Addiction is not a choice. It’s not a moral failing, or a character flaw, or something that “bad people” do. Most scientists and experts agree that it’s a disease that is caused by biology, environment, and other factors.

Harmful consequences, shame, and punishment are simply not effective ways to end addiction. A person can’t undo the damage drugs have done to their brain through sheer will power. Like other chronic illnesses, such as asthma or type 2 diabetes, ongoing management of addiction is required for long-term recovery. This can include medication, behavioral therapy, peer-support, and lifestyle modifications.

References:

1. National Institute on Drug Abuse. The Science of Drug Abuse and Addiction: The Basics.
2. Grant B, Saha TD, Ruan WJ. “Epidemiology of DSM-5 Drug Use DisorderResults From the National Epidemiologic Survey on Alcohol and Related Conditions–III.” The Journal of the American Medical Association, January 2016.
3. ASAM. Definition of Addiction.
4. Volkow ND, Koob GF, McLellan AT. “Neurobiologic Advances from the Brain Disease Model of Addiction.” The New England Journal of Medicine, 28 January 2016.
5. “Drugs, Brains and Behavior: The Science of Addiction.” National Institute on Drug Abuse, July 2014.
6–7. Volkow ND, Koob GF, McLellan AT. “Neurobiologic Advances from the Brain Disease Model of Addiction.” The New England Journal of Medicine, 28 January 2016.
8. “Drugs, Brains and Behavior: The Science of Addiction.” National Institute on Drug Abuse, July 2014.
9. Volkow ND, Koob GF, McLellan AT. “Neurobiologic Advances from the Brain Disease Model of Addiction.” The New England Journal of Medicine, 28 January 2016.
10. Swendsen J, Burstein M, Case B. “Use and Abuse of Alcohol and Illicit Drugs in US Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement. The Journal of the American Medical Association, April 2012.
11. The National Center on Addiction and Substance Abuse. Addiction Risk Factors.
12. “Drugs, Brains and Behavior: The Science of Addiction.” National Institute on Drug Abuse, July 2014.
13. “Drugs, Brains and Behavior: The Science of Addiction.” National Institute on Drug Abuse, July 2014.

Renée’s story began as thousands of others have over the last decade. When her nephew Bobby was still in elementary school, long before he ever considered taking a drink or using a drug, decisions were made within the medical community that would profoundly impact his adolescence.

In 1995 the American Pain Society identified the negative impact of poorly managed pain on the overall health of our nation. Five years later, when Bobby was ten years old, the Joint Commission on Health Organization Accreditation added pain as the fifth vital sign. This meant that in addition to taking a patient’s temperature, pulse, blood pressure, and breaths per minute during each visit, a patient was asked about pain. If pain was identified, physicians were instructed to reduce the pain level by the utilization of narcotic pain medications.

This decision, though well intended, may have opened the door for the opioid epidemic of the last decade. Within a short period of time, millions of patients were beginning to use opiate-based medications for even modest levels of dis- comfort.

Sadly, this decision convinced an entire generation of physicians and health-care professionals to overuse narcotics to cover up chronic pain rather than actually treat the pain itself. Not unlike Valium, which was never intended for prolonged use in its treatment of anxiety, narcotics, which are effective in acute pain management, became the medication of choice for chronic pain.

Studies have shown that while cumulative pain levels remained constant among Americans, prescriptions for pain medications more than quadrupled between 1999 and 2010. 7

By 2013, hydrocodone was the most commonly prescribed drug in the United States. 8

This well-meaning decision was an effort to help patients cope with all levels of pain, but it ended up challenging the most fundamental foundation of the Hippocratic Oath: do no harm.

Physicians began to view narcotic medications as safe and commonplace, becoming as comfortable with their use as if they were using aspirin, acetaminophen, or ibuprofen. Without addressing the historical hazards of addiction associated with these medications, young physicians continued to overestimate the effectiveness of narcotics for pain control and underestimate their risks. In their effort to help, driven by a policy they did not write, a public health crisis began brewing.

In a relatively short period of time, millions of patients in the United States were prescribed opioid therapy for chronic pain. In fact, 245 million prescriptions were filled for opioid pain relievers in the United States during 2014.9

This increase in opioid prescribing is also associated with increased opioid-related visits to the emergency department and deaths from drug overdose.10

An individual who is prescribed opioids for the treatment of pain is three times more likely to develop an opioid addiction than an individual without an opioid prescription. Furthermore, individuals prescribed low-dose or high-dose chronic opioid therapy are 15 or 122 times more likely, respectively, to develop opioid addiction.11

It is now estimated that approximately four out of ten patients on this medical regimen will abuse their medications.12

These policy changes led to increased use of Oxycodone, Percocet, and Vicodin, which created higher levels of addiction. Additional ramifications impacted an entire generation of emerging adults. It soon became clear that because their brains were still developing, they seemed more prone to dependency.

If their prescriptions for narcotics were interrupted for any reason, they were often driven to an even more powerful pain reliever—heroin.

Heroin use more than doubled among young adults ages 18–25 from 2002 to 2013. 13

Heroin use has increased across the United States among men and women, most age groups, and all income levels. Some of the greatest increases occurred in demographic groups with historically low rates of heroin use: women, the privately insured, and people with higher incomes. 14

Heroin overdose mortality has quadrupled.15

Bobby, like thousands of his generation, walked into the series of medical missteps which led to the heroin epidemic. There is any number of dazzling statistics that illustrate the impact that heroin and over-prescribed opioids have had on the emerging adult population. However, there are two statistics that scream louder than all the rest.

Accidents are the primary cause of death for individuals aged 18 to 25 years. Historically, car accidents have represented the bulk of these fatal accidents. However, in 2009, more young people between the ages of 18 and 25 died from drug overdoses than from car accidents.16

The United States represents 5 percent of the world’s population yet consumes 75 percent of the world’s prescription drugs. (In 2009 the United States consumed 99 percent of the world’s hydrocodone, 60 percent of the world’s hydromorphone, and 81 percent of the world’s oxycodone). 17

Every parent, physician, politician, health-care provider, and the concerned family member should take a deep breath and allow these statistics to propel them into action.

Tragically, young people are extremely capable of hiding their drug use until it truly spirals out of control. Even when their use becomes unmanageable, families often misunderstand what is going on or are paralyzed to act because of lack of information.

Even more destructive is the power of shame which may immobilize family members from intervening.

The shame and vulnerability research of Brené Brown, Ph.D., supports this. Dr. Brown says shame is the intensely painful feeling that we are unworthy of love and belonging. It is the internalized belief that “I am not good enough,” “I don’t measure up,” “I’m not as smart as I should be,” “I am not muscular enough,” and/or “I can never seem to make my parents happy or live up to their expectations.”

These voices of shame plague our young people and create an internal environment that makes it impossible for them to see their true value. Prescription opioids and particularly heroin can temporarily relieve the emotional agony experienced so often by our young people. The ultimate tragedy of heroin addiction is that it causes greater levels of shame, requiring more drug use each day just to keep going.

When families learn of a loved one with a heroin addiction, shame can bring about blindness. Just as the heroin addict temporarily relieves their own psychological pain with the drug, the family escapes their emotional pain by redefining the problem. Perhaps it is simply “hanging around the wrong crowd,” “partying too much,” or any number of other reasons. For almost any other illness—cancer, pneumonia, or depression—as soon as the family identifies the symptoms, they seek help from other family members or health-care professionals. Sadly, this is not so in the face of heroin addiction.

Addiction occupies space in the public mind as a failure of character rather than a medical affliction, a lack of willpower rather than a legitimate disease, a choice that’s made rather than an illness that strikes. On an individual level, shame drives addictive illness and interferes with a family’s ability to get help. On a much broader scale, the shame associated with heroin use carries such a powerful stigma that the culture itself interferes with family members supporting their loved one.

When family members see their loved one suffering, what can they do to stop the downward spiral of this insidious illness? The family must reach beyond the shame, talk to each other, and get help.

If you are concerned that your loved one is addicted to narcotic pain medication and/or heroin, search for the overdose reversal drug, naloxone (also known as Narcan), through your pharmacy or family physician. If naloxone is administered quickly, it can counter the overdose effects, usually within two minutes, allowing enough time for the EMS to arrive.

Once the individual has been stabilized, the first step is to get outside help. Treatment works, even though there may be a return of symptoms.

Finding a qualified professional to guide the family is of paramount importance. This is easier said than done and, like searching for the right doctor or therapist, a good fit is essential. During my time in this field, many families have asked me how best to find a professional with the necessary qualifications.

The chosen mental health professional must have specific training, certification, and licensure in substance abuse treatment. Academic degrees do not necessarily determine competency. I urge you to check on the qualifications in your state.

Professionals with degrees in Social Work, Counseling, Rehabilitation Counseling, and Psychology should have specialty training and/or certification in the area of substance abuse treatment. Many states now require the licensing of substance abuse professionals.

If you find a professional with the appropriate credentials, these are important issues to discuss:

The professional must believe addiction is an illness and use language to support this belief, the language of the medical community. Use of the correct language validates it is an illness and supports recovery while helping to reduce shame.

The professional must determine whether outpatient or inpatient (residential) services are required and should use American Society of Addiction Medicine Placement Criteria. A thorough assessment should determine the diagnosis and the diagnosis determines the appropriate level of treatment. Some addiction professionals are connected to different treatment centers, and they may use these. This is something families need to be aware of.

It is important that the professional utilizes drug testing. Drug testing is an important step of recovery for many reasons: it provides accountability, patients get positive reinforcement when they test negative, and it’s helpful to have a track record for future employment. If professionals do not regularly drug test their patients as a part of treatment, proceed with caution.

The professional must have a working knowledge of Alcoholics Anonymous, Ala-non, and Narcotics Anonymous.

The professional must view recovery holistically, and encourage the use of other recovery aids such as psychotherapy and the integration of self-help groups (AA, NA, or others). It is important that they have familiarity with any AA and NA young people’s meetings in their area.

Determine how the provider or treatment team will respond to a relapse. This should be addressed at the beginning of treatment. Family members need to know that it is not expected and, if it occurs, they should be included. Having a signed release of information makes it possible for the supportive family members to work with the therapist to stabilize the patient before the relapse gains increased energy.

Ask about interventions: the professional should not have a “confrontational and shame-based approach” to dealing with the addicted. The addicted young person is filled with self-loathing and is aware of the pain he has caused the family. It is important to maintain a loving approach to the discussion of treatment with clear and reasonable expectations. A family meeting with the patient should not be a surprise attack.

Finding an addiction specialist who fits your needs is a necessity, but there are also many other ways in which friends and family can support a loved one who may be struggling from an addiction.

Many of these steps support work they are doing with the addiction specialist.

Create a low-stress alcohol-and-drug-free environment.

Establish realistic expectations, especially related to alcohol and drug use.

Reinforce small steps toward improvement.

Be informed about the effective use of medication in recovery.

Work with the professional(s); work as a recovery team.

Abstinence with twelve-step involvement

Establishing positive rewards and negative consequences

Frequent drug testing to reinforce success

The use of recovery mentors and/or coaches, positive role models

Management of relapse, when or if it occurs

Modified lifestyle to include a good sleep-wake cycle, healthy eating, exercise, and mindfulness

Active and sustained monitoring for at least one year

In the face of addiction, it is important to ask for help and to use all the resources available. I recommend the following:

It Takes A Family: A Cooperative Approach to Lasting Sobriety, by Debra Jay.

“Dying to be Free,” Huffington Post: http://projects. huffingtonpost.com/dying-to-be-free-heroin-treatment National Institute on Drug Abuse, The Science of Drug Abuse and Addiction: https://www.drugabuse.gov/ publications/media-guide/science-drug-abuse-addiction- basics

Becky Georgi, MS, LPC, LCAS, CCS, has invested over twenty-five years working with adolescents, young adults, and their families through substance abuse education, prevention, and treatment. She holds licenses as a clinical addiction specialist, a certified clinical supervisor, and a licensed professional counselor. Recently, Becky and her husband, Jeff, cofounded Bluefield: A University Recovery Community in Durham, North Carolina, to serve students and their families who are committed to a path of recovery, self-discovery, and academic excellence after returning to university after substance abuse treatment. She is currently the director and owner of Georgi Educational & Counseling Services (GECS), providing substance abuse training and consultation for a statewide project in South Carolina, and is an adjunct associate in the Department of Psychiatry and Behavioral Sciences, Division on Addiction Research and Translation at Duke University Medical Center. She earned her BS and MS from Indiana University and completed a postgraduate certificate program in Family Therapy in South Bend, Indiana, through the Menniger Foundation.

Works Cited

Beaudoin, Francesca L., et al. “Prescription Opioid Misuse among ED Patients Discharged with Opioids.” American Journal of Emergency Medicine 32.6 (2014): 580–585.

Centers for Disease Control and Prevention (CDC). “Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999–2008.” Morbidity and Mortality Weekly Report (MMWR) 60.43 (2011): 1487.

Centers for Disease Control and Prevention. “Vital Signs: Today’s Heroin Epidemic—More People at Risk, Multiple Drugs Abused.” Centers for Disease Control and Prevention (2015).

Compton, Wilson M., Christopher M. Jones, and Grant T. Bald- win. “Relationship between Nonmedical Prescription-Opioid Use and Heroin Use.” New England Journal of Medicine 2016.374 (2016): 154–163.

Dasgupta, Nabarun, et al. “Association between Non-Medical and Prescriptive Usage of Opioids.” Drug and Alcohol Dependence 82.2 (2006): 135–142.

Edlund, MJ, et al. “The Role of Prescription in Incident Opioid Abuse and Dependence among Individuals with Chronic Noncancer Pain: The Role of Opioid Prescription. Clinical Journal of Pain 30.7 (2014): 557–564.

Jones, Christopher M., et al. “Vital Signs: Demographic and Substance Use Trends among Heroin Users—United States, 2002– 2013.” Morbidity and Mortality Weekly Report (MMWR) 64.26 (2015): 719–725.

Jones, Christopher M. “The Latest Prescription Trends for Controlled Prescription Drugs.” National Institute on Drug Abuse, https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/cjonesnid a-bhccprescriptiontrendsslides.pdf. Accessed August 4, 2017. 348

SAVING BOBBY

Manchikanti, Laxmaiah, Bert Fellows, Hary Ailinani, and Vidyasagar Pampati. “Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten-Year Perspective.” Pain Physician 13 (2010): 401– 435.

Mathews, Anna W. and Melinda Beck. “Generic Vicodin Was a Top Medicare Drug in 2013, Data Shows.” Wall Street Journal, https://www.wsj.com/articles/generic-vicodin-was-a-top-medicar e-drug-in-2013-data-shows-1430 697811?mg=prod/accounts-wsj. Accessed August 4, 2017.

Paulozzi, Leonard J. “Prescription Drug Overdoses: A Review.” Journal of Safety Research 43.4 (2012): 283–289.

Rudd, Rose A., et al. “Increases in Drug and Opioid-Involved Overdose Deaths—United States, 2010–2015.” Morbidity and Mortality Weekly Report (MMWR) 65 (2016).

Wisniewski, Angela M., Christopher H. Purdy, and Richard D. Blondell. “The Epidemiologic Association between Opioid Pre- scribing, Non-medical Use, and Emergency Department Visits.” Journal of Addictive Diseases 27.1 (2008): 1–11.

7 See Center for Disease Control and Prevention, 2011. 8 See Mathews and Beck, 2015.
9 See Jones, 2015. 10 See Dasgupta et al., 2006; Wisniewski, 2008; and Center for Disease Control and Prevention, 2011. 11 See Edlund et al., 2014. 12 See Beaudoin et al., 2014. 13 See Jones et al., 2015. 14 See Center for Disease Control and Prevention, 2015; Rudd et al., 2014; and Compton et al., 2016. 15 See Rudd et al., 2014.
16 See Paulozzi et al., 2012. 17 See Manchikanti et al., 2010.