, a medication that can rapidly reverse opioid overdose, is easy to administer and more readily available than ever. In many states, relatives and friends can obtain prescriptions for an automated injector or nasal spray in case their loved one overdoses and in some states no prescription is required. Drug overdose is a tragedy that can be prevented by knowing who is at greatest risk, and how and when to take action.

Beyond CDC Guidelines for Opioid Prescribing: What’s Next?

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It was billed as a compassionate approach to pain. Instead, the aggressive prescribing of opioid painkillers such as OxyContin, Percocet and Vicodin became the driver of an addiction epidemic that has caused overdose deaths to more than double since 2002.

So there’s much to praise in new prescribing guidelines released recently by the Centers for Disease Control and Prevention (CDC) that seek to change that narrative. Most notably, the guidelines encourage doctors to use non-opioid drugs wherever possible and to limit any opioid painkillers they do prescribe to low doses and less than a one-week supply. Many experts believe doctors will embrace the recommendations and the results will be transformative, helping to prevent new opioid addictions from taking hold.

Equally important, the guidelines don’t overlook those already struggling with an opioid use disorder. For these patients, doctors are urged to offer or arrange evidence-based care. That includes medication-assisted treatments such as buprenorphine, methadone and extended-release naltrexone (Vivitrol).

Those of us who treat opioid-dependent patients hope this recommendation is met with the same adherence as the prescribing limits. While reining in the prescribing of opioids is a positive step, it is not a magic bullet. In fact, limiting pain pills isn’t without risks. In some instances, it simply moves the problem from abusing prescription pain pills to abusing that other opioid — heroin. A 2012 study in The New England Journal of Medicine concluded, for example, that reformulating OxyContin did indeed decrease the number of people misusing it, but it “generated an unanticipated outcome: replacement of the abuse-deterrent formulation with alternative opioid medications and heroin, a drug that may pose a much greater overall risk to public health than OxyContin.”

Thus, while the CDC prescribing limits are an important step in stemming the growing tide of use, the war against opioid addiction needs to be waged on multiple fronts. We cannot overlook treatment and prevention of relapse.

The new guidelines go into effect immediately, but it will take time to see the full impact of the changes. Unfortunately, this doesn’t solve the current crisis of overdose deaths. For that, we need to focus on getting people into treatment. So far, our record isn’t good. According to the Substance Abuse and Mental Health Services Administration, 21.2 million Americans ages 12 and older reported that they needed treatment for a drug or alcohol use problem in 2014, but only about 2.5 million people received it. Meanwhile, more than 40 Americans die each day from prescription opioid overdoses alone.

Opioid addiction is a disease that responds best to a combination of behavioral therapies and medical attention, and that can include pharmaceuticals such as buprenorphine, methadone and naltrexone. I find a newer option, Vivitrol, an injectable form of naltrexone, to be particularly advantageous. Vivitrol is the only once-monthly, non-addictive, non-narcotic FDA-approved medication to prevent relapse to opioid dependence. Unlike replacement therapies such as methadone and Suboxone, Vivitrol works by blocking certain brain receptors related to euphoria. That means the patient cannot experience a high while on it. And its once-monthly dosing helps patients adhere to their treatment plan rather than having to take a daily medication. That said, all of the medication-assisted treatments are viable options, and the public needs to be aware that they exist and are effective.

There is no question that there needs to be more judicious prescribing of opioid painkillers. But for the millions of Americans who are already in the throes of addiction thanks to the practices of the past, focusing on prevention is not enough. We need to embrace all aspects of the new CDC guidelines and improve access to and support for effective treatment of the disease.

The Intersection of Sex, Drugs and Impulsivity

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Humans are determined reward-seekers. It’s a built-in motivation that keeps us on the hunt for food, water, sex and nurturing — things that keep us alive and thriving.

We also universally prefer those rewards to come sooner rather than later. In some people, however, that preference is more pronounced than in others. And we have a word for it: impulsivity.

In large part, impulsivity is a reward deficiency — a tendency to value immediate gratification over future rewards, even when it’s not in the person’s best interests. Researchers have a name for it: delay discounting. An impulsive person, for example, might drive off the lot with a car they’ve fallen in love with even though they could save money by waiting a couple of months for a promised sale.

This heat of the moment mindset can spice up life in small doses, but it can also bring serious downsides. Impulsivity has been linked to addiction, for example, and it’s not hard to see why. A person who has trouble valuing future rewards over immediate ones is going to find it tougher to say no to another drink, for example, or to walk away from a slot machine before all their money is gone. Impulsive people also try drugs and alcohol at a younger age, which is known to elevate addiction risk.

Complicating the picture, substance abuse can change the brain in ways that increase impulsivity, so each issue can make the other worse.

Impulsivity also fuels risky sexual behavior. Substance use does as well. Put the three together and problems escalate. A study of 3,000 high students found, for example, that those who scored high on impulsivity reported that they used alcohol or marijuana before sex, had five or more sexual partners, and “never refused unsafe sex” at much higher rates than those who scored low on impulsivity.

In time, impulsivity, sex and addiction can get tangled up in one another, elevating the negatives and causing problems to snowball.

Following the Reward Pathways

A growing body of research, especially research using brain imaging technology, has helped increase our insights into these interconnections.

When a person encounters a reward, or even when anticipating a reward, the brain releases the chemical dopamine along reward pathways. The brains of those who score high on impulsivity scales, however, show disproportionately more dopamine activity in response to an immediate reward and less dopamine activity when presented with a delayed reward. The greater the dopamine drop-off over time, the more impulsive the person.

Drug use boosts dopamine transmission, reinforcing the thrill of the immediate reward and making impulsivity worse. With repeated use, the substances begin to alter the brain circuitry that assigns importance to stimuli. This increases the person’s craving for the drug, as well as increasing the motivation to obtain natural rewards such as sex. Chronic drug use also causes chemical and physical brain changes that increase sensitivity to dopamine, another spur to impulsivity. Rewards that have to be waited for begin to seem less and less worth the effort. All this makes relapse more likely for those trying to control their substance use.

Research in Parkinson’s disease has also taught us much about impulsivity. The disorder’s bodily tremors and rigidity are thought to be the result of damage to dopamine neurons. Medications that compensate for that lost dopamine were found to have an unexpected side effect for a significant percentage of people: an increase in problems with issues such as gambling, sex, eating and spending. Dopamine release, this reaction made clear, is directly related to behaviors and can trigger problems with impulse control.

Treating Impulsivity

So for those who recognize impulsivity in themselves and fear where it might lead or who are already struggling with its effects, what can be done to lessen that tendency to make counterproductive choices?

Impulsivity’s delayed discounting is thought to be about 40% genetics, but it is also believed to be connected to deficits in the brain’s memory systems. After all, you can’t value a future reward if you can’t remember what it’s worth.

That means that working on memory through simple memory training exercises can help. Research has shown, for example, that memory training decreases impulsivity in newly sober amphetamine addicts.

Another treatment for impulsivity is a technique called prospection. This is a type of mental time travel in which the person projects themselves into the future and thinks about the rewards that might await. For example, a person who wants to stop drinking might visualize waking up sober, rested and ready to take on the day rather than feeling hung over and miserable. In time, the brain learns to assign value to what might be rather than only seeing reward in immediate gratification.

Interestingly, both techniques are built into the framework of Alcoholics Anonymous and are believed to explain part of its success in helping many with addictions maintain their sobriety. The repetition and practice that comes with learning and living the 12 steps improves memory, while the story sharing that is a hallmark of the group helps participants imagine a better future and learn to want what those who are successful in their recovery have created for themselves.

Memory training and prospection are techniques that don’t give results overnight. (The impulsive person must learn to delay gratification here as well.) But the brain, as research now makes clear, is capable of great neurochemical and even physical change. And it’s encouraging to know that where impulsivity is concerned, simply dreaming of a better future might help you achieve it.