By Eileen Reynolds
Every day, 115 people in the United States die of an opioid overdose—a death toll so high that it’s caused the nation’s overall life expectancy to drop for two years in a row. In 2016, opioids claimed 63,600 American lives, more than those that died during the HIV/AIDS epidemic’s peak in 1995 and more than the total number of US soldiers killed during the entire Vietnam War. The CDC (Centre for Disease Control and Prevention) estimates the economic burden of the epidemic at US$78.5 billion per year, and in the states where the death rate is highest—West Virginia, Ohio, New Hampshire, Pennsylvania, and Kentucky—there are tremendous social costs as well, including for the children of drug users, who often end up being raised by other relatives or entering the foster care system.
Drug addiction has often been thought of as a problem primarily affecting inner cities, but the current crisis is most visible in rural communities. So the race is on to adapt strategies that have been effective in curbing drug-related urban death rates to a new landscape.
That’s where researchers like Holly Hagan, a codirector of NYU’s Center for Drug Use and HIV/HCV Research and professor at the Rory Meyers College of Nursing, come in. Hagan is a nurse and epidemiologist whose research has focused primarily on the infectious disease consequences of substance abuse, and she previously served as principal investigator in New York City on the National HIV Behavioral Surveillance Project. More recently, she was tapped to chair the Executive Steering Committee of the Rural Opioid Initiative, a collaborative project of the CDC, the NIH, the Substance Abuse Mental Health Services Administration, and the Appalachian Regional Commission that funds nine research projects in areas with some of the highest rates of overdose and hepatitis C infection.
NYU Research asked Hagan to help separate myth from fact regarding opioid addiction—and to talk about the small things we all could do to help end the epidemic.
How’d we get here? It’s complicated
What we now call the opioid crisis didn’t appear overnight, and its causes are complex. But Hagan says that most experts date its origins to a change in thinking about pain management that took place during the 1990s. Whereas opioids had previously been used to treat acute, post-operative pain or to help alleviate the suffering of cancer patients at the end of their lives, when there was little risk of addiction, pharmaceutical companies began marketing the drugs to doctors as safe and effective for managing chronic conditions, such as back pain and sports and work injuries.
“There was a concern that there was a lot of untreated pain in this country, which was a legitimate concern,” Hagan explains. “But there was also a lot of deceptive advertising, particularly on the part of a company called Purdue Pharma, that really downplayed the abuse potential and risk of addiction.” One Purdue Pharma ad campaign that used the slogan “I got my life back” featured patients speaking about how the drug Oxycontin—billed as a nonaddictive opioid—had helped them alleviate chronic pain. “Many of those people are now dead from overdose,” Hagan says.
Several states as well as New York City and other counties and municipalities have filed lawsuits against the company over the past year. But at the time, the marketing push—which included cherry-picked and often flawed studies that seemed to show a low risk of addiction—was successful, and the number of prescriptions for opioids skyrocketed.
“The pendulum swung toward a very liberal attitude around these drugs. Kids would go to the dentist to have a wisdom tooth removed and they’d come home with a 14- or 28-day prescription, which was way beyond what they needed,” Hagan says. “People with legitimate pain were not adequately monitored and developed dependence on the medication over time, while people who didn’t have pain suddenly had easier access to these drugs.”
When officials finally began to try to limit the number of prescriptions and the drugs became more difficult to get, people who were already addicted—and facing the debilitating effects of withdrawal—were left to seek out illicit sources.
“Now, in much of the country, the opioid epidemic has shifted into a heroin epidemic,” Hagan explains. “That’s a huge concern because once you start injecting, you increase your risk for HIV, hepatitis C, and overdose.”
Rural areas are hit hardest for a variety of reasons—some of them economic
Many of the communities being studied in the initiative Hagan is overseeing are the same ones that have seen high rates of unemployment and economic depression in recent years—and that’s probably not a coincidence. “In places like Ohio, West Virginia, Kentucky, and Illinois, factories have closed down, coal mines have laid people off, and people don’t have work,” Hagan says. “They don’t have any hope about the future.”
Those feelings of idleness and despair may already be risk factors for drug abuse, but add to that the fact that many people in rural areas are employed in manual labor—where injury risk is high—and you have a recipe for potential addiction.
Isolation, low education levels, poverty, and lack of opportunity—problems often associated with inner cities, Hagan says—are also factors in many of the rural settings she’s studying now.
Bystanders may have an important role to play—even if it’s just in countering common myths about addiction
Interested in doing what you can to help? Hagan suggests attending an overdose prevention training, where you’ll learn the signs of an overdose and how to administer the medication naxalone—which reverses the effects of opioids—and turn the person on their side and call 911. “That could save a life,” she says. “You can think of it like your civic duty as a bystander—the same way lots of people learn CPR.”
In addition to advocacy work on the benefits of safe injection and needle exchange programs, Hagan says concerned citizens can also help by gently correcting some misconceptions about such efforts. “There’s no conflict between harm reduction and drug treatment,” she explains. “Every needle exchange program I know of has very strong ties to drug treatment programs, along with systems for referring people and helping them to get on Medicaid, which will help them pay for substance abuse treatment. The goal of harm reduction is to keep them healthy until they’re ready to recover and stop using drugs.”
Finally, Hagan says, it’s helpful to resist the urge to moralize. “You have to remember that the effects of these drugs are so strong that you don’t need to have a history of abuse and neglect to develop a substance use disorder,” she says. “It can be the result of simply being exposed for a long time, often when the drugs are coming from a doctor. There are cases where parents had no idea their son was still taking Oxycontin for a sports injury, and then one day went in his room and found him dead. How can you blame those parents? They trusted that healthcare professionals wouldn’t put their child in harm’s way. We have to keep talking to one another about these issues, even when the conversations are difficult.”
This article originally appeared in the Spring 2018 issue of NYU’s Research Digest and is reproduced with permission.
Eileen Reynolds is an Associate Professor of Medicine at Harvard Medical School. She is an expert in pharmaceuticals.