Hooked in Georgia

After reaching a crisis state, is there good news about opioid addiction?

Graham Skinner is a devoted husband and father of two with a successful career as a business development representative at Blue Ridge Mountain Recovery Center, a residential treatment center for drug addiction and alcoholism located in scenic Ball Ground, north of Atlanta. But just a decade ago, Skinner was hooked on heroin.

The drug addiction that consumed – and almost ended – Skinner’s life began somewhat innocently. Once an honor student and starting quarterback for Norcross High School, Skinner was prescribed hydrocodone and other opioid pain medications following injuries on the football field.

At first the drugs brought relief from the pain of a knee injury and concussions, but soon he was using them to ease other types of pain – including feelings of low self-esteem he found hard to shake despite his athleticism and academic success, and later, the sudden and unexpected death of his mother. “When I used the drugs I felt good. Everything seemed OK,” he says.

But things were not OK. Skinner became unable to function without the drugs. His craving for them was so strong that he was willing to pursue them at all costs – sometimes going to the emergency room pretending to have kidney stones and at one point even undergoing an unneeded appendectomy so he could receive the pain medications that would follow. When getting the pills became difficult and expensive, he turned to heroin, a cheaper, stronger and more deadly alternative that was readily available on the street.

His addiction robbed him of the comfortable middle-class life he had grown up with as well as his expectations of the future. He gave up a football scholarship at one college, knowing he would fail the drug test required to play, and flunked out at another; he had frequent run-ins with the law, spent several short stints in rehab and lost the respect of his friends and family as he manipulated and stole from them to support his habit.

But it was the prospect of a long-term incarceration – or death from an overdose – that eventually put an end to the drug use, says Skinner, who woke up in the bathtub of a Dunwoody hotel following a heroin overdose. “Overdosing was rock bottom for me – it really scared me really bad,” he says. “I was willing to do whatever I had to do to stay alive.”

Thanks to a father who had refused to support his son’s using lifestyle, yet was ready to get him help as soon as he was ready to receive it, Skinner was soon on his way to No Longer Bound, a faith-based residential addiction program for men in Cumming. At No Longer Bound, Skinner not only began his own recovery process, he also developed a passion for helping others who were going through what he had struggled with.

Crisis Costs

Skinner knows he was fortunate. Many others in his situation are not. In 2009, the year he entered treatment at No Longer Bound, more than 500 people in Georgia died from opioid overdoses, according to the National Institute on Drug Abuse. By 2017 that number had doubled – there were 1,014 overdose deaths involving opioids in Georgia, the institute reports. Georgia, along with the rest of America, was in a crisis.

While loss of life undoubtedly is the most tragic cost of the crisis, it is not the only one. In 2013, the economic burden of prescription opioid overdose, misuse and disorders in the U.S. was estimated at $78.5 billion, over a third of which was from increased healthcare and substance use treatment costs.

In Georgia alone, healthcare costs associated with opioid misuse were estimated at $447 million in 2007, according to a 2016 white paper released by the Substance Abuse Research Alliance (SARA). SARA is a program of the Georgia Prevention Project, a statewide nonprofit working to prevent and reduce drug use among teens and young adults. Given the increase in overdose deaths and misuse of opioids in Georgia over 11 years, some estimates indicate that healthcare costs associated with opioid misuse in Georgia have increased by 80 percent since 2007, SARA reported.

Why Opioids? Why Now?

Despite the widespread use of marijuana, benzodiazepines, amphetamines, methamphetamine, cocaine and various party drugs, an estimated two-thirds of drug-related deaths are due to opioids. Experts attribute this in large part to the highly addictive nature of the drugs and the ways people – who might otherwise be unlikely to seek recreational drugs – are first introduced to them.

Opioids are a class of medications that act on the nervous system to relieve pain and produce feelings of pleasure. Commonly prescribed opioids include oxycodone, hydrocodone, codeine and morphine. Like Skinner, many people get hooked on opioids after receiving a prescription from their doctor.

“We are doing a study of the people we treat, and most of them tell us that they got their first opioid dose from a physician or other prescriber when they had an injury or wisdom teeth taken out,” says Dr. J. Paul Seale, director of the Department of Family Medicine’s Addiction Medicine Fellowship at Navicent Health and Mercer University. “Those are appropriate uses, but they also introduced people to opioids, which 20 years ago wouldn’t have led down a pathway to addiction.”

The difference in the past two decades is the way in which the drugs have been prescribed. “Up until that time, opioids had been reserved for severe pain after an injury or surgery and also for the end-of-life, severe cancer pain,” says Seale, who is also a board-certified specialist in addiction medicine practicing at Family Health Center, Navicent Health in Macon. “Those were the two settings opioids were used a lot for. In this country, we had not used opioids for chronic non-malignant pain for fear of the risk of addiction.”

The crisis began in the 1990s as traditional prescribing patterns were changing. The introduction of a long-acting narcotic called OxyContin and the promotion of research findings suggesting the risk of addiction was low for most people prompted doctors to begin prescribing opioids longer term for problems like chronic back pain or arthritis.

The more the drugs were used, the more likely the people taking them were to get hooked. In a short amount of time, opioids start to change the chemistry of the brain leading to drug tolerance – which means that one needs to have an increased dose to achieve the same effect. If they use the drugs long enough, all people will develop opioid dependence, and stopping the drug will cause physical and psychological symptoms of withdrawal such as muscle cramping, diarrhea and anxiety.

Further, Seale says 8 percent to 12 percent of people who use them long-term for non-malignant pain will develop addiction, an urge so powerful that they will risk their jobs, their lives and their families to continue using. Addiction increases the risk of overdose, which occurs when high doses cause breathing to become too slow or stop, leading to unconsciousness and death.

“People who become addicted to prescription pain killers and cannot obtain their drugs legally have to get them off the black market through a dealer,” says Janet Cox, clinical/program director of Synapse in Atlanta, an intensive outpatient program that blends traditional evidence-based therapies with emerging neuroscientific technologies to treat substance abuse.

Many, like Skinner, turn to a cheaper and more deadly alternative – heroin. Indeed, a 2013 study found eight out of 10 heroin users reported using prescription opioids before beginning heroin.

“Many of my clients, when they get into heroin, go to what is called ‘The Bluff’ in [Atlanta] where they can buy it right on a street corner,” says Cox. “Their addiction puts them in a very dangerous place where they can be robbed or murdered as opposed to even the drug killing them.

“These are intelligent, kind, loving human beings this happens to,” Cox adds. “When people are addicted, they will engage in very negative behaviors despite the fact that is not their true value system.”

A New Look at Addiction

If there is a positive to the opioid crisis, it may be that it has increased the awareness of – and in some cases attitudes toward – addiction, says Aaron Johnson, director of the Institute of Public and Preventive Health at Augusta University, which has received federally funded grants for projects including training healthcare professionals to identify and address alcohol and drug use in their patients and efforts to identify and treat incarcerated individuals with a history of substance abuse before their release.

Rather than a problem of the rich or the poor, the urban or rural, young or old, opioid addiction affects people of all ages and from all walks of life, including mothers and fathers, teenagers from affluent suburbs, executives in corner offices and even the elderly, as doctors have prescribed drugs to relieve pain that once was accepted as a consequence of old age.

“I think the opioid crisis in a lot of ways has moved the [addiction] field forward because there is more of a recognition that substance use disorders are a disease – a chronic disease – and need to be treated as a chronic disease,” says Johnson.

“Addiction is a disease of the brain,” says Cox. “Treatment should be targeted at improving the health of the brain – which for many people is a new concept.

“If you had a heart condition and went to a cardiologist, you would expect him to do something more than sit and talk with you about it, yet treatment for addiction has traditionally focused almost entirely on talk therapy and counseling,” she says.

While counseling – both one-on-one and in groups – is still a crucial part of treatment, Synapse also offers services such as nutritional counseling, neurocognitive testing, a computer lab for cognitive rehabilitation and problem-solving therapy. Like most other programs it includes medication-assisted treatment (MAT), which for opioid addiction is typically buprenorphine.

Medication treatment for opioid addiction once meant methadone. A long-acting opioid that blocks the effects of other opioids and doesn’t create a high, methadone is offered only through federally regulated centers.

“We have found that if you offer people a comprehensive treatment program with methadone and other support services, about half will stop using other opioids,” says Seale.

The U.S. Food and Drug Administration (FDA) approved buprenorphine, another opioid, for opioid addiction in 2002. It has been found to be safer and more effective than methadone. Usually taken under the tongue on a daily basis, buprenorphine blocks the effects of and cravings for opioids. Rather than being restricted to limited centers, buprenorphine is available from primary care physicians and, since 2017, nurse practitioners and physician assistants who have become licensed providers.

In 2018, the FDA approved a combination of buprenorphine and naloxone, a drug that can reverse an opioid overdose if caught early enough. Naloxone nasal spray is now available in many Georgia pharmacies without a prescription, and a number of different programs have begun making free naloxone kits available to high schools and universities and through public libraries, YMCAs and community events.

Peale recommends keeping the drug on hand if you live with a known opioid abuser.

Signs of Hope

New attitudes toward addiction and the increased availability of buprenorphine and naloxone are just a couple of advances that promise to make a difference in the crisis. Others include the development of provider guidelines by the Centers for Disease Control and Prevention (CDC); enhancement of the Prescription Drug Monitoring Program, which requires doctors and pharmacists to enter opioid prescriptions into a centralized database to deter people from getting opioid prescriptions from more than one source; improved educational efforts targeted at teens, healthcare providers and patients; and passage of the Comprehensive Addiction and Recovery Act (CARA), the first major federal addiction act in 40 years that authorizes more than $181 million in federal funds each year for opioid prevention and treatment programs.

There are already some signs the situation is improving. Although the latest statistics for overdose deaths are from 2017, statistics for emergency room visits related to drug overdoses – which are maintained and updated monthly by the Georgia Department of Public Health – show a downward trend. ER visits for drug overdoses are down 8 percent since this time last year.

“Overall we are in much better shape than we were two or three years ago,” says Jim Langford, chair of SARA and executive director of the Georgia Prevention Project. “Georgia has made great strides in the past two years in addressing the epidemic.”

In 2016, the group produced a white paper outlining two overarching recommendations and 10 legislative recommendations for Georgia to implement. A report card issued by SARA early this year shows great progress in key issues – the most comprehensive of which was the need for the Georgia Department of Public Health to begin and implement a strategic plan to guide the state’s response to the epidemic.

“And they have done that,” says Langford. “There have been several hundred people involved. We have six or seven committees that have had lots and lots of people involved, and they are coming along quite well.

“Some of the key recommendations we have done really well on,” he says. “The Georgia legislature has done some things and so has the Georgia Department of Public Health. A lot of different parties are parts of the puzzle, and it requires leadership from the governor’s office and lieutenant governor’s office to move these things along.”

Most of the efforts taking place in the state are being funded federally, with funds coming not only from the Department of Health and Human Services and the CDC, but also from some unlikely sources, including the U.S. Department of Agriculture and the National Library of Medicine.

Like the opioid epidemic and its victims, the efforts to stop it must be diverse.

“I do a lot of lectures. I tell people there is not one thing that is going to fix this, there is not one magic silver bullet,” says Langford. “I heard one guy say there’s not a silver bullet, there’s silver buckshot – it’s going to require work in a lot of different areas: Working with schools is important. Working with treatment and recovery is important. People will have to have a place for affordable treatment. You have to have a good warm line [an addiction crisis support line staffed by people who have been through similar issues] to help people who want help. You’ve got to train emergency room departments so they know how to handle an overdose. You have to train law enforcement so if they find someone has had an overdose, they know what to do.”

But overall, he says, the message is hopeful. “It took us 20 years to get into this mess, and it is going to take us time to get out. But we’re on our way.”