The Opioid Crisis: Causes and Consequences in NH, Part I

By Kim McNamara, NH Health Officer

If we truly value life, human dignity and compassion, we will financially, ethically and without uneducated preconceptions, whole-heartedly provide the care and support needed by our community members and their families who are being decimated by the current opioid addiction tragedy.

Advanced studies in neurobiology at the cellular, molecular and genetic levels have led us out of the dark ages when “drug abuse” and “addiction” were not understood as the pathophysiological conditions they are. Substance Use Disorder (SUD) is the common terminology used for what is now known to be a chronic, relapsing disease of the brain; and as such is much more effectively addressed by therapeutic interventions than punitive ones.  We begin to see a science-based progression from solely a law enforcement approach to this crisis, to a public health response.  Public health is much better suited (or should be) to advocate and provide support for services across a complete continuum of care.  A public health response must include education, prevention, medical intervention, therapeutic and recovery services for the entire community, at the time they are needed. Currently New Hampshire comes up woefully short, despite the hard work of many dedicated souls because we began so very far behind.

In opioid abuse, the structure and function of the brain is altered and can cause changes in thoughts and behaviors. This leaves many people suffering from SUD incapacitated to a level they would not have imagined. Understanding the medical basis of this current crisis and how it is so intricately tied to our medical practices, as well as the role of a health care approach in successful treatment and recovery, allows us to embrace it as the public health issue that it is. From there we can compassionately and effectively join in the fight. Public health operates on a community level, and this issue needs a community response.  Approaching this as a health issue allows us to use the infrastructure and concepts we already have in place to address other public health issues.  Care on all levels must be available and coordinated so people can move successfully out of the grips of SUD through treatment and into sustained recovery.  SUD can and is being treated successfully every day. There are many happy, productive, successful people in our communities that are living proof that therapeutic intervention works.  

Opioids, also known as narcotics, are substances derived from the opium poppy, or synthetic compounds produced for similar effects. They are some of the most addictive drugs known. They come with many names, both generic and brand name. Many are legally prescribed such as morphine, tramadol, codeine, fentanyl, hydrocodone, Vicoden, hydromorphone, Dilaudid, Demerol, methadone, oxycodone, OxyContin, Percocet, etc. Consumers often do not understand that they are all “opioids.” Others are illicitly produced and may go by the same names, and of course, heroin is a well-known street opioid. It is an important part of public health education to teach parents, grandparents, caregivers, students and other citizens about the many names of this drug class, so they recognize the powerful and potentially dangerous medications they may come across in their homes, when visiting friends and relatives, at work, school or elsewhere in the community. Even legally prescribed medications become illicit drugs when they are taken by people for whom they were not prescribed.

Many compounds today are more powerful than those of earlier generations. Fentanyl, an opioid first developed for the hard-to-treat, severe pain associated with cancer, is up to 100 times more potent than morphine. The availability of illicit fentanyl has exploded in New Hampshire and is largely responsible for the overdose death rates we are experiencing.

Consider this: in the 1960’s, 80% of heroin addicts began their addiction with heroin. Only 20% were first addicted to prescription opioids. Today that trend is reversed. Current studies show that up to 85% of persons suffering from heroin addiction were first addicted to prescription opioids. There were many contributing factors in this reversal. For instance, vital signs measure the body’s most basic functions. Prior to the 1990’s, four signs – temperature, pulse, respiration rate and blood pressure were typically monitored in patients. In the 1990’s, pain became the “fifth vital sign” and was measured on a self-reported scale of 0-10. It was no longer a sign of a condition, rather it became a parameter that needed to be addressed and alleviated.  Since pain measurement is subjective, the evaluation and management of pain levels proved to be a difficult task for physicians, as was the promotion of non-opioid pain management alternatives. The 90’s also saw increased drug marketing campaigns for new opiate choices and more liberal prescribing practices for their use.

Once in the body, heroin and other opioids act on the brain, spinal cord, GI tract and other organs simultaneously.  In the brain stem where the critical autonomic processes are regulated, opioids cause changes in blood pressure and respiration. Most overdose deaths are caused by the opioid depressing the respiratory center to the point where the person stops breathing.  In the pain pathway of the brain and spinal cord, opioids produce pain relief. In the reward pathway where many functions necessary for the survival of our species occur, opioids can produce euphoric effects.  These effects can lead to persistent opioid use despite harmful consequences.  The changes in brain structure and function can occur quickly, long before a person realizes they are dependent.  It has been shown that as little as one month of medically monitored opioid administration can cause measurable changes in the brain. These drugs are also dangerous because the difference between the amount required to produce the desired effect and the amount that will cause respiratory depression is small and difficult to predict.

New Hampshire has a significant opioid problem.  According to The National Survey on Drug Use and Health (NSDUH) in 2012-2013, 18-25 year old NH residents reported the highest rates of illicit drug use in the nation at 10.04%.  Prescription practices and an abundance of opioids sitting in medicine cabinets throughout New Hampshire are not the only sources feeding this beast.  Much of the heroin and fentanyl flooding our streets is trafficked from Mexico through the interstate system.  These drugs are abundant and cheaper than purchasing medications.  In 2013, 193 New Hampshire citizens lost their lives to drug overdoses.  In 2014 that number rose to 325. In 2015 we lost 428.  For comparison, in 2015 we lost 114 lives to traffic accidents.

Making escape from the spiral of substance misuse even more difficult is the excruciating physical withdrawal people experience when opioids are discontinued.  They can be haunted by overwhelming cravings, cold sweats, muscle and abdominal pain, nausea, vomiting, diarrhea, involuntary body movements, severe agitation, anxiety and sleeplessness.  Medication Assisted Treatment (MAT) includes the use of medication along with counseling and other support, and has been shown to be an effective method of achieving long-term success. 

New Hampshire’s residents are particularly vulnerable to disastrous outcomes because we do not have nearly the amount or type of intervention and treatment services required.  It is nothing short of cruel when a person desperately seeking help to save their own life is told that there is no available treatment, or if they don’t have money, they can’t receive treatment, or the waiting list is several months long, or call back every day to see if we’ve had a cancellation (or death)…This is a an epic failure of public health in our state and we need to work tirelessly and with lightning speed in each of our communities to bring the resources needed to ensure adequate and timely treatment for all who suffer  from SUD.

In the next edition of the newsletter, we will look at the community effects and costs of this epidemic and review the gaps and assets in service capacity within our state to address it.
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