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Guest Perspectives by Gabriel Nathan
These guest perspectives of Gabriel Nathan are part of a series of occasional essays on issues related to opioid use, stress, veterans issues and suicide
Droning On and On: The Price of Detached Warfare
In Terry Gilliam’s epic fantasy (and epic box-office failure) “The Adventures of Baron Munchausen” (1988), Vulcan, God of the Underworld, explains the alleged “virtues” of non-combat, long-distance warfare to the Baron, his eight-year-old compatriot, Sally Salt, and the Baron’s long-time, long-suffering friend/servant, Berthold. The dialogue appears in its entirety, thanks to IMDB’s movie quote section here:
Baron Munchausen: What's this?
Vulcan: Oh, this is our prototype. RX, uh, Intercontinental, radar-sneaky, multi-warheaded nuclear missile.
Baron Munchausen: Ah! What does it do?
Vulcan: Do? Kills the enemy.
Baron Munchausen: All the enemy?
Vulcan: Aye, all of them. All their wives, and all their children, and all their sheep, and all their cattle, and all their cats and dogs. All of them. All of them gone for good.
Sally: That's horrible.
Vulcan: Ahh. Well, you see, the advantage is you don't have to see one single one of them die. You just sit comfortably thousands of miles away from the battlefield and simply press the button.
Berthold: Well, where's the fun in that?
This film was written and shot long before drones were first ever used in modern warfare—the first instance, apparently, was during the invasion of Afghanistan in 2001, CIA devices carrying antitank missiles, but the writers of the film— Gilliam himself and actor/writer Charles McKeon—couldn’t have been more sardonically prescient about attitudes towards this type of warfare, which would, on its face, depersonalize combat by making the pursuit and elimination of an enemy as clean and antiseptic as possible. Regrettably, as with most things, the reality of drone warfare-from-afar turned out to be anything but surgically sterile.
In a recent feature piece in The New York Times, investigative journalist Dave Philipps examines the case of Air Force Captain Kevin Larson who flew 650 combat missions in just five years and was the recipient of twenty medals for outstanding service and accomplishments—most of them, of course, secret only to himself and his superiors. In 2020, he ended his life in the woods, with his own assault rifle as, appallingly ironically, drones buzzed overhead looking for him. He was fleeing what he believed to be a lengthy prison term for using psilocybin mushrooms to help himself cope with the myriad PTSD-like symptoms he was experiencing, and the ensuing unraveling of his marriage and his life. What he couldn’t have known was that the Air Force had just decided to dismiss him, not send him to prison. It didn’t matter. He’d already shot himself.
There are many pervasive myths surrounding mental health, trauma, PTSD, suicide, and the armed forces. In a previous Perspective, I wrote about how the suicide rates are actually higher for non-combat veterans than they are for combat veterans, and some reasons why that might be. We might think that doing search and rescue is “easier” than engaging hostiles or scouring unfamiliar landscapes for IEDs, just as we might think of drone warfare in the same manner as Oliver Reed’s character, Vulcan, breezily described it in “The Adventures of Baron Munchausen” but the fact remains that war is war, and there is no such thing as a “surgical strike”, there is no such thing as a total absence of collateral damage. The collateral damage is sitting in a chair staring into a monitor; unable to speak about what s/he does, unable to articulate what it feels like to relentlessly stalk another human being from thousands of miles away, watch them be affectionate with their wife and children and pets, and then blast the shit out of them one day when someone says, “Go.”
There is no such thing as “easy work” when it comes to ending the life of another human being. And there will always be a price to pay; whether the other person’s blood gets in your mouth or not.
Outcomes like what happened to Captain Larson can be avoided; through total civilian and uniformed embracing of non-traditional treatments for PTSD and trauma like psychedelics and MDMA, through radical and total de-stigmatization of help-seeking behaviors; whether you’re flying drone missions or cleaning toilets, and through the elimination of the pissing contest that exists in various strata of the armed forces—mine’s bigger than yours, my load is heavier, my mission is more substantive, my pain is greater.
Pain is pain, and war is war. Plain and simple.
GUNS GUNS GUNS GUNS GUNS GUNS SUICIDE GUNS GUNS GUNS
Chances are, you’re not going to like this article.
Read it anyway. Maybe it’ll save your life.
As of January, 2022, it is estimated that there are over 400 million guns in America; 393 million of those (that’s 98%, for you math geeks) are in the hands of civilians. The average gun-owning American is estimated to own five guns.
However you feel about guns, I think you’ll at least agree with me that that’s a lot of guns in America.
Americans love guns and cars. This particular American doesn’t love guns; but he does love cars, so I was curious, when writing this article, about how many vehicles there are in America. There are approximately 276 million vehicles (that’s cars, trucks, buses, motorcycles, and other motorized things) on the streets, driveways, yards, showrooms, lots, and tucked away safe in the garages of America. (That’s 124 million more guns than vehicles. Again, simple math.)
There are lots of suicide prevention and awareness advocates who stay peculiarly silent on the topic of firearm suicide, and I know some of the reasons why and, because I’m smart and cute, I’ll happily speculate about some more unstated reasons why.
• Ignorance of 2A cultures and communities
• Inexperience with firearms, firing ranges, terminology
• Fear of “politicizing” suicide prevention/awareness
• Not wanting to appear divisive or confrontational
• Fear being shamed, embarrassed, or dismissed by those with more experience and knowledge
• Perceived or real inability to gain trust of key stakeholders in the firearms milieu
• Fear of open hostility the moment firearms are even brought up to someone who owns a gun(s)
Fortunately, I don’t give a shit about any of those things. I will not broadcast what experience I may or may not have had with firearms to induce buy-in, or give myself some kind of imaginary and meaningless cred among members of the 2A community just so that I have permission to talk about saving lives. If you want to write me off, that’s your decision, but I didn’t spend time and effort writing this article for my health and wellbeing; I wrote it for yours. So let’s talk turkey:
Guns are designed to kill. Who? Well, statistically; yourself.
In America, homicide is the 16th leading cause of death—suicide is the 10th. 3 out of every 5 American firearm deaths are suicides. So, statistically, if you own a firearm, you’re far more likely to use it on yourself than you are on some poor bastard breaking into your house at night who probably isn’t armed and probably isn’t intent on killing you anyway; he most likely just wants to rifle through your shit for enough money to buy some meth or whatever he’s hooked on.
We know that firearms are the most lethal means. If you try to kill yourself with any method other than a firearm, chances are, you’re going to fail. And we know that most people who survive a suicide attempt and receive prompt and comprehensive treatment don’t try again. With a firearm, however, you don’t get that chance, because your odds of dying during a suicide attempt skyrocket: 9 times out of 10, you’re going to die. Firearms are used in half of all deaths by suicide.
Still with me? Good; there’s more.
Simply having a firearm in your home triples your risk for taking your own life. If you don’t care much about that, maybe you’ll pay attention when I tell you that the same elevated risk of dying by suicide applies to everyone else in your household: that’s right—your domestic partner, your children, the elderly relative for whom you’re caring.
If you think I’m “one of those people” who thinks the 2nd Amendment made sense in 1789 but is thoroughly psychotic in 2022; you’re right. I am. I think that, if the founding fathers were resurrected today and saw what firepower looked like today, if they were shown security footage of Newtown, Parkland, Columbine, the Pulse Nightclub, the Route 91 Harvest Avenue Music Fest, Virginia Tech, Fort Hood, the El Paso Walmart, Washington Navy Yard, Aurora Movie Theatre (getting bored yet?) I think they would throw up all over their silk waistcoats and never stop. However, I know and understand that abolishment of the 2nd Amendment is a non-starter and would result in even more bloodshed from gunfire than there already is in this country already, so I guess we’re left with harm reduction, as far as suicide prevention goes.
So. What can we ‘Mericans do?
Well—here’s what we know: we know that anyone can be at risk for taking their own life. Anyone. Active military, decommissioned, honorably discharged, under-honorable, dishonorable, addicted, in recovery, clean/straight-edge, LGBTQIA+, BIPOC, Caucasian, and on and on and on—living in a mansion, living in a box or a 1984 Chevy Chevette (see? I told you I like cars); it doesn’t matter. We know that risk goes up if you own a firearm, so measures can be taken to mitigate that risk:
• Have a safety plan.
When we’re talking about suicide prevention, a safety plan is essential, because you may already be living with depression or some other kind of mental health condition or some other factors that may make you at higher risk for taking your own life, and you can be therefore aware of that risk and take steps to mitigate while you’re feeling good. That’s when you make the plan; not when you’re feeling bad or heading towards or already in crisis.
A safety plan can be proactively telling loved ones (with whom you live or not) and/or friends or colleagues what some of your warning signs are when you’re just starting to backslide. Maybe you will stop answering texts right away, or responses will get curt or you’ll be evasive. Maybe you’ll stop eating lunch in the breakroom with everyone else and revert back to eating alone in your car. Maybe you’ll stop going to church—or start going a lot. Tell people these things that way, if they notice them, they can take some appropriate action and maybe intervene. Give friends and family members area hotlines, warm lines, mobile crisis numbers in case you don’t feel like reaching out yourself. Part of your safety plan might involve someone asking if they can come over to check on you and maybe call a warmline together.
A safety plan might also involve having a trusted friend or relative take temporary custody of any and all firearms you have in your home until you are feeling more stable. Have a pre-discussed arrangement about how the transfer will work and how getting them back will work so there is mutual clarity and understanding. It’s a big responsibility, but people who love you will do it. Likewise, there are sheriff’s departments/law enforcement agencies, and some participating gun shops and firing ranges that partner with initiatives like Hold My Guns to provide a liberty-based temporary storage option for firearm owners who are experiencing distress.
• Understand suicide risk
This is vital, and I believe strongly and passionately that the, “hey, not ME!” approach to firearm suicide is perhaps the most deadly preconceived notion perpetuated by gun owners. Nobody thinks anything can be them, until it is. No firearm owner could ever possibly conceive that they would shoot someone out of “road rage,” but it happens. Wasn’t the perpetrator of that violence a “responsible gun owner” before that happened? Didn’t they have a permit to carry? Didn’t they take the NRA-sponsored training? Didn’t they know how to disassemble, clean, and reassemble their firearm in the dark? It doesn’t matter; because things happen. We’re human beings. And one of the things that can happen—to anybody—is suicide.
There is a fundamental problem in the realm of suicide, and it’s #notme. That won’t be me. No way. I’m good. Well, that’s great that you somehow have the ability to look into a crystal ball and know for certain that you’re never going shoot yourself to death, and it’s so great that you’re “good.” But being “good” isn’t a static thing. It isn’t permanent. You know why? Because life happens. People get cheated on. People get fired. People get publically shamed and cancelled. People get investigated. People get assaulted and raped and traumatized. People get addicted. People get exposed and humiliated. People get divorced and lose custody of their children. People get cars and houses repossessed. If you think that suicide only happens to people with mental illnesses, think again. Life has the unique ability to smack the shit out of all of us, so if you think that you’re somehow immune to all that, and the five guns (on average) you own pose no risk to you or your family throughout the course of human life; sorry. You’re dreaming. And you don’t understand suicide.
• Store it safe
Like everything to do with firearms, safe storage, though it is evidence-based and is proven to reduce suicide risk among firearm owners and their families, is controversial. Like all of the above, I clearly don’t care. I have been advocating for safe storage (locking up your firearms, unloaded, and locking up your ammunition, separately) for years, and I’m not going to stop because I know it makes sense. I know it slows down someone who is experiencing suicidal thoughts. I know it gives more time for that person to stop and think about what they are doing, because they have to go through multiple steps to make a non-lethal thing lethal, and that time that it buys may actually be lifesaving. “But I need it locked-and-loaded in case some armed thug comes busting into my house in the middle of the night.”
In 2020, there were 33,296 armed robberies in America. In that same year, there were 45,979 recorded suicides. We know what’s on the news more often; but which is actually the bigger problem? Which should you… fear more? And which should you take active, logical, lifesaving steps to prevent?
You’ve got a Ring, deadbolts on your doors, locks on your windows, motion-sensor floodlights, your crazy ass dog running around, and that fancy alarm system all to guard against robberies.
What are you doing to guard against suicide? Please leave your thoughts and contacts about this article in the form below. You're also invited to email me directly at email@example.com
SUICIDE RISK IN THE DEPLOYED/NON-DEPLOYED VETERAN POPULATION
There is a common misconception, at least among laypersons, that Veterans who have “seen the shit” (i.e., have been deployed and engaged in overseas combat) are more likely to experience PTSD and are, therefore, at a higher risk for suicide. Unfortunately, the facts do not bear out this assumption, and it is an assumption that has deadly consequences.
According to the VA, the suicide rate among deployed Veterans, as compared to the general U. S. population, is 41% higher. For non-deployed Veterans, it’s 61% higher. That’s a figure that should give all of us—uniformed and civilian alike—pause.
The VA report does not speculate (because speculation, at least in official documents, isn’t very “gub’mint”) on possible causes for WHY the suicide rate for non-deployed Veterans might be higher. Still, I’m happy to speculate because I ain’t gub’mint and most likely never will be:
From my experience, I believe that suicide can result from becoming hopelessly suffocated by the three S’s: stigma, secrecy, and shame. I believe that many non-combat Veterans struggle with a.) the stigma of knowing that, even though they weren’t deployed, they are suffering from PTSD and perhaps other mental health challenges (some may have very well pre-existed their armed service) and the shame they feel because, hey, I didn’t get my buddy’s brains splattered all over me in Iraq or Afghanistan—what right do I have to be fucked up and need help? And so they resort to secrecy—if I say nothing, if I tell no one, then I won’t have to confront those other two S’s. As a result, they effectively go underground with their pain: eschew well-intentioned offers of support and help, begin withdrawing and isolating, perhaps resort to maladaptive coping mechanisms like alcohol and, or drugs, but the unaddressed issues and the pain only get louder and, all the while, there are firearms in the house. And so, what may once have been manageable is now a powder-keg.
The fact of the matter is: non-deployed Veterans have just as much of a “right” to experience mental health challenges as they have a “right” to access the mental health services needed to help them overcome those challenges. This isn’t the Suffering Olympics: oh, well, this guy over here did three tours, so he has it much worse than me! No. Fuck that. A police officer might very well have PTSD due to trauma experienced in the line of duty. Still, law enforcement culture (and indeed pop-culture) tirelessly assumes that, unless you’ve pulled a dead baby out of a pool or witnessed your partner get shot, you’re fine. Get back to work.
Well, that’s bullshit, and we know better. There is no shame in seeking help for PTSD, or any other mental health challenge, whether you’re deployed or not. And another thing; the suicide rate for Veterans is at its highest three years after leaving service—for deployed and non-deployed service members, so keep that in mind when thinking about your buddies and yourself.
Perspective #29: 100 Million Ways Expands its Mission!
100 Million Ways (100MW) has expanded its mission: “To support scientific data collection to determine the impact cannabinoids have on opioid use and PTSD, and the associated anxiety, depression, and decreased quality of life and to provide an online community to support people with these life challenges who are interested in cannabinoids as a wellness treatment option.”
100MW is excited to announce a collaborationthat it will partner with the Weed For Warriors Project (WF4WP) to bring the 100MW "Odyssey Registry" to this larger membership and provide additional mental health services and a mentor training certification program to those living with PTSD and chronic pain.
Question: Can cannabinoids be an adjunct to psychological counseling to better treat PTSD? Does participation in a web community bring value to veterans with PTSD?
About two million Americans live with opioid use disorder (OUD); 62% of them also have a mental illness. US veterans of Iraq and Afghanistan with a mental health diagnosis, especially PTSD, have an increased risk of receiving opioids for pain and are at high-risk for OUD and adverse clinical outcomes. In partnership with WF4WP, 100MW will be examining the impact cannabinoids have on opioid use and determine if cannabinoids help people with PTSD deal better with anxiety and depression.
Together they will be creating a web community that is inclusive for people beyond opioid users, incorporating the needs, services, and resources for veterans who have PTSD.
While there is overlap in the life challenges faced by opioid users and those who have PTSD, there are also specific needs, services, and resources for each group. The 100MW’s home page will welcome veterans as well as opioid users. The Blogs and Perspectives web sections will be expanded to include expert writers to address weekly items and issues that veterans deal with. The Resources and Information sections will have sub-headers for veterans and the web news section will address news items for veterans. Discussion threads and "Sagas" will incorporate items and issues for veterans as well.
In addition, the aforementioned Odyssey Registry, a web-based data collection platform, is an anonymous, secure data collection module that may help users understand their level of anxiety, depression, and quality of life and enable them to monitor how those measurements change over time.
The Odyssey Registry has been modified to be more inclusive with specific attention to PTSD. In addition, the web-based registry provides two options forto those interested in participating: 1) a full registry, which explores the impact of opioids on people using opioids and their families and friends, and 2) a shorter version for quality of life management. Finally, both registries will provide feedback to participants about how they are doing compared to their previous data and compared to the registry population at large.
Perspective #28: Paying People To Stay Sober—A Revolution in Care or a Risky Incentive.
California is About to Find Out
In an effort to fight the state’s rampant drug overdoses, California lawmakers want to pay those individuals with addictions to stay sober.
Governor Gavin Newsom has requested permission from the federal government to use tax money via Medicaid to pay people with addictions to stay sober, according to The Associated Press (AP). Legislation, currently working it’s way through California’s legislature has already passed the State Senate, will pay those living with drug dependence or addiction to stay sober using a program called “contingency management.” It’s a fairly straightforward program that pays people living with drug use disorders money for each drug test they pass over a period of time. Once you complete treatment with zero tests coming back showing that you used drugs, you can earn up to a few hundred dollars through a gift card, according to AP.
While the idea seems radical, it has already been employed by the federal government in an effort to address drug abuse amongst veterans. In addition, similar programs have been used in states including New York, Virginia and Georgia, where drug courts require individuals in inpatient rehabilitation programs to volunteer for 24-hour community work for which they get paid. In Seminole County, Florida, the sheriff was able to cut the jail population by half by paying for defendants to stay sober and get treatment. Ohio, California, and Texas all have payment programs for sobriety as well. The North Carolina Harm Reduction Coalition plans to offer individuals living with addiction money for a year of sobriety. The idea is catching on among some drug treatment specialists as well because research is showing it to be incredibly effective at treating substance use disorders.
One example of the effectiveness of these programs comes from Tyrone Clifford. He took part in a similar program from the San Francisco AIDS foundation, a nonprofit providing a contingency management program for people living with substance use disorders in the San Francisco Bay Area.
Clifford told AP that he was paid $2 for his first negative drug test, which increased with each negative drug test thereafter. After 12 weeks, he had earned about $330 from the program.
“I thought, I can do 12 weeks. I’ve done that before when my dealer was in jail,” Clifford told AP. “When I’m done I’ll have 330 bucks to get high with.” But, instead of using his money for drugs, he used it to purchase a laptop to help him go back to school. He says he’s been sober since the program ended and hasn’t used drugs in 11 years.
Contingency programs are a great example of how a seemingly radical program can have an outsized impact on individuals and communities that need it the most. If it goes well for California, we might see more state-mandated contingency management programs in the future.
READ MORE: California looking to pay drug addicts to stay sober [AP]
Perspective #27: Cannabis and Cannabinoids for Pain Relief - Overcoming Its Limitations and Optimizing for Relief
In our last perspective, we discussed cannabis and cannabinoids for pain management and disease prevention. This perspective takes a different approach, addressing how to overcome limitations of cannabis to obtain pain relief.
Cannabis has been used since antiquity for recreational and medical purposes. Current medical usage is most commonly for pain, although it is also used for anorexia, nausea, glaucoma, and seizures. In 1996, California’s Compassionate Use Act was the first state law legalizing its use, primarily as another option for analgesia and antiemesis for patients with AIDS. Since then, other states have passed laws authorizing cannabis use for varied indications, including pain. With negative consequences of excessive opioid prescribing creating a crisis in America, it is helpful to examine whether cannabis can provide a complementary alternative or adjunct to opioids or other available analgesics.
Pain can arise from various causes; sometimes, the pain has obvious sources, for example, postsurgical or cancer-related pain. Other times, pain can have less obvious causes, such as chronic back pain, pain caused by fibromyalgia, or neuropathic pain. Generally, pain is conceptualized as “nociceptive,” a signal from the body to the brain signaling impending or actual injury, or “neuropathic,” meaning that the nervous system is itself the source of pain. However, these two categories are not exclusive and may also include pain related to inflammation which is a natural response by the immune system to an injury to the body or damage to the nervous system itself.
As is often the case for new treatment options like cannabis, with limited data characterizing effectiveness or optimal use, passionate opinions based on personal experiences and observations dominate discussions of the merits, limits, and potential adverse effects. At the same time, a growing body of evidence may support the use of cannabis as a complementary or alternative to opioids or other pain relievers. The fact that cannabis has developed a cult following, with certain groups integrating it fully into their daily wellness or religious practices, reflects these passions. Similarly, enthusiasts claim that because cannabis is “natural,” it is perfectly safe without any risks. The fact that cannabis is generally considered non-toxic and won’t kill or cause permanent injury to the body supports this perception, even though it doesn’t tell the whole story about the overall potential benefits and risks. Thus, while it’s important not to be unfairly critical of cannabis for pain relief, it’s also important not to be so uncritical as to ignore its risks, limitations, and potential ways in which its benefits may be improved, and risk minimized.
Overcoming unreasonable skepticism and uncritical optimism among both users and empirical investigators alike has slowed the rigorous evaluation of its risks and benefits, contributing to cannabis’s failure to become an approved medicine that can be prescribed by doctors, dispensed by pharmacists, and paid for by insurance companies.
Smoking cannabis, particularly cannabis that is high in Δ9-tetrahydrocannabinol or THC, is associated with health risks including lung disease, cardiovascular disease, acute pancreatitis, and cannabinoid hyperemesis syndrome. Cannabis users are also at increased risk for occupational injuries and can contribute to impaired driving. In addition, cannabis use during pregnancy may be associated with increased neonatal morbidity or death. And finally, the myth that marijuana is not habit-forming has been dispelled by studies showing that forced abstinence of use can result in rebound hyperalgesia and craving, which may be evidence of its effectiveness or the risk of developing cannabis use disorder. Regardless, a better understanding of how to use cannabis to best provide relief while minimizing the risk of harm is essential for advancing its safe and effective use as a medicine. As cannabis prohibition comes to an end, our ability to gather more valuable data about its benefits and risks for individuals will allow us to scrutinize better what makes it an effective medicine and how to best mitigate its known and potential risks.
The first thing we notice when evaluating the risks of cannabis is that much of the severe risks are most associated with the use of higher-THC cannabis. Organ-specific toxicity, cognitive risks, the diminution of gray matter in the brain in chronic cannabis users have long been recognized empirically, showing that potential adverse effects following months to years of use include, but are not limited to—executive functioning, information retrieval, learning, abstraction, motor skills, and verbal abilities. And that these adverse effects are more profound with the use of higher-THC cannabis. Such deficits are most significant when cannabis is used by younger persons, as the brain is thought to develop into the mid-20s. Additionally, psychopathological consequences of cannabis use can include psychosis, schizophrenia, worsened social functioning in schizophrenia, bipolar disorder, depression, and anxiety. Again these effects are more likely with the use of higher-THC cannabis.
Objective data on the efficacy of high-THC cannabis for pain management is mixed. In some studies, Cannabis is shown to help relieve neuropathic pain, with pain relief being generally contingent on the amount of THC. Unfortunately, higher-THC cannabis, similar to opioids, also produces more cognitive side effects, raising the risk of impairment and other adverse mental effects. In addition, evidence of efficacy for other conditions, including fibromyalgia, headaches, and rheumatoid illnesses, is less compelling than that for neuropathic pain. Even cannabis’ efficacy for cancer pain has been questioned. A recent review notes that while cannabis may have potential use in treating cancer pain, those existing human studies are of poor quality, limited size, and outdated (5).
Still, other studies suggesting the use of cannabis as a complementary pain reliever when combined with opioids indicate that cannabis may help reduce the number of opioids needed to manage pain, enhancing the therapeutic potential of both products while potentially reducing the risks associated with them (6). Unfortunately, it remains challenging to conduct clinically relevant medical cannabis research in the United States because of the drug’s Schedule I status and the requirement that all cannabis be obtained from a single farm at the University of Mississippi. Furthermore, research involving a cannabinoid drug product called Sativex, which contains equal amounts of THC and cannabidiol (CBD), found it effective for treating cancer-related pain, suggesting that our narrow notion of cannabis as medicine may limit our understanding of its potential.
Cannabidiol is a non-intoxicating cannabinoid with a good safety profile (NIDA Director Nora Volkow, MD, has asserted that CBD appears to be a “safe” drug). In addition, it has analgesic, anti-inflammatory, and neuroprotective effects, which may be helpful for pain management. Additionally, CBD modulates the intoxicating effects produced by THC and provides mild relief from anxiety possibly related to stress and inflammation. However, data suggests that over time as the amount of THC in cannabis sold commercially has increased, the amount of CBD has decreased (10), suggesting the possibility that cannabis has become more intoxicating but less therapeutic due to higher amounts of THC being more associated with potentially undesirable adverse effects. More recently, efforts to find cannabis containing lower concentrations of THC and higher levels of CBD have led to the development of high-CBD cannabis cultivars, which are commonly grown as hemp having fewer side effects and greater health benefits for those seeking pain relief without the acute intoxicating effects of too much THC.
A broad range of products containing therapeutically beneficial amounts of cannabinoids, including THC and CBD, ensuring a uniform, well-characterized supply of cannabis is crucial for overcoming these challenges and improving the quality of data providing patients with an effective alternative or adjunct to opioids and other pain relievers. Another fundamental challenge is identifying biomarkers that are consistently correlated with the in vivo effects of cannabis for pain relief because cannabinoids are fat-soluble. And because cannabinoid metabolism and utilization vary between individuals; blood levels are not directly correlated with their effects. This makes it challenging to optimize dose-response and minimize adverse side effects.
In summary, while the safety profile of cannabis shows it to be non-toxic, it is not without risks or adverse side effects. Furthermore, there is a lack of controlled clinical research to establish scientific credibility for its effectiveness – with an equal lack of scientific evidence showing limited effectiveness, likely related to the general absence of CBD. This suggests that while cannabis will continue to be used medicinally in a less rigorously controlled fashion, controlled clinical trials need to be done to understand its optimal use in the role cannabis can play in pain management.
1. Zhang, M. W., & Ho, R. (2015). The cannabis dilemma: a review of its associated risks and clinical efficacy. Journal of Addiction, 2015.
2. Metz, T. D., Allshouse, A. A., Hogue, C. J., Goldenberg, R. L., Dudley, D. J., Varner, M. W., ... & Silver, R. M. (2017). Maternal marijuana use, adverse pregnancy outcomes, and neonatal morbidity. American journal of obstetrics and gynecology, 217(4), 478-e1.
3. Nader, D. A., & Sanchez, Z. M. (2018). Effects of regular cannabis use on neurocognition, brain structure, and function: a systematic review of findings in adults. The American Journal of Drug and Alcohol Abuse, 44(1), 4-18.
4. Aviram, J., & Samuelly-Leichtag, G. (2017). Efficacy of Cannabis-Based Medicines for Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Physician, 20(6), E755-E796.
5. Wilkie, G., Sakr, B., & Rizack, T. (2016). Medical marijuana use in oncology: a review. JAMA oncology, 2(5), 670-675.
6. Haroutounian, S., Ratz, Y., Ginosar, Y., Furmanov, K., Saifi, F., Meidan, R., & Davidson, E. (2016). The effect of medicinal cannabis on pain and quality-of-life outcomes in chronic pain. The Clinical journal of pain, 32(12), 1036-1043.
7. Boehnke, K. F., Litinas, E., & Clauw, D. J. (2016). Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. The Journal of Pain, 17(6), 739-744.
8. Maher, D. P., Carr, D. B., Hill, K., McGeeney, B., Weed, V., Jackson, W. C., ... & Kulich, R. J. (2019). Cannabis for the treatment of chronic pain in the era of an opioid epidemic: a symposium-based review of sociomedical science. Pain Medicine, 20(11), 2311-2323.
9. Fallon, M. T., Albert Lux, E., McQuade, R., Rossetti, S., Sanchez, R., Sun, W., Wright, S., Lichtman, A. H., & Kornyeyeva, E. (2017). Sativex oromucosal spray as adjunctive therapy in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy: two double-blind, randomized, placebo-controlled phase 3 studies. British journal of pain, 11(3), 119–133.
10. ElSohly, M. A., Mehmedic, Z., Foster, S., Gon, C., Chandra, S., & Church, J. C. (2016). Changes in Cannabis Potency Over the Last 2 Decades (1995-2014): Analysis of Current Data in the United States. Biological psychiatry, 79(7), 613–619. https://doi.org/10.1016/j.biopsych.2016.01.004
Perspective #26: Cannabis And Cannabinoids For Pain Management And Disease Prevention
● Cannabis and cannabinoids have anti-inflammatory and neuroprotective properties.
● Studies suggest that cannabinoids may reduce the risk of cancer, metabolic disorders, and neurodegenerative disease, leading to chronic pain.
● Cannabinoids stimulate the creation of new nerve cells in animal models.
● Cannabidiol (CBD), a cannabis derivative, has been shown to block an enzyme responsible for breaking down bone-building compounds in the body, possibly reducing the risk of age-related bone diseases like osteoporosis and osteoarthritis.
● Applied topically, cannabinoids have been shown to have more potent antioxidant effects than vitamins E and C and can repair damaged skin.
Cannabinoids connect the brain to the body in a way that helps to modulate the regulation of homeostasis across all body systems. Since cannabinoids in cannabis are so similar to the chemicals created by our bodies, they can interact with the body to affect the modulation of regulation of homeostasis across our body systems through a complex interaction with our immune system, nervous system, and virtually all of the body’s organs. Thus, endocannabinoids bridge the gap between body and mind. And, by understanding this system, we might begin to recognize a mechanism that positively connects brain activity and states of physical and mental health and disease.
A 2017 review of the efficacy, tolerability and safety of cannabis-based medicines for chronic pain management found mixed results on the use of cannabis-based medicine for pain management in patients with rheumatic diseases and cancer pain. Also in 2017, The National Academies of Sciences concluded that cannabinoids are effective in treating chronic pain. Cannabis-based medicines undoubtedly enrich the possibilities of drug treatment of chronic pain conditions, but It remains the responsibility of the health care community to continue to pursue the rigorous study of cannabis-based medicines to provide evidence that meets the 21st-century standard for evidence-based clinical care.
In another selective review, published in 2017, of cannabis for cancer-related pain found evidence suggesting that medical cannabis reduces chronic or neuropathic pain in advanced cancer patients. However, the results lacked statistical power due to a limited number of study participants. Therefore, more controlled research is needed with large sample sizes to establish the optimal formulation, dosage, and efficacy of different cannabis-based therapies. Considering the vast number of people already using cannabinoids for many diseases and disorders and also recreationally, it has become a social responsibility to get statistically significant numbers to support or refute claims.
Reduced Risk Of Diabetes & Obesity
Several studies have shown that regular cannabis users have a lower body mass index, smaller waist circumferences, and reduced risk of diabetes and obesity. One 2011 report published in the American Journal of Epidemiology, based on a survey of more than fifty-two thousand participants, concluded that rates of obesity are about one-third lower among cannabis users. This is despite the findings that participants tend to consume more calories per day. This activity is potentially related to THC’s stimulation of ghrelin, a hormone that increases appetite and increases carbohydrates’ metabolism. CBD on its own was shown in a 2006 study to lower the incidence of diabetes in laboratory rats. In 2015 an Israeli-American biopharmaceutical collective began stage 2 trials related to CBD use to treat diabetes. In addition, research has demonstrated that CBD helps the body convert white fat into weight-reducing brown fat, promoting normal insulin production and sugar metabolism.
In a 2013 study published in The American Journal of Medicine, over 4,600 subjects, researchers found that current cannabis users had fasting insulin levels that were up to 16% lower than their non-using counterparts, higher levels of HDL cholesterol that protects against diabetes, and 17% lower levels of insulin resistance. Insulin resistance results in excess insulin being produced, promoting sugars into stored fat, leading to weight gain and obesity. Thus, a growing body of research exploring the interplay between cannabinoids and insulin regulation may lead to significant breakthroughs in treating or preventing obesity and type 2 diabetes. Unfortunately, respondents who had used cannabis in the past, but were not current users, showed similar but less pronounced benefits suggesting that the protective effect of cannabis is not permanent.
Improved Cholesterol And Lowered Risk Of Cardiovascular Disease
In the same 2013 study reference above, researchers compared the effect of cannabis on metabolic function comparing non-users to current and former users. It found that current users had improved cholesterol levels with higher blood levels of high-density lipoprotein (HDL-C) or “good cholesterol.” Another study involving over 700 members of Canada’s Inuit community found that regular cannabis users had slightly lower LDL levels or “bad cholesterol.” This suggests that cannabis may help prevent heart diseases like atherosclerosis or stroke.
Atherosclerosis is linked to diet and lifestyle and is common in developed Western nations. It is a chronic inflammatory condition involving the progressive depositing of atherosclerotic plaques (immune cells carrying oxidized LDL) in veins and arteries. A growing body of evidence suggests endocannabinoid signaling plays a critical role in the pathology of atherogenesis. The condition is now understood as a physical response to injury to the lining of veins and arteries caused by high blood pressure, infection, or the excessive presence of an amino acid called homocysteine. Studies have shown that inflammatory molecules stimulate the cycle leading to atherosclerotic lesions. Existing treatments are moderately effective, though they carry numerous side effects. Cannabinoid receptors interacting with plant-derived cannabinoids increase anandamide and 2-AG production, the body’s natural cannabinoids, down-regulating the body’s inflammatory responses.
Furthermore, a 2007 animal study involving cannabidiol (CBD) showed a cardioprotective effect during heart attacks via cannabinoid receptor activation, suggesting it be beneficial for cardiovascular illness and health.
Reduced Risk Of Cancer
Could cannabidiol help prevent tumors and other cancers before they grow? A 2012 study showed that animals treated with CBD were significantly less likely to develop colon cancer after being induced with carcinogens in a laboratory. In addition, several studies showing that THC may prevent or reduce tumors in animal models have been published, including one study published in 1996, which found that THC reduces the incidence of both benign and hepatic adenoma tumors. In yet another study published in 2015, scientists analyzing the medical records of over eighty-four thousand male patients in California found that those who used cannabis, but not tobacco, had a 45% lower rate of bladder cancer than the average expected rate. Finally, and most recently, a 2020 meta-analysis review, published online in The Journal of Cannabis and Cannabinoid Research, suggests that cannabis may reduce cancer risk in the United States.
Maintains Brain Health & Create Resilience To Trauma & Degeneration
Cannabinoids are neuroprotective, meaning that they help maintain and regulate brain health. The effects appear to be related to several actions they have on the brain, including removing damaged cells and the improved efficiency of mitochondria. CBD and other antioxidant compounds in cannabis also work to reduce glutamate toxicity. Extra glutamate, which stimulates nerve cells in the brain to fire, causes cells to become over-stimulated, ultimately leading to cell damage or death. Thus, cannabinoids help protect brain cells from damage, keeping the organ healthy and functioning properly. CBD has also been shown to have an anti-inflammatory effect on the brain.
Cannabinoids support and regulate good brain health. As the brain ages, neurogenesis slows. Therefore, to maintain brain health and prevent degenerative diseases as we age, our nerve cells need to be protected, and new nerve cells need to be continuously created to replace those damaged by injury or illness. A 2018 review of low doses of CBD- and THC-like cannabinoids were shown to encourage the creation of new nerve cells in animal models, even in aging brains. CBD has also been shown to help prevent other painful nerve-related diseases like neuropathy, arthritis, and Alzheimer’s disease.
Protects Against Bone Disease & Broken Bones
Cannabinoids are facilitative of the process of bone metabolism—the cycle in which old bone material is replaced by new at a rate of about 10% per year, crucial to maintaining strong, healthy bones over time. CBD, in particular, has been shown to block an enzyme that destroys bone-building compounds in the body, reducing the risk of age-related bone diseases like osteoporosis and osteoarthritis. In both conditions, the body is no longer creating new bone and cartilage cells. Instead, CBD helps spur the process of new bone-cell formation, which is why it has been found to speed the healing of broken bones and, due to a stronger fracture callus, decrease the likelihood of re-fracturing the bone (bones are 35–50% stronger than those of non-treated subjects).
Protects & Heals The Skin
Research published in 2012 showing CBD can repair damage from free radicals like UV rays and environmental pollutants suggest potential skin health benefits. The skin has the higahest amount and concentration of CB2 receptors in the body. Therefore, when applied topically as an infused lotion, serum, oil, or salve, the antioxidants in CBD can repair damage from free radicals like UV rays and environmental pollutants. In addition, cannabinoid receptors can be found in the skin and seem to be connected to the regulation of oil production in the sebaceous glands.
Cannabis-based topical products being developed to treat related issues from acne to psoriasis and promote faster healing of damaged skin. Historical documents describing the use of cannabis preparations for wound healing in animals and people from various cultures spanning the globe going back thousands of years suggest that cannabis for skin health and healing has a long tradition. Today the use of concentrated cannabis oils to treat skin cancer is gaining popularity. Several well-documented cases of people curing melanoma and carcinoma-type skin cancers with topical CBD and THC products. A recent study, published in 2021, investigating the roles of cannabinoids in melanoma found that “cannabinoids, individually or combined, reduced tumor growth and promoted apoptosis and autophagy in melanoma cells.” Cannabis applied topically is not psychoactive, so the safety and tolerability are superior to oral on inhaled products.
Anti-inflammatory and Neuro-Protective
A 2021 study reviewing the effects of cannabis on the skin found that Cannabinoids are potent anti-inflammatory and neuroprotective agents. CBD has been shown to interact with the endocannabinoid system in many organs, helping to reduce inflammation systemically and protecting the nervous system. The therapeutic potential of cannabinoids for inflammatory and neurodegenerative conditions is wide-ranging, as inflammation and neurodegeneration are involved in a wide range of diseases and illnesses.
The best way to avoid chronic pain and manage it is to prevent diseases or learn to manage the conditions that cause it. While there are many different types of pain, many conditions that can lead to long-term chronic pain include uncontrolled inflammation and neurodegeneration, two areas where cannabis has been shown to have great potential for benefit. In addition, injuries or illnesses that are inflammatory or have excessive inflammation as a symptom can be challenging to treat and manage as inflammation can prevent the body from healing. Using cannabis or cannabinoids can help promote a healthy inflammatory response and support the central nervous system. A healthy inflammatory response means improved recovery from illness and injury and may mean less pain and a lower risk of long-term health challenges.
Responding to the Opioid Crisis: Lessons from the COVID-19 Pandemic
COVID-19 offers valuable insights about human behavior and public health that is applicable to the chronic pain and opioid overdose crisis.
In February 2020, national leaders began to recognize the start of what was to become a global health crisis. Governments began declaring public health emergencies and reorganizing healthcare and public health institutions to provide new funding, equipment, services, and personnel. The President invoked the Defense Production Act allowing resources and contracts to be expedited in order to promote national defense. The Centers for Disease Control and Prevention (CDC) put staff on the ground in places experiencing surges to collect data, inform their work, and influence public health policies. And finally, the National Institutes of Health (NIH) and the US Food and Drug Administration (FDA) helped develop vaccines and therapeutics that have saved lives and are bringing a swift end to a world-changing pandemic.
This comprehensive, whole government response to COVID-19 stands in stark contrast to how we’ve dealt with another national public health emergency: the opioid overdose crisis. Despite a nearly 40% decline in opioid prescriptions in the last five years, overdose deaths have increased thanks to the use of illicit drugs such as fentanyl. The report by the American Medical Association (AMA) Opioid Task Force calls for greater access to the opioid antagonist, naloxone (Narcan), and to remove barriers such as prior authorization that hamper access to addiction treatments.
“It is past time for policymakers, health insurers, pharmacy chains, and pharmacy benefit managers to remove barriers to evidence-based care for patients with pain and those with a substance use disorder,” said Patrice Harris, former president of the AMA and chairwoman of the Opioid Task Force.
We agree, but as we learned with the COVID-19 pandemic, it’s not just the people who are getting sick and needing care or the heroic healthcare professionals who put their health on the line to provide that care, but it was also the essential workers and caregivers who protected the elderly and most vulnerable sacrificing their freedoms to protect and care for others. So too, must we provide support for and care for the caregivers, friends, and family of those supporting those living with chronic pain, opioid dependence, and opioid use disorder (OUD) whether they are in recovery or not.
While some metrics are suggesting that we are moving in the right direction, others are telling us that we are missing some critical elements that sustain and maintain addiction, including limited access to medication-assisted therapies (MATs) and drugs like naloxone, an opioid antagonist that reduces overdose deaths by reversing the effects of opioids can be life-saving, but only if they are available and accessible at the time.
There are other concerning statistics from this task force that suggest we might be doing it wrong. Deaths involving prescription opioids decreased from 12,269 in 2015 to 11,904 in 2019. During the same period, deaths from fentanyl increased from 5,766 to 36,509. Deaths from other illicit drugs also increased; cocaine from 5,496 to 15,974, methamphetamines and other stimulants from 4,402 to 16.279, and deaths involving heroin increased from 10,788 in 2015 to 14,079.
In their report, the AMA called for removing barriers preventing addicts from gaining access to medical treatments and drugs like naloxone. Unfortunately, according to the report; “Health insurance companies continue to delay and deny access to non-opioid pain care and evidence-based treatment for OUD, while pharmacy chains, pharmacy benefit managers, and state laws continue to inappropriately use arbitrary guidelines to restrict access to legitimate medication that some patients need to help manage their pain.” Only 21 states and the District of Columbia have laws limiting insurers from employing prior authorization for OUD services or treatments.
Prior authorization prevents physicians from using methods other than MAT and naloxone to combat pain. Not only do we need to allow doctors to prescribe non-opioid pain management, but we also need states to enforce mental health and OUD parity laws requiring insurers to provide equal benefits for substance abuse treatments as they do for medical and surgical care. Only eight states have moved to enforce the laws meaningfully.
Despite a rising number of opioid overdose deaths since the 1990s, it took more than 25 years for the opioid crisis to be declared a public health emergency after more than 700,000 people had died. Overdose deaths are climbing in the US, and more resources have been mobilized than ever before; the slow and measured approach to the crisis is not near the scale of the COVID-19 response.
The different ways governments react to these twin crises raise the questions: Why are the responses so different, and what can we learn from our successes and failures during the COVID-19 crisis to finally and meaningfully respond to the opioid overdose crisis?
Now it’s fair to point out that the opioid crisis and the COVID-19 pandemic are very different but are no less similar in how they have affected not only individuals but whole families and entire communities, both causing unprecedented disruption to lives and leaving no one untouched, either directly or indirectly. The economic and social impacts of the overdose crisis may be smaller and more concentrated. And while COVID-19 arrived suddenly, threatening everyone, the opioid crisis has been a part of the national conversation for decades, and while many people know someone affected by OUD or chronic pain. Many Americans, unaffected by opioid dependence or touched by overdose, may not yet understand how severe the crisis is. Lastly, COVID-19 does not carry the same stigma as an addiction, which many still perceive as self-inflicted injury or illness which only affects people who are criminalized and considered morally deficient.
While we may not respond to overdose on the scale of COVID-19, we can still learn from our experience responding to it. First and foremost, we must treat the opioid overdose crisis like the public health and national security crisis it is. We need central command centers to monitor the threat. We need protocols and resources available and accessible to those who need them. We need political leaders surrounded by experts communicating rapidly to ensure information and resources are available where they need to be and before they need to be there.
Currently, disparate entities managing our response to the opioid crisis often lack a complete understanding of their community needs, let alone the broader needs, and generally act in an uncoordinated manner. Without better coordination between the CDC, local health departments, and community-based organizations, it will be challenging to accelerate efforts towards effectively responding to the opioid overdose epidemic. While establishing command centers and involving medical and public health experts and community-based organizations, including people with lived experience, would go a long way, we also need to address root causes and better support caregivers and communities impacted by the opioid overdose crisis.
We must also work towards more significant health equity, investing more in those communities and individuals most acutely affected to reverse the most acute decline.
COVID-19 made clear that equitable access to resources is essential for there to be equitable outcomes. The struggle for equity in COVID-19 reflects the broader struggle to access healthcare and provide resources to the more vulnerable populations to keep them safer. BIPOC communities were among the last to get access to COVID-19 testing, treatments, and vaccinations. Recognizing these inequities, the Biden Administration is committing $10 billion to ensure that COVID-19 vaccines are equitably distributed and that testing and treatment are available.
Not surprisingly, similar disparities exist with the opioid crisis: communities disproportionately affected have less access to MAT and other resources to prevent overdose deaths. As with the COVID-19, to end the pandemic, we need to ensure that the infrastructure required to support the efforts is brought to communities most affected and lack them. Just as pop-up testing emerged during the COVID-19 pandemic, pop-up harm reduction services save lives. Drug testing and needle exchange service programs introduced with the same urgency as vaccination sites would save lives. The same investment made to combat COVID-19 disparities is also needed to address overdose deaths.
While the US’s response to COVID-19 has been, in many ways, less than ideal, it has provided lessons for what’s necessary to rise to the challenge of a public health emergency. The attention from the attorney general suggests the time may be right to seize this opportunity and build a system that provides lasting solutions to the opioid overdose epidemic while making a down payment on addressing the root causes by supporting those living with OUD and their caregivers, families, and communities. Reach out to the 100 Million Ways Foundation and join the community.
Perspective #24: Mentorship: A Positive Impact on Mental Health and the Journey to Recovery
Become a Fellow and mentor other individuals
Fellowship is about personal growth and development
Buddies = mentor each other https://hundredmillionways.surveysparrow.com/s/MEMBERSHIP-APPLICATION/tt-479748
Addiction, Environment and Community: A New Model Of Addiction Connecting The Individual with Their Environment and Putting their Relationship’s Front and Center.
Become a fellow today by joining 100 Million Ways recently launched fellowship program. Interested individuals can join the program to learn about addiction and the latest strategies for long term recoveryhow to educate others. Most importantly, fellows will have the opportunity to mentor other individuals and join this supportive community on the journey to recovery. The stories we’ve been told about addiction are a lie. Addiction isn’t a moral failure and it’s not simply a disease. Everyone who uses addictive substances doesn’t become addicted or even dependent.
In 1971, 15% of U.S. service members in Vietnam were actively addicted to heroin. President Richard Nixon created a new office dedicated to fighting the evil of drugs. He wanted to study what happened to the addicted servicemen once they returned home, expecting a high relapse rate. However, of those soldiers who returned home not addicted to heroin, only 5% relapsed in the first year. Soldiers who returned home still addicted to heroin had a 90% relapse rate. This went against everything everyone knew about heroin specifically and about addiction generally.
To understand why this is happening, we need to understand our environment and our relationships in order to understand the causes of our behavior.
Practices, Habits, and Rituals
From the 1960s through the 1980s, scientists believed that you had to change people’s goals and intentions to change their behavior. What we discovered was how challenging it is toisthat it is tough to change people's attitudes. A and that the assumption that behavior change would just follow an individual's change in attitude was false. Public health campaigns aimed at increasing the number of people who donate blood can work well. But campaigns getting people to quit smoking are often less effective. What does work is joining a group of people committed to quitting smoking.
Behavior and the Environment
Our behavior and our environment are tightly connected. If you do something enough, you can change what you want to do but can’t always change what you do. Our physical environment continues to shapes our behavior. When you do something in the same sort of physical environment, you tend to outsource control over your behavior to the environment. This can happen when you get into a car and start driving to work on a Sunday instead of to the park. Much of what you do in a day is done in the same way in the same place; these behaviors become habitual and your brain goes into a kind of auto-pilot.are affected by your environment and affect your attitudes.
Behavior and the Environment
For someone addicted to, or dependent on opioids, their environment is deeply ingrained with theseir behaviors. The surroundingIt becomes a powerful mental cue to perform that behavior. Over time those cues become very hard to resist, whether we want to or don't need to, and despite our best intentions, despite our resolutions, we do. It’s as if the environment dictates the behavior except that we are very much integrated with it.
There are No Good Behaviors or Bad, only Good Choices and Bad Choices.
We shouldn’t feel pushed by our surroundingsthe environment, but that is often how we feel. To overcome that, we need to understand that we are as much a part of the environment as it is a part of us. So to change behaviors, we first need to disrupt the environment in some way so that we can change our behavior.
Changing your environment is easier said than done but can be as simple as choosing to change your relationship with yourself and other people. All communities begin with two, which is why 100 Million Ways are excited to introduce its mentorship and fellowship program to support this community. This program is based on case studies and research with thewhich the understanding that more research is needed. We will collaborate with scientists and researchers to collect good clinical data showing the benefits of cannabis-based medicines for reducing the number of opioids used by people who are addicted or dependent on opioids for chronic pain.
The program is simple, and anyone can be a fellowbuddy. A fellonwbuddy is anyone who needs a friend, someone living with opioid addiction, or someone who is dependent on opioids for chronic pain. A buddy can also be a friend, family member, or caregiver for someone addicted or dependent on opioids for chronic pain who needs support. 100mw acknowledges that the opioid epidemic doesn’t just affect those using opioids; it also affects their friends, family, and the entire community.
For those interested in taking the next step, we will be offering training for mentors who will be qualified to provide peer support for people on their journey with opioid addiction, emphasizing harm reduction and a trauma-informed approach.
Further opportunities for fellows interested in advancing our research and evidence-based approaches to reduce dependency and the impact of the opioid epidemic on individuals and our community by changing people’s relationships with their environment and building healthy relationships and communities will be available.
For more information, visit www.100mw.org.
You can also support our work by supporting us on Patreon or.
Or donating on our website.
Perspective #23: Opioid Use Disorder and Recovery: A Trauma-Informed Approach
keyword: #addiction, #trauma, #recovery, #opioid_use_disorder,
Media depictions of people in recovery who are suffering trauma and living with opioid use disorder (OUD) are often shown at their worst. Media depicts people being coached to dig deep into their memories to recall past traumas, cry, scream, or otherwise “get it out” in order to heal. This experience looks painful because it is. Yet, it is supposed to be cathartic. It’s supposed to allow you to feel the pain and to let it go – but this is rarely effective since the experience of trauma prevents healthy processing. Typically, our brains process experiences and the emotions involved with those experiences separately. This allows us to recall events and the feelings distinctly associated with them, thus enabling us to remember events without triggering the associated emotions. Traumatic memories are processed and encoded differently. They are processed as a single embodied experience where you cannot recall the event itself without the associated emotional response. This means that every trigger is likely to provoke memories of the event and the related emotions. By recalling a traumatic experience, you effectively retraumatize yourself to a degree similar to the actual event. This is not helpful.
Traditional approaches to OUD, from 12 step programs to inpatient and outpatient rehabilitation, have much in common with this approach. Retelling your story in meetings, digging deep into your past (including sexual history, which for many of us includes rape, trauma, and abuse), and sharing it with others is often mandatory or, at a minimum, “suggested.” But is this the best way to approach a person whose opioid use is driven by trauma?
A Better Approach
Experts in trauma-informed addiction treatment suggest that instead of focusing on the story of “what happened,” it is better to focus on the physical feelings and the thoughts that followed. Trauma is often understood as something terrible that happens to people when in fact, it is the debilitating symptoms that many people experience following a perceived life-threatening or overwhelming situation. In other words, what happens is less important than what you feel after it happens. The acute symptoms of trauma, including acute fear of danger, going outside, or people experiencing flashbacks and nightmares, having panic attacks, and being unable to connect with other people, are just a few of the ways trauma can impact people. Ultimately a concussion can be caused by any experience triggering arousal and an increase in the release of stress hormones related to the bodily stress response, also called the fight, flee, freeze, or fawn response. These are the symptoms that need to be addressed for any treatment to be effective since they can also trigger people to drink or use drugs, creating a negative feedback loop whereby trauma leads to substance use problems causing more trauma leading to more substance use.
Trauma-related OUDs and SUDs are treatment-resistant because trauma changes the brain at a fundamental level, similar to how opioids change the brain. Research has shown evidence of overactivation of the opioid system in PTSD with diminished opioid receptor–binding potential in the amygdala, which is the integrative center of the brain for emotions, emotional behavior, and motivation. Further research suggests endogenous opioid system dysregulation in depression, implying new therapeutic approaches integrating somatic therapies with cognitive-behavioral interventions and community-based approaches may be beneficial.
When addressing people with OUD in recovery, it’s essential to understand that their disorder stems from a misperception about themselves and their relationships with others in their environment. At the level of perception, trauma causes people to see threats where others see manageable situations. Second, the brain’s “filtering system” stops working, making it difficult for people to distinguish between what matters now and what does not. This makes it challenging to engage with ordinary situations while maintaining your sense of yourself and your ability to feel pleasure or connection with others. This defense mechanism evolved to help us survive terrifying situations, but its lingering impact can make it difficult for people to move on and drive people to use drugs to deal with this loss of self.
All of this happens in the thinking part of your brain which relies on filtering information about the world. You can’t just “think” your way out of addiction; you have to feel your way and manage your relationships with your environment. This can be frustrating for people, including therapists, who want to believe that people can “make the decision” not to feel how they feel or behave the way they do. If it were that easy, most people would have done it already. That even evidence-based approaches like Cognitive Behavioral Therapy or 12 Step Recovery programs can fail a person whose OUD are related to trauma and who cannot turn off the trauma-response long enough to access the cognitive parts of their brain and process their emotions in ways that don’t lead to disordered or drug-seeking behavior.
Feeling Your Trauma
Trauma is an embodied experience. There is extensive literature on the subject showing how a therapist can combine physical techniques with talk therapy to help patients process the physical sensations of their trauma to better talk about them. These techniques are explored in books such as In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness by Peter Levine and The Body Keeps The Score by Bessel van der Kolk. The takeaways from these two books for people suffering from trauma and living with OUD are:
● Talking about traumatic experiences may not help; it may even hurt. Forcing yourself to relive the events that led to your trauma can itself be traumatizing, making symptoms worse, not better.
● Processing trauma can be painful, and your body may hurt. Pain is a common side effect of processing trauma. Mindfulness, bodywork, and relaxation techniques can relieve physical tension and are essential in processing trauma and working through the symptoms and side effects.
● Do not try to justify how you feel. Trauma is an individual experience, and you have nothing to prove to anyone that what you went through was “bad enough” to be traumatic. Focus on your healing, not the judgment or opinions of others.
● Set boundaries. When processing trauma, you have the right to protect yourself by choosing the type of environment you are willing to put yourself in and the people you are eager to be around.
● Avoid environments that make you feel uncomfortable and defensive. Please do not feel like you have to share your experiences to work with a therapist or sponsor immediately (or at all) or answer questions from friends or family whose concern or curiosity may blind you to the effect it can have on you.
While it may be hard to draw these boundaries, sometimes you may be in situations where you have no choice. A firm “No” works more often than you may think. Setting boundaries can be challenging once someone has been identified as an “addict” because oftentimes, that person is denied freedoms and privacy that would be taken for granted in regular life. Historically, cruel and humiliating interrogations and punishments have been inflicted on addicted persons in an attempt to “break down denial” and make them see the consequences of their actions. These techniques can be highly harmful. Treatment should be healing, not re-traumatizing. In the future, we all must embrace trauma-informed treatment to help those living with OUD overcome past traumas and be successful in their recovery.
The Somatic Experiencing Trauma Institute
Healing Trauma by Peter Levine
NICABM: Three Ways Trauma Changes the Brain.
In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness
Perspective #22 “Managing Hope in Recovery: A Journey of Rehabilitation, Reconciliation, and Reintegration"
Managing hope in recovery is one of the many challenges for people living with an opioid or substance use disorder (SUD) or dependence - especially challenging for those who are also living with chronic pain that cannot otherwise be well-managed. Understanding how differently we each respond to intervention and having realistic expectations improves your opportunity to succeed.
In the beginning it is important to take it day by day, hour by hour, moment by moment. An active commitment to recovery takes a lot of energy, but you will get better at it as time goes on. Recovery is like a muscle, the more you exercise it the stronger it gets. Of course, exercise can cause muscle injury like recovery can fail and become relapse. None-the-less, the more effort you put into your recovery the more likely you will see progress.
Accept that relapse happens; bad habits die-hard and we often take a step backwards to take to steps forward. Managing hope means having patience with yourself, your expectations, and your progress. This goal is more likely to be achieved as the quality of your life improves – and quality of life will improve as you reduce the amount of opioids you need to manage chronic pain or addiction.
Navigating life's journey without a map
The road to opioid use and misuse is different for everyone as is the road to recovery. Each person's path will be determined by their past, present, and future potential. How you live in each moment and the choices you make determine how many or how few choices you may have in the future. And while everyone's path may be their own there are some terrains to watch out for, each with their own character.
The Three R's of Real Recovery: Rehabilitation, Reconciliation, and Reintegration
Rehabilitation is a process that includes discovering tools and mechanisms for finding the emotional and social support necessary to begin the process of making changes in your life. This means changing your relationships to substances and often requires changing your relationships with individuals not interested in the path to recovery. It also means finding alternatives to deal with the pain and suffering you experience. By changing these relationships you begin to promote general health and mental wellness. This involves learning how to manage your frame of mind and impulses at the right time to avoid missteps on your path to recovery.
Reconciliation is a process that takes time and effort. It's an opportunity for introspection and acceptance of yourself. We are all accountable and responsible for our behaviors, but when you reconcile yourself with your past, you can start to move forward in life, recognizing the reasons for your relationships and understanding why you act the way you do and how you can think, behave, and act differently.
Reintegration means reordering your relationships with the self and its environment - realigning and prioritizing those who provide nurture and promote individual life, liberty, and their pursuit of happiness. This is the goal; this is the hope - for everyone regardless of their struggles with opioids. The goal of reintegration is to become fully integrated in your profession and your community and to work towards self-actualization - realizing your l potential. Feeling good. This process is open ended. It is something that should get better. However, setbacks are a part of life – life happens - so it is important to be resilient and diligent to stay on your path to your recovery.
Managing your hope is essential on your journey towards recovery. Navigating the 3R’s of rehabilitation, reconciliation, and reintegration is a time for you to be patient, patient with yourself. Your journey includes developing positive emotional and social support, taking time for introspection and acceptance of yourself, and realigning and prioritizing your community. Reach out to 100 Million Ways for a community of hope.
Perspective #21 The Axis of Trauma - Obesity, Mental Health, and Substance Use Disorder
Homeostasis is omnipresent in all living things. It is the ability to maintain stability within a changing environment and requires constant adjustment. Homeostasis occurs within individual organisms, groups of individuals, and their environment. At a biochemical, physiological, sociological, and environmental level, the stable functioning of healthy organisms depends upon successfully maintaining homeostasis. The dysregulation of homeostasis (dyshomeostasis) jeopardizes the well-being of individuals, families, communities, and the environment in which they live. By understanding how biological, sociological, and environmental factors can disrupt homeostasis, we can better understand how they impact individuals’ health and well-being and how society relates to obesity, mental health, and substance use disorders.
Here’s what research shows:
● 60%-70% percent of adolescents with a substance use disorder (SUD) also have a co-occurring mental health disorder.
● Rates of relapse for single-focus treatment programs at one year post-treatment are 60%-70%.
● 70%-80% of individuals who participated in programs that treat co-occurring conditions alongside SUD show no relapse at one year post-treatment.
By understanding the implications of this data, more personalized, integrated treatment programs addressing the whole person have considerably better outcomes than traditional programs focusing only on the need to take personal responsibility and control over one’s behavior, especially when these programs are started early. Recovery is not merely abstinence; hustling a person through detox and sending them home with a list of AA meetings they can attend is probably not sufficient. It takes a coordinated effort to address lifestyle, family dynamics, and underlying mental health issues contributing to the related underlying conditions.
When Feeling Good Feels Bad
When our brain rewards us for doing things that make us feel bad, it can override behavioral controls, disrupting homeostasis. Eating foods or using drugs to feel good is a natural adaptive response to an environment containing endemic stress and easily accessible illicit drugs and highly palatable energy-dense foods. Obesity further disrupts homeostasis by changing how the parts of our brains responsible for regulating feeding behavior affect control and hedonic reward. Dyshomeostasis, the breakdown of homeostasis, plays a central role in causing obesity, addictions, and chronic conditions. Prevention and treatment efforts targeting the underlying causes of dyshomeostasis may reduce rates of obesity, lessen the health impacts of addiction, and raise the quality of life of people suffering from the effects of chronic stress. Such prevention and treatment efforts will improve individuals’ impulse control, reduce overall stress, lower anxiety, improve mood, and otherwise help people feel calm and content.
Nearly two-thirds of new opioid prescriptions for chronic pain are for obesity-related health conditions. The adverse health effects of obesity are mostly well known: obesity is a public health problem made worse by chronic stress and social isolation. When people are active, they are less likely to be obese and more likely to have better health outcomes overall, as measured by how long they live and their susceptibility to diseases like heart disease or diabetes. Obesity doesn’t only affect health. It also increases the risk of depression and suicide. A 2014 study found that obesity was associated with more than double the increased risk of depression and three and a half times increased risk of suicide.
These findings are not surprising given how much more likely obese people are bullied and isolated by social stigmas surrounding obesity, mental illness, and addiction. As a result, they are more likely to resort to negative behavior to cope. While there are potentially other factors contributing to the obesity epidemic, the fact that most American’s fail to meet the government’s recommended dietary guidelines strongly suggests that by getting people to eat healthier and be more active, not only can we reduce the risk of obesity but also contribute to better mental health outcomes and lower risk of becoming addicted or dependent on opioids.
For decades people living with obesity, mental health problems, or opioid dependence were treated as weak and immoral, lacking the will or desire to overcome their negative behaviors. First, we told people with substance use problems to quit using as if abstinence were a matter of will alone. Next, we said that people suffering from mental health disorders, like depression, should just stop being sad as if that were a choice they could make. Now, we tell people with obesity to just stop eating so much and be more active, as if it were that simple. Not surprisingly, these simplistic approaches do not work.
Substance Use Disorders (SUD)
Science is starting to understand that SUD is not caused by a character flaw but rather a complex interaction between our genetics, environment, and society. We know that SUD and mental illness are inextricably connected, especially in the adolescent population. We know evidence-based therapies can treat SUD with a wide array of integrative practices. We also know that people with SUD, mental health disorders are often obese and are more likely to become isolated and feel lonely.
Mental Health Disorders
Science is also starting to get a better handle on mental health treatment. As the stigmas attached to mental health disorders fade, people are coming forward to get the treatment they need helping even those with severe mental illness to manage their symptoms and lead productive, fulfilling lives.
Here’s what research shows:
● 18.5% of adults in the U.S. experience a mental health disorder.
○ Less than half – just 41% – of those adults receive adequate professional treatment.
● 20% of adolescents age 13-18 have a mental health disorder.
○ 11% experience a mood disorder
○ 10% have a conduct or behavior disorder
○ 8% have an anxiety disorder
● Only 50% of youth with a mental health disorder receive adequate professional treatment.
We know treatment works, but the data clearly shows that not everyone who needs treatment can get the help they need. Additionally, there is often a significant delay between the onset of symptoms and participation in treatment. Many people who experience their first symptoms as adolescents don’t seek treatment until they are well into adulthood. This increases their risk of developing related health problems, including obesity and SUD. Fortunately, we are starting to understand the complex relationship between individuals’ behavior and mental health and the biological and environmental foundations from which they arise. The data suggest that education and intervention early in life should become a normal process. However, the data also shows we still have a long way to go.
Unfortunately, we are not as close to getting treatment for obesity right: we still shame people considered to be overweight, obese, or fat. A recent article outlines the depth and severity of this problem: we still assume the primary reason people struggle with their weight is that they are weak-willed; unable to keep their hands out of the cookie jar or go for a walk. And it’s not just kids in elementary school and middle school. Medical doctors do it, the media does it, clothing brands and advertisers do it, and a multi-billion-dollar industry selling weight-loss cures does it. We all do it to some extent because we live in a society that normalizes it.
Here’s what research shows:
● 39% of adults in the U.S. meet the criteria for obesity.
● 5% of children and adolescents meet the criteria for severe obesity.
● Fad diets do not work – but medically supervised dietary changes combined with support and attention from providers and loved ones do work.
Like treatment for substance use and mental health disorders, treating obesity means treating/educating the whole person – starting when that person is young - not just policing the foods they eat or how much exercise they get. It involves looking at their entire lives and not judging them for being obese or overweight. It means changing our attitudes and perceptions about people’s size, weight, and health and how we value people’s lives. That can be hard to do, so it takes a concerted but worthwhile effort because, like substance use and mental health disorders, it is highly probable that there is an underlying biochemical or physiological mechanism at work.
A Whole-Person Approach
The areas where the paradigm is shifting, in the treatment of substance use and mental health disorders, must also be applied to the treatment of obesity. Mental health professionals know that treating the whole person works better than treating the symptoms of substance use or mental health disorders alone. People with SUDs often have a co-occurring mental health disorder and vice-versa. People with mental health disorders are at greater risk of SUD. We also know that removing the stigma of obesity, substance use, and mental illness means that more people will come forward and get the help they need. Therapists know what works and understand what we need to do. And collectively, we’re starting to realize that to do what’s suitable for people struggling with obesity, substance use, and mental illness. We first need to change the way we think about the causes of obesity, substance use, and mental illness to appreciate the complex relationships between the underlying causes of behavior so that what works for mental illness and substance use can be applied to obesity, further supporting individuals as the whole person, on their road to recovery.
We are beginning to recognize that when it comes to the treatment of obesity, substance use, and mental illness, that we have been doing it wrong, but as the paradigm shifts and as we learn about what needs to be done to treat obesity, substance use, and mental health effectively, the question becomes, will we step up and do it?
Visit 100 Million Ways and see how one organization is building a community to help break the chains of opioid dependence and substance use disorder.
Perspective #20: The Opioid Epidemic and Gun Violence
The opioid epidemic is driving gun violence in America in unexpected ways.
Researchers have long recognized that alcohol is a factor in gun-related violence. Past studies showing an association between gun violence and illicit drug use tended to group opioids with other drugs such as cocaine. Recent research specifically examining the relationship between opioid addiction and gun involvement found that opioid-dependent people are more likely than alcohol-dependent individuals to be involved with guns. These results suggest the full impact of opioids is even more significant than initially thought.
The study, published in 2018 in the journal Drug and Alcohol Dependence, found more than half of opioid users reported being present when shots were fired; about one-third reported owning a gun, carrying a firearm, or being shot. Compared with alcohol-dependent individuals, opioid-dependent individuals are 12 times more likely to take a gun for protection, seven times more likely to have been shot at, and six times more likely to have a gun-related arrest on their record. The takeaway is that people dependent on opioids are more likely to lead gun-involved lives, putting them at risk of dying from overdose and gun violence.
Researchers in a study published in 2018 surveyed 386 people seeking inpatient opioid detoxification and 51 people seeking alcohol withdrawal management in Fall River, Massachusetts. They found the rate of gun possession among respondents was more than double the rate of Massachusetts residents generally. They also found nearly one-third of opioid-dependent respondents that carried guns for protection had been shot at, and about half had been threatened with a gun or been present when shots were fired. For those who did not own a firearm, more than half said they could get a one quickly if they desired one. Further analysis found that being male, a person of color, experiencing homelessness, and being incarcerated at any point is significantly associated with increased gun involvement. In contrast, and suggesting possible interventions, higher self-control scores are associated with a significant decrease in gun involvement.
The illicit nature of the drug market means that being involved with guns may not be an irrational or unnecessary power trip. People who are opioid-dependent and reliant on the illicit market find themselves more often in unsafe situations. Carrying a gun could be considered a practical and self-protective measure and contributes to the perilousness of communities affected by the opioid epidemic.
Here are some more sobering statistics to contrast the twin crises of opioids and guns facing the country.
● In 2016 in the US - 1,681,359 years of life lost to opioids– 916,869 years of life lost to guns.
● In 2015 in the US - 1.7x more likely a white person dies of an opioid overdose than a Black person– 1.9x more likely a Black person dies of a gunshot than a white person.
● In 2016 in the US - 13.3 opioid overdose deaths per 100,000 - 4.6 gun homicides per 100,000 (82% of all gun homicides happen in the US)
● $504 billion is the estimated cost of the opioid crisis in 2015 – $229 billion is the estimated annual cost of gun violence.
● In 2016 on an average day in the US - 96.2 people are killed by guns kill – there are 115 opioid-related deaths.
While the opioid crisis and gun violence are devastating communities, some of the efforts to combat them prove ineffective or even counterproductive. Mass shootings and drug overdoses naturally evoke fear and outrage; unfortunately, new laws and restrictions rarely reduce harm and often make matters worse. Good evidence-based public policies must rely on data.
While the availability of certain types of guns may make certain acts of gun violence more deadly, the fact that most gun deaths and most mass shootings are committed with handguns suggests we should pay more attention to “why” rather than simply “how” so many people are dying. In 2017 the CDC reported that 47,600 Americans died of opioid-related deaths. Similarly, death from opioids is blamed on the excessive prescription of opioids by doctors for addicting the population and moved to restrict the number of opioids doctors could prescribe - - despite data consistently showing no correlation between prescription volume and the nonmedical use of opioids or opioid addiction. In addition, medically prescribed opioids have lower overdose rates ranging from 0.022% to 0.04%.
People often mistake dependence for addiction, forgetting that they are two different things. Opioid dependence, while it can be a step away from addiction, is still a physical dependence on opioids that is characterized by the symptoms of tolerance and withdrawal. Addiction is more complicated. Addiction is marked by a change in behavior caused by the biochemical changes in the brain after continued opioid abuse. Substance use becomes the main priority of the addict, regardless of the harm they may cause to themselves or others. Addiction causes people to act irrationally when they don’t have the substance to which they are addicted in their system.
The National Institute on Drug Abuse director states that opioid addiction in patients is uncommon “even among those with preexisting vulnerabilities.” Studies showing a “misuse” rate of 0.6% in patients prescribed opioids for acute pain and roughly 1% in those on chronic opioid treatment suggest that medically prescribed opioids are not the driving force behind the opioid crisis. In fact, despite high-dose prescribing being down 58% since 2008, the overdose rate continues to rise, involving fentanyl or heroin 75% of the time. Furthermore, evidence showing a steady exponential increase in nonmedical use of drugs since the 1970s suggests complex socio-cultural factors drive the root causes of the opioid crisis. With prescription opioids becoming less available, both medical and nonmedical users find cheaper and deadlier options in the illicit market.
Opioid dependence is real but need not be inherently harmful. Many patients rely on opioids to control their pain well enough to live a healthy life. With new restrictions and crackdowns on prescribers, many chronic pain patients are being cut off from their medication, causing many to self-medicate with unpredictable and dangerous drugs on the black market and some even turning to suicide. The opioid crisis is also a consequence of prohibition and the dangerous black market it fuels, combined with a lack of safe alternatives to opioids for chronic pain, such as cannabis. Reducing overdoses requires redirecting resources from restrictive, prohibitionist interventions to those focused on reducing the harm resulting from drug use and providing safer alternatives to opioids or with opioids for managing chronic pain.
Drug overdoses and gun deaths are serious problems that require changing the status quo and embracing evidence-based policies and political realities, not fears demanding policymakers “do something” even if it is the wrong thing. Bad policies motivated by fear inevitably fail because they obscure problems instead of solving them, making bad situations tragically worse.
Perspective #19: Pandemic Isolation and the Opioid Epidemic.
81,003. That’s the number of people who died from drug overdoses in the 12 months ending last June 2020. That is a 20% increase and the highest number of fatal overdoses ever recorded in the U.S. in a single year.
Drug deaths started spiking last spring as the coronavirus forced shutdowns and caused shelter-in-place orders. More recent statistics from cities throughout the U.S. and Canada show the crisis has only deepened. In Colorado, overdose deaths were up 20% and those involving fentanyl doubled; British Columbia reported nearly five overdose deaths per day in 2020, a 74% increase over the previous year; a study released this month showed emergency room overdose visits increased 45% during the pandemic, even as total ER traffic slowed.
The pandemic has ushered in stress, isolation, and economic disruptions, all known triggers for addiction and relapse, while robbing people of access to treatment options and support systems. Addiction specialists across the country report that the historic Covid-19 pandemic colliding with a preexisting drug epidemic, made even deadlier by the readily available and less expensive potent synthetic opioid fentanyl, has been devastating for their patients. Many have been lost to follow-up ; some have died; others have relapsed.
The increase in opioid deaths is a setback. We were finally making headway, thanks to growing public attention and government funding. Overdose deaths were falling in 2018 for the first time in years. But the spread of fentanyl erased those gains, and the pandemic has further undercut efforts to control the opioid epidemic. With public health officials rightfully focused on the coronavirus, suffering and death due to substance abuse have fallen off the radar.
The financial toll of the pandemic means many cash-strapped health care systems are cutting addiction treatment programs just when they are needed most. Even as opioid overdoses have skyrocketed amid the coronavirus pandemic, states are nevertheless slashing addiction treatment program budgets. Covid-19 has exacerbated the opioid crisis, and escalated overdose deaths, patients are falling out of recovery as the pandemic drags on, wearing people down. Jobs have been lost yielding economic stress, and grief - all taking a toll.
Addiction reshapes the brain; this has made the pandemic particularly challenging for those with substance use disorder. People in recovery have hypersensitivity to stress and diminished capacity to experience normal levels of reward.
Other pandemic-related factors are increasing the death toll as well. The pandemic is disrupting the supply chain for drugs. Users turn to unknown suppliers ending up with counterfeit drugs that look like prescription pills but contain fentanyl which lead to more overdoses. With stores closed and restrooms and public spaces inaccessible during the pandemic, people are now using drugs in public, rushing, not always taking time to be safe. Making this even more complicated, people who lose their supply or relapse and start using again are susceptible to overdose because their tolerance can fall sharply after a period of not using.
It’s the isolation that is the major contributor to the rising number of deaths. It keeps people from their social support networks and gives them more privacy to use. There is less opportunity to participate in any form of community. People can’t be around friends, go to the gym or restaurants; all of the everyday activities that help mitigate anxiety and depression are gone. Addiction grows in the dark, and in the pandemic, you have more people who are alone, not accountable to friends and family, and at risk. That can be fatal for someone using drugs: If they overdose, no one is nearby to administer the antidote naloxone or summon help.
Addiction is a disease that wants to get you alone and kill you, and the pandemic has created that lonely scenario for dying. People are isolated so it’s no surprise that the opioid epidemic has grown. The past year has also been challenging for organizations that provide treatment and other support for people in recovery. Social distancing requirements mean clients must now line up outside and wait for services, even in the bitter cold. Methadone clinic lines and packed waiting rooms leave clients vulnerable to the coronavirus requiring them to make appointments and practice social distancing in clinics, but if you don’t have a working phone, it’s hard to make appointments as the pandemic has shuttered libraries, coffee shops, and shared spaces that served as places for people without housing to charge phones and access services.
The pandemic has forced the cancelation of addiction support meetings and may be the ultimate “gateway drug.” There is hope; virtual therapy and outpatient services are more accessible now that federal restrictions for addiction medication have been loosened in response to the pandemic. The need for services remains high; while other businesses are closing their doors, more addiction clinics are opening as COVID winds down.
People are desperate for treatment but afraid to get it. As with other areas of medicine during the pandemic, the ability to deliver medical and support services for addiction virtually has been transformative but imperfect. On the plus side, new technologies could help provide treatment to the estimated 90% of people with substance use disorder who go without access to treatment.
Virtual sessions are not for everyone. It’s harder to develop rapport and earn trust over a screen. Opioid use disorder is stigmatizing. People with OUD know they’re going to be judged, so gaining trust is more challenging when you’re not in an office where you can close the door and sit face to face. A patient commented that “virtual sessions cannot check his urine so it’s easier to cheat.” So much of communication is non-verbal, gained from sitting in a room with other people, sharing, seeing their body language, responding naturally rather than mediated by technology. There is warmth, intimacy, and commonality in physically shared spaces that are inherently lacking in virtual spaces like Zoom. While more research is needed to prove that virtual therapy can be as effective as in-person sessions, it’s certainly better than nothing.
Perspective #18: How Technology Can Help Us to Overcome the Opioid Crisis
February 24, 2021
Today I want to talk about opioid overdoses. This isn't a fun, happy subject to talk about. However, we must recognize the magnitude of the problem and understand how through technology, innovation, and public policy, we can mitigate the problem, significantly reducing the amount of detriment this does to people with substance use disorder, to their families and to our society.
Overdose deaths are the #1 cause of accidental death for those under 50. Your friends, family, and neighbors under 50 are more likely to die from an unintentional drug overdose than in a car accident, a fire, or by guns. More people died in 2017 from drug overdoses than in the entire Vietnam war. Opioids affect people from all walks of life, from people with doctorates to people who haven’t graduated from high school. From young mothers to their unborn child. People who use drugs typically use opioids at about the same rate that ordinary people eat food every 4 to 6 hours.
In harm reduction, rule number one is never, ever use alone. That is not always practical, especially during a pandemic, but try not to use alone - access to life saving medications such as Naloxone (Narcan), which quickly reverses overdoses in minutes after being sprayed up a nose, needs someone there to administer this life saving medication. Finally, we need to work with lawmakers to increase access to treatment and educate people about harm reduction strategies, such as testing for adulterated drugs.
These measures are significant and tackle some of the major obstacles preventing people from successfully recovering from opioid use disorder. However, overdoses are still going up and life expectancy in the US, for the first time, is going down because of this epidemic.
When COVID- 19 hit, the country immediately passed a $1.9 trillion stimulus package. Suppose a small fraction of that money was put towards funding and identifying evidence-based solutions to these problems combined with good public policy. We could save many lives and help people cope with the combined impact of a pandemic and an ongoing opioid crisis.
This problem is not going away. It's getting worse year after year. It will not be going away until we recognize the devastating impact on our society and embrace data-driven approaches to finding solutions.
One possible solution to this problem may be found in existing technologies many people wear on their wrists. With the rise of wearable computing and the internet of things (loT), we are getting more comfortable being around technology and recognizing its importance in our everyday life. We are more comfortable trusting technology to inform us and guide our behavior. This opens up a massive opportunity for us to combine things such as wearables with sensors capable of monitoring our health, allowing us to take charge of our well-being in ways that we have never been able to do in the past.
Currently, Apple has a watch that will call 911 if it recognizes that you have fallen and is already saving lives. What if it could also be used to identify people experiencing an overdose? If you use alone, this might save your life. This could be an exciting area of development for an enterprising entrepreneur looking to do meaningful work that could prevent accidental overdose deaths and save lives.
Another way the technology could help solve the opioid crisis is precision medicine. Recent advances in DNA sequencing and analysis have identified correlations between a person's DNA and their risk of developing substance use disorder (SUD). Scientists have known that a person's DNA can affect the way they react to certain drugs. A person may have a genetic variant or variance that causes them to metabolize a drug more quickly or more slowly than normal. Additionally, epigenetic factors which underlie some of the interplays between the environment and our genes are also implicated in drug abuse risk. Studies have shown that DNA methylation, the most studied epigenetic mechanism in humans, is altered by opioid misuse or dependence. What if a test were available to determine a person's risk of developing SUD? Doctors could use it to identify genetic or epigenetic risk factors to educate their patients, inform patient care and improve health outcomes.
We cannot ignore the needs of those suffering chronic pain any more than those living with SUD. We must acknowledge people with SUD as patients. We must improve health coverage for access to complimentary alternatives or adjuncts to opioids for pain management, such as cannabis. We must leverage technology to improve the lives of those living with SUD by informing them about their risk, helping to monitor their health, providing support in their addiction, and practice harma reduction tactics to prevent overdose deaths.We need to provide realistic pathways to physical and mental wellness. We need to prevent - but accept relapse. It is only by taking a comprehensive and holistic approach to solving a problem that intersects our lives and affects our communities that we will make progress.
Perspective #17: Friends, Family and the Road to Recovery
Feb. 11, 2021
A strong support network, including family members, friends, counselors, and health care providers, are an important part of recovery from opioid use disorder (OUD). Whether a person has recently started using, is entering treatment, or is already in recovery, having family and friends’ support can be crucial for a person’s recovery. Starting a conversation about opioids can be difficult, but it’s important to start the conversation and keep it going when it gets tough.
Talking to someone about their opioid use
Let’s start with how to have a conversation with someone who you are concerned about. Talking to someone you care for about addiction can be awkward, challenging, and a little terrifying, especially if the reasons for having the conversation have to do with changes in their behaviors or attitude. You may worry that you’re being intrusive or that bringing it up could make the problem worse or hurt your relationship. But if someone you care about shows signs of opioid abuse or dependence, it’s important to confront the situation early before it becomes a problem you can’t avoid. By starting a conversation, you may be the turning point that leads your loved one to recovery.
Before confronting someone regarding concerns about their drug use, be prepared that they may not be ready to hear what you have to say. They may go through stages similar to those of grief before being able to accept your concerns: denial, anger, downplay the problem, depressed and eventually accepting. The best thing you can do in all of these situations is to listen more than you speak. By asking guiding questions and keeping the conversation going, you allow your loved ones to talk about what’s going on in their lives, share how they are feeling, and hopefully open up the lines of communication so that your loved ones feel less alone, less isolated and start working toward acknowledging that they have a problem and committing themselves to their recovery.
Here are some ways to start a conversation with someone you’re concerned about. The key here is to focus on what you see, how you feel, and what you think. The goal is not to judge or shame, but ultimately to listen and understand.
—I just wanted to check in with you to see how you’re doing.
—I noticed that you’ve been acting a little differently lately. Is everything okay?
—I’m worried about you.
—I’ve noticed you’ve been drinking a lot more than usual lately. Is there anything you need to talk about?
—I’ve noticed you’ve been using more pain medication and I’m worried about you. Is your pain worse? —I want you to know that I’m here for you if you need anything.
Once the conversation has started, you can ask more leading questions such as these:
—How long have you been feeling like this?
—Is there something you’re trying to escape from or to forget?
—Is your pain worse?
—Do you feel that your drug use is a problem?
—How would you feel trying not to use your pain medication for 24 hours? A week?
—How can I best support you right now?
—Have you thought about getting professional help?
Remember, you’re there to listen and to be supportive. You’re not there to fix the situation or lead the conversation. Listen to what is said and respond directly, when appropriate, with encouraging words, such as:
—I want you to know that you are not alone.
—I am here for you, and I want to help you in any way that I can.
—I know it doesn’t seem like it right now, but you can be in control of your life again.
—I may not understand exactly how you feel, but I love you, and I’m here to help.
The best thing you can do in these situations is to listen, asking guiding questions, and allow the person you care about to talk about what’s going on in their lives.
Talking with someone living with OUD
Treating OUD is hard. It’s important to seek professional help by contacting a local addiction center or mental health professional. Even your family doctor may have experience treating people living with OUD or can refer you to someone who does. Some doctors and clinics specialize in treating OUDs and getting an initial evaluation can be a critical first step on the road to recovery.
Find a local support network. Alcoholics Anonymous and Narcotics Anonymous aren’t for everyone, but they can be a good place start. These groups provide a network of encouragement and solidarity with those who are working to overcome their addictions. Follow up with your loved one on their own treatment. As they make changes to their social habits, exercise routine, or other behaviors to help them cope with their addiction, be sure to acknowledge those changes and affirm them. Change can be scary and old habits can come back quickly if not supported. And remember, everyone is different. Some may make progress quickly and stick with it; while others may relapse. Some may take a long time to come around, but when they do, they are fully committed. It takes time to find the “right fit” when it comes to treatment. Not all programs will work for everyone, and it may not be easy, but it’s important to be patient, forgiving, and kind towards those who are struggling to live with their condition.
Be encouraging. People living with OUD often believe that they will never recover from their condition or that their addiction is a personal moral failing, and that they are undeserving of help. They may feel shame about things they’ve done or said, people they’ve hurt, or relationships they’ve harmed. They need someone who can always remind them that they are worthy, that they are loved, that things can get better and will.
What not to say when talking with someone living with OUD
“Don’t threaten, don’t force, don’t lecture, or use harsh words. No matter how frustrated you feel, you can’t “scare someone into recovery.” Threatening to kick them out, cut them off, or take their children away from them if they don’t stop will only play into their fears and insecurities, pushing them farther away and possibly leading them to make even more harmful or rash decisions. You also can’t force people with OUD disorder to stop using or taking drugs – but you can provide them with the support and encouragement they need to choose to seek help and get treatment. Lecturing also doesn’t work. It will only make the emotional pain they feel worse by compounding it with your feelings of disappointment or disillusionment. Lecturing can feel productive to the person doing the talking but can make your loved ones feel like they’re not being heard; that they are a burden, or affirm other negative thoughts they have about themselves.
Using harsh words, like “alcoholic,” “drug addict,” or “junkie,” can minimize the feelings your loved ones have shared with you and can make them feel that you weren’t listening or don’t care about their feelings. It's not your job to assign labels to other people’s struggles. Instead of labeling, focus on describing the challenges using words or phrases like “problems with alcohol” or “difficulty with drug use.” Don’t assign blame or guilt. Avoid saying things like, “you’re ruining your life,” “your drug use hurts me,” or “think about what you’re doing to your family.” These kinds of comments will also reinforce the negative feelings and emotions a person has about their condition and push them farther away and deeper into crisis.
Don’t minimize or make excuses for their problem. Saying things like, “oh, you’re just stressed right now” or “you could stop if you wanted to” can interfere with your loved one’s recovery process, which starts with acknowledging that there is a problem. When you talk with someone under the influence, don't try and reason with them. They're not in a clear frame of mind, cannot fully understand you, and may react more negatively than if they were sober.
OUD can be difficult to overcome. It’s impossible to know what kind of challenges your loved one will face along the way. Setbacks or even relapse are not a reflection on the strength of your personal relationship, and they do not mean that your loved one doesn’t care or doesn’t want to recover. Don’t blame yourself, and don’t blame the person you care about. You can’t cure someone else’s addiction. Even if you could, it isn’t your responsibility. It’s up to the individual to make a personal commitment to their own recovery. The only thing you can do is to love and support them on their journey. To celebrate them in recovery and help them to pick themselves up when they fall short.
Visit 100MillionWays.Org and check out Buddy-Bot, a peer support process, and join the conversation.
Perspective #16: Bad Advice for People Living with Addiction or Dependence
January 26, 2021
You may not believe this, but some of the best advice you get can actually be the worst advice. Bad advice can sometimes validate what we already knew to be true but were in denial about it. This advice is not meant to be helpful nor to be followed. The goal instead is to highlight some myths about recovery. To be aware of things that can cause confusion or misunderstanding about what is helpful for those living with addiction or with a dependence on opiates. You may meet individuals on your journey or recovery that are so caught up in their own problems or mistaken beliefs about recovery that their advice should be suspect. What follows are some examples of the worst advice you are ever going to hear about addiction, dependence, and recovery. It is strongly recommended that you ignore this advice completely.
To Break Free of Addiction, You Need to First Reach Rock-bottom
The idea that you need to lose everything to escape addiction is based on a misunderstanding of what hitting rock bottom actually means. There is nothing magical about hitting rock bottom. You can decide that you have reached this point at any time you like. Rock bottom simply means that you have decided you are ready to change, that you have lost enough, and do not want to lose anything more. The problem with waiting until you lose everything is that you are more likely to die while waiting to stop. This is because the deeper you fall into addiction, the harder it can be to make the necessary changes in your attitude or behaviors to break free.
A better option is to recognize when you are giving up things you want or need because you need to satisfy your desire for a drug you crave. When you refuse to give up anymore, you are ready. The sooner you ask for help and commit to your recovery, the more likely you are to be successful. There is no benefit to staying trapped in a cycle of addiction for even one minute more than you have to. I know, easy to say. But the sooner the better, because it gets worse and life flies by while you wait to stop. Life is absolutely better free from the shackles of addiction.
There is Only One Road to Recovery from Addiction.
Most experts agree that a ‘one size fits all’ approach to addiction recovery is not effective. People are different, they become addicted or dependent for different reasons, and they struggle with their addiction for different reasons. Different approaches to sobriety are necessary. What works for one person might now work for you or someone else. You should not feel guilty about wanting to try a different path to your recovery. And you should not feel guilty about having to try different paths.
You Only Get One Chance at Recovery.
Since there is no “one size fits all” road to recovery, this means that for many, failure is part of the process. The road to recovery has many on-ramps and off-ramps. Falling off the wagon, as they say, only means you get up, dust yourself off, and get back on the wagon. You may fear judgment and feel shame about r failure; this isn’t easy, find pride in starting again. It takes willpower, a commitment to self-care, and a willingness to feel compassion for yourself and forgive yourself for your failures. Start again and focus on rebuilding a life worth living.
Sobriety is All about Willpower
For some, willpower may be enough. For most, it may be enough to stay sober for a few days, maybe a few weeks or months, but it is unlikely to be enough to keep you going long-term. This white-knuckle, cold-turkey approach to recovery tends to mean treating recovery as if it were a punishment, something to be endured rather than embraced. Recovery is not a punishment; it is a gift. Relying on only willpower, often motivated by fear of failure, can be exhausting. Again, it works for some. Once you have been sober for a little while, this fear of failure may fade – but could be replaced with a kind of irrational confidence that if you survived the worst, whatever else happens you’ll handle it. However, if you can’t handle it and if you don’t have the support you need, you may find yourself falling back into addiction. This is why it is important to find a web community and build a life community away from addiction. With a community you will no longer have to rely on willpower alone to stay the course. It is a place to share feelings, get or give experiential advice and be anonymous. Explore participating in online communities. 100MillionWays.Org offers a free BuddyBot program for online peer support.
Sobriety Requires a Certain Belief System.
Epistemology matters. Understanding what we know about things and how we come to know them is essential for distinguishing between justified beliefs and opinions. The fact that there are so many successful paths to recovery proves that no single set of beliefs are necessary. In fact, trying to believe things because they make you feel uncomfortable may actually prove detrimental in the long run. Listen to the facts then pick and choose which elements of any recovery approach appeal to you without having to accept every aspect of it. The best advice is to use trusted sources for information and only use what works for you.
You Can Never Safely Drink or Use Drugs Again After a Period of Sobriety
Most people who have developed physical addiction or dependence on any drug, are unlikely to ever be able to use the substance again safely. There are many examples of people relapsing after successfully recovering from addiction – even with long periods of sobriety. To fully break free from the cycle of addiction or dependence, you need to accept that substances have no place in your life. There can be no ambiguity about this, or else it can be the seed of your own relapse. For others, abstinence is not an option. For those who experience chronic pain and are physically dependent on medication, it may be necessary to find a healthy balance between abstinence and effectively managing symptoms. In these cases, it may be helpful to consider complementary or alternatives approaches for managing symptoms. If you need pain medications, try to use stronger drugs less frequently. Just using less strong pain medications like opioids will improve your quality of life and decrease your chance of dying from an overdose. The blogs and perspectives posted in 100MillionWays.Org touch on many of these subjects. Share your personal saga if you are so inclined.
Only the Most Serious Cases Require Medical Supervision
Addiction is a disease formally called substance use disorder. A medical disease can benefit from medically supervised care. Modern medicine relies on evidence to guide decision making. This applies to both individuals and groups; knowing what works for most helps to determine what will work for an individual. Depending on the case and the individual, a medically supervised detox can be helpful to those who want to break free of their addiction or dependence in a way that will increase their comfort levels and make them more likely to stick with their recovery and stay sober over the long-term.
Overcoming Addiction Is All You Need To Do To Live A Perfect Life
One of the most common reasons individuals relapse after a period of sobriety is a disappointment due to unrealistic expectations. Life happens. The road to recovery is a journey, not a destination. There is no graduation or event to mark the end of a successful recovery. The only guaranteed reward for a successful recovery is sobriety in itself. While you may notice some improvements in your life due to ending the cycle of addiction or dependence, that is only the start of your journey. There will be many challenges that you will face on your journey so it is important to be prepared to face these challenges soberly and with realistic expectations. Sobriety is a kind personal development course that lasts a lifetime but if you stick with it, your life will continue to improve as long as you continue making positive changes. Eventually, you may reach a stage where you can enjoy a sense of serenity most of the time. However, you will not arrive at this place overnight and aren’t guaranteed to stay there should you arrive.
You Will Never Not Miss Using Drugs
Some who have been physically sober for a long time still miss using alcohol or drugs. This fact underscores the seriousness of addiction and how deeply it can affect you, but his fact does not mean that everyone will feel the same way. For some, embracing sobriety is the end of their journey, but without building a better life free of substances, you may find lingering feelings of nostalgia preventing you from moving on completely. You can build a better life where drugs no longer hold your interest free of those feelings towards drugs that might draw you back in.
Feeling Depressed Means You Need to Work Harder at Recovery
Depression, like addiction and dependence, is a medical condition and experiencing depression has nothing to do with how hard you are working at your recovery. If you find that symptoms of depression prevent you from getting the most out of recovery, see a doctor and get a proper diagnosis and treatment. It’s a disease like substance use disorder. But through your journey it is most important to only accept medical advice from those properly qualified to offer it.
We invite you to explore the 100 Million Ways, read the blogs, and share your own saga.
Perspective #15 Community Solutions for
Opiate Addiction and Dependence
January 11, 2021
Media coverage of addiction issues tends to focus on individual stories and recovery against the odds. Celebrities confessing their struggles and describing their recovery as dramatically as possible along with confessions and criminal indictments. This creates an impression that addiction is a problem caused by individuals affecting individuals and that treatment starts and ends with the individual overcoming their addiction or dependence on opiates. Viewing opiate addiction or dependence as a "personal problem" isolates us from the reality of its community roots, impact, and responsibility.
The Stigma of Addiction
There is a saying that "every addict impacts six other people in their addiction." This is true but it also means that every recovering addict will affect six other people in their sobriety. This means that recovery is possible through connection to others in your community. This includes services provided by the community at large for those struggling with opiate addiction or dependence as well as friends and family. Unfortunately, not everyone has access to treatment services which means that many are reliant on informal connections and support from friends and family who may not be qualified or able to provide meaningful support. Some may be resistant to entering treatment and recovery, even when services are made available. This can be due to stigma or denial about the seriousness of their condition. This stigma and the beliefs about addiction take the focus away from the community and place it solely on the individual.
Here are some common false beliefs about addiction:
1. Addiction is a moral failing caused by personal weakness or character flaw, that a person with sufficient willpower and character can overcome addiction by sheer strength of will.
2. Addiction is caused by our biology and that physical differences in addicts explain why some people become addicted or dependent while others don’t suggest. This suggests that medication or lifestyle changes alone can overcome opiate addiction or dependence
3. Addiction is an attempt to "self-medicate" or treat trauma or other mental health issues and that treating the trauma or depression will resolve a person’s desire to use drugs.
4. Addiction is caused by family dynamics related to generations of drug and alcohol use. Often these families face additional issues such as poverty, crime, or neighborhood drug use. The solution then is to change the dynamics of the family which encourages addiction, address the related social problems, and find a connection with a healthier support group.
5. Addiction is caused by feelings of alienation, a "hole in the soul" that needs to be filled leading a person to feel isolated and lack direction resulting in them filling that whole with drugs and getting high. The solution is to help the person connect with something greater than themselves, a higher power, and to develop a greater sense of purpose.
Most treatment professionals agree that addiction is the result of all of these things and that only by recognizing ALL of these possible explanations for addiction can we ever hope to play a useful role in recovery. Addressing all of these areas increases the likelihood of successful, long-term sobriety.
Many of these factors involve making changes to our communities and families, giving our families and our communities ownership over addiction and dependence thus making them a pillar of treatment programs that are vital in making long-term recovery a viable reality. Humans are social creatures. We live within layers of a connected society made up of individuals. It is very difficult to heal in the confined space of individuality. Treatment that is embedded within a community has a much greater chance of addressing the root causes of addiction and dependence.
Solutions to the Stigma of Addiction
Traditional approaches were founded on scare tactics, such as “Just Say No” campaigns or “This Is Your Brain on Drugs.” These programs, such as DARE and Scared Straight, do not work. They have consistently been demonstrated to have little to no long-term impact on a person's decision to use alcohol and drugs. And showing people in hand-cuffs does not change long term recovery rates. Another approach is crisis-based and mandatory treatment. People who are forced to enter the recovery process through interventions, criminal charges, medical crisis, job threats, custody battles, and divorce ultimatums are often enough for a person to temporarily interrupt their use of drugs. Unfortunately, research shows that while mandated treatment has a better treatment completion rate than "self-referred" clients, over the long term they are no more likely to maintain their sobriety.
Community-Based Solutions to Opioid Addiction and Dependence.
Social marketing emerged in the 1970s as a way to shift the traditional consumer-focused marketing strategies selling products to selling ideas and services to enhance the health of the general community. Examples include commercials and billboards encouraging prenatal care, discouraging smoking, and wearing safety-belts. This approach was effective at changing community conversations about smoking and drunk driving, as well as what to do when you become pregnant. This strategy may be key to shifting the conversation about recovery from an emphasis on getting people through treatment quickly and into recovery to a social awareness about the root causes of addiction and a shared understanding that addiction is a chronic condition requiring longer-term support from a variety of sources. Social marketing could be a powerful tool for sharing stories about successful long-term sobriety and what it takes to stay sober long term.
Social marketing can also challenge stigmas replacing dramatic pictures of addicts at rock-bottom with more compelling images of recovery and sobriety showing the collective benefits of sobriety. Instead of focusing on what people will lose through addiction or dependence, focus on what people will gain through their recovery and sobriety. They get their families back, their careers, their children, a stable home, long-term relationships, better physical health, and more compelling interests.
What this all means is that a healthy community is the only known cure for addiction and that people with long term sobriety need to "come out" and demonstrate that recovery is not just possible, but probable with the right individualized self-care plan AND support from the community.
Please consider joining the online community at 100.MillionWays.Org. You will make it a better place!
1. The effectiveness of Drug Abuse Resistance Education ...
3. The media and addiction recovery - William White Papers
4. Social marketing - Wikipedia
Perspective #14 Cannabinoids in Cannabis Improve Resilience in Patients with PTSD and Reduces Drug
Craving and Anxiety in Patients Recovering from Opioid Use Disorder
January 3, 2021
A new study shows that cannabis could help those living with Post Traumatic Stress Disorder or
PTSD. It adds to a growing body of research suggesting a key role for cannabinoids in managing
risks associated with the disorder. PTSD is a chronic condition that can occur after a traumatic
incident causing those who experience it to relive their trauma over and over again, causing stress,
anxiety, and depression, and leading to panic attacks, hypervigilance, overwhelming emotions,
detachment from loved ones, and sometimes even self-destructive or addictive behavior.
Researchers found that people with PTSD who used cannabis saw greater reductions in their
symptoms and were more than two and a half times more likely to recover from PTSD during the
study than those who weren’t using cannabis. Sadly, PTSD is not an easy condition to treat or to
live with. Still, some PTSD sufferers say they’ve found relief from their intense symptoms through a controversial treatment - medical cannabis. People with PTSD are also more likely to experience
chronic pain which puts them at risk of developing an addiction or dependence on opioid pain
The incidence of PTSD and other psycho-social and pathophysiologic conditions have led to the widespread use of opioids in the United States which has resulted in an unprecedented epidemic of opioid addiction and dependence. A few treatments for opioid use disorders (OUD) are currently available, such as methadone and buprenorphine, and can help reduce opioid use and reduce the risk for opioid-involved overdoses. In some areas, however, these medications are underutilized and difficult to access, creating a treatment gap in which those who need medications face barriers to actually receiving them. Furthermore, 20-40% of OUD patients do not want to take agonist treatments.
A randomized, placebo-controlled clinical trial designed to test whether cannabidiol (CBD), a non-
intoxicating cannabinoid that is found in the cannabis plant, could reduce drug craving and anxiety
in recently-abstinent individuals with heroin use disorder, found that, compared to those who
received a placebo, individuals who received a dose of CBD medication showed reduced craving
for heroin as well as reduced anxiety lasting for about a week. The study involved 42 participants
who received one of two different CBD medication doses, or a placebo, once a day for 3 days. They
were then exposed to drug-related or neutral cues to see whether CBD could reduce opioid
cravings and anxiety, factors strongly associated with relapse to opioid use. The study medication
used in this study, EPIDIOLEX, is an FDA-approved plant-derived CBD medication in a liquid
formation. In addition to measuring the effect of the medication on opioid craving, anxiety, the
authors also collected measures of positive and negative emotions, vital signs (skin temperature,
blood pressure, heart rate, respiratory rate), and salivary cortisol levels, which measure stress
response. Authors examined whether patients who received CBD, compared to those who received
placebo, showed differences in opioid craving, anxiety, positive and negative emotions, or vital
signs, after being exposed to the drug or neutral cues. The results were very promising.
● Individuals receiving the CBD medication reported fewer cravings after being exposed to
drug cues compared with individuals receiving placebo.
● CBD reduced measures of stress response after the drug cue.
● Individuals receiving CBD reported less anxiety after being exposed to drug cues compared
with individuals receiving placebo with no significant differences between those receiving the
low-dose vs. the high-dose of CBD.
The implications of this study in light of the impact of the opioid epidemic underscore the need to
identify as many strategies as possible to curb opioid addiction and more effectively manage
In the past few years, scientists have asked whether or not cannabis could help individuals recover from opioid use disorder or serve as a less-risky pain management approach than pharmaceutical opioids. The small, experimental study here shows a potential benefit of CBD in reducing cue-induced craving and anxiety in heroin-abstinent individuals. This suggests a potential role for CBD in relapse prevention of opioid use disorder and showed that CBD substantially decreased cue-
induced craving and anxiety.
If you are interested in learning more about CBD or have your own story to share, please reach out
and let us know.
Perspective #13 Opioids and the Holidays: How To Have A Safe and Sober Holiday Season
Dec. 16, 2020
The first key to surviving the holidays is to have a realistic attitude about the potential for stress, anxiety, and conflict and what triggers these feelings. The holiday season may bring even more triggers, especially if you struggle with SUD, addiction, or dependence on opioids.
The risk of excessive drug and/or alcohol use during the holidays is real and the consequences include the potential for harm such as from motor vehicle accidents or overdose. The US Department of Transportation reports that fatalities related to impairment account for more than 25% of all vehicular crash fatalities in the US with many people dying in December alone.
The increased availability of drugs and alcohol during the holiday season can be difficult to resist. Drinking with friends and family during the holidays is a long-standing tradition in our country and the temptation to indulge is strong. In fact, 25% of the alcohol industry’s profits are earned between Thanksgiving in New Year’s, little more than a month.
This period of heightened use is particularly dangerous for a country where SUDs continue to be a major public health concern. While there is some reason for optimism, that is tempered by the reality that opioid use disorder remains a persistent threat to the health and well-being of all Americans.
Between 2018 and 2019 opioid use disorder decreased from 2 million to 1.6 million Americans. Efforts to increase access to treatment, psychosocial and community recovery have had a positive effect. Pain reliever misuse also decreased significantly from 2018 along with heroin initiation and heroin use among 18 to 25-year-olds. Despite these gains, opioid overdose deaths increased in 2019 underscoring the risk of potent synthetic opioids such as fentanyl and the continued need to engage people in treatment and recovery services.
People who are at risk of opioid relapse must be aware of and on guard against triggers that may tempt individuals to seek relief through harmful substances. It’s somewhat common for individuals to seek treatment in January after overindulging over the holidays by misusing drugs or alcohol, having self-destructive thoughts, and engaging in harmful behaviors. Often these cases are serious, coming to treatment through intoxication, withdrawal, or self-harm, and may require inpatient care.
This can be avoided by following some simple tips and understanding that addiction and dependence are not moral failings, they are disease states that can affect anyone. Be kind to yourself, understand and forgive your failures so that you can work on them is the first and most important step.
If you are concerned about your ability to stay sober over the holidays you must first be realistic about how the holidays can increase stress and anxiety and lead to dangerous behavior. Next, it’s important to take steps before entering the holidays to avoid problems that may trigger a relapse.
First, be kind to yourself. If you have a history of drug or alcohol misuse, it’s important to protect yourself and recommit yourself to recovery remaining centered and engaged with like-minded individuals in your community is essential. Don’t isolate.
Second, be kind to others, even if they are not kind to you. Embrace the holiday season and try not to be too self-absorbed, show kindness to others by taking part in volunteer activities. Get involved and stay engaged.
Third, take care of your physical health. Eat well, get enough sleep, and exercise regularly. Your physical health is tied to your mental health. According to a study published by the Harvard School of Public Health, running for 15 minutes a day or walking for an hour can reduce a person’s risk of major depression by 26%.
Fourth, stay safe. Avoid triggers by avoiding environments where drugs and alcohol are being used. If you find yourself in a situation where you might be tempted, be aware of where the exits are, and be prepared to leave. Fifth, stay positive. It is entirely possible to enjoy the holidays without misusing drugs or alcohol. Participating in fun wholesome activities that allow you to connect with others in a way that doesn’t involve substances. Cook, decorate, play games, and sing songs. Discover the joy of wholesome pleasures.
This year you may find yourself in a better place than you were in last year, you may find yourself worse off than you did last year. However you find yourself, there’s always an opportunity to take stock of your successes and your failures and get validation and support from friends and loved ones and celebrate or recommit yourself to recovery and lasting sobriety.
Finally, don’t be afraid to embrace harm reduction strategies that can help you through the holiday season. Managing stress can be difficult but studies have shown that high- CBD cannabis or medicinal marijuana instead of harder drugs, can help manage stress and promote relaxation and a more positive mental attitude, but don’t overdo it. Too much THC, in particular, can have the opposite effect, making you feel more stressed, anxious, and less relaxed. So indulge, in moderation, enjoy yourself, your family, and the holiday season.
Perspective #12 Does safe access provide safety from suicide?
Dec. 4, 2020
How can we build a compassionate community for those in recovery while at the same time criminalizing and marginalizing addicts and those suffering from dependence or addiction to opioids? The answer is, we can’t. In order to break the cycle of addiction and dependence, we must first acknowledge the inherent humanity of those who suffer and struggle to understand that addiction and dependence is a natural part of the human condition under stress and in the absence of community. One in four patients receiving long-term opioid therapy in a primary care settings struggle with opioid use disorder. A growing body of research points to the value of a holistic approach to recovery. Unfortunately, there are many barriers to access holistic care within a patient's community. Stigma associated with treatment and the limited availability of care can make overcoming these challenges a critical obstacle for engaging patients safely, comfortably, and compassionately to support sustained care. There are five elements which can contribute to a successful holistic approach to the treatment of opioid addiction and dependence: 1. The stigmas associated with opioid addiction treatment must be addressed by embracing medication-assisted harm reduction treatment along with psychosocial and community interventions in order to engage, support, and reintegrate those suffering from opioid use disorders into their communities.2. You must commit to combining medication-assisted therapy with supportive psychosocial and community interventions to support long-term recovery. Research shows that patients who are treated with medication and other interventions have better outcomes than those who are not. 3. Pain relief is the most common reason leading patients misuse opioids. Managing pain without the use of opioids including natural products such as cannabis, exercise, or other healthy lifestyle approaches for pain management is key to improving wellbeing and reducing dependency on opioids.4. Don’t be limited by limitations. Many communities lack resources for effectively responding to the opioid crisis. Embracing alternatives such as Telehealth, or other online resources can help bridge the gap between effective treatments and convenient access.5. Involving family members in the opioid recovery process is crucial for building long-term stability and community for those in recovery. Difficulty managing family conflicts can be a key contributor to opioid abuse. when family conflicts are resolved, and families are involved in the recovery process not only are those conflicts able to be addressed but the consequences are able to be resolved. In the fight against addiction, a holistic view of the needs of those who suffer is key to ensuring their recovery. Without access to holistic care, those who suffer face a challenging battle from addiction to wellness. An innovative and integrated approach that focuses on building bridges from addiction and dependence to community and care is the key to empowering patients to overcome their addiction or dependence and lead healthy dynamic lives.
Perspective #11: Wow - What an election? In regards to cannabis, "What does it mean?"
November 25, 2020
These reforms passed decisively as Americans of all political stripes abandon the prohibitionist approach to drugs. With Arizona, Montana, New Jersey and South Dakota all legalizing adult-use, one-third of all Americans will live in a state where cannabis is legal in some form.
Here’s a summary of what was approved on Election Day 2020:
ArizonaVoters passed an initiative legalizing adult-use marijuana for adults 21 years and older. Under the new legalization law, adults will be able to possess up to an ounce of marijuana in public and cultivate up to six plants for personal use.
MississippiActivists passed medical cannabis legalization allowing patients with debilitating medical issues to obtain cannabis after getting a doctor’s recommendation. It includes 22 qualifying conditions, such as cancer, chronic pain and post-traumatic stress disorder. Qualified patients would be allowed to possess up to 2.5 ounces of cannabis per 14-day period.
MontanaVoters approved a measure to legalize marijuana for adult use and establish a legal system for cannabis production and sales.
New JerseyVoters approved a referendum calling upon the state legislature to legalize adult use cannabis. Under legislation submitted to the state legislature after the passage of the referendum, adults 21 and older would be allowed to purchase and possess up to an ounce of marijuana or five grams of concentrates. Adult use retail will not be available right away, but medical cannabis dispensaries would be able to sell marijuana products to adult consumers immediately. A rules and regulations bill will still have to be passed and appointees for the Cannabis Regulatory Commission will have to be selected. Ultimately cultivation, processing and sale will be legal
OregonVoters passed two separate initiatives, legalizing psilocybin mushrooms for therapeutic purposes and decriminalizing the possession of drugs. The psilocybin measure will allow adults to access psilocybin mushrooms in a medically supervised environment.
The decriminalization measure removes all criminal penalties for low-level drug possession offenses. Criminal penalties will be replaced with a $100 fine or a health assessment to be completed within 45 days.
South DakotaVoters legalized both medical and adult-use cannabis. The adult-use measure legalized the possession and distribution of up to 1 ounce of cannabis and will allow the cultivation of up to 3 plants. The medical cannabis initiative allows patients suffering from debilitating conditions to possess and purchase up to 3 ounces of medical cannabis from a licensed dispensary.
Washington, D.C.Voters approved a local initiative decriminalizing the possession of a wide range of natural psychedelic entheogens, including psilocybin, ayahuasca and ibogaine. Under the new law, possession and use of the psychedelics will be among the District’s lowest law enforcement priorities.
Summary“This historic set of victories will place even greater pressure on Congress to address the glaring and untenable conflicts between state and federal laws when it comes to cannabis legalization,” Steve Hawkins, executive director of the Marijuana Policy Project, said. “The federal government is out of step with a clear national trend toward legalization.”
“We can put an end to the social injustices and other harms that result from the criminalization of marijuana,” he said. “While cannabis legalization is not the cure-all to end the war on drugs, it is a necessary step and would provide an opportunity for many long-oppressed communities to finally have a chance to heal.”
It is our opinion that regardless of political differences, there is a growing consensus that past drug control policies have failed and need to be replaced with more sensible policies that put public health first and treat drug dependence and substance use disorders as health problems that need to be addressed medically not putatively. Let us know what you think!
Perspectives #10—Cannabis 101: "Everything you wanted to know about cannabis but were afraid to ask"
November 18, 2020
Many natural products contain drugs similar to those found in prescription medication. That doesn't mean they are the same things. What ultimately differentiates the two is potency, purity, and use. One caveat is that natural products may contain other ingredients which may confound or compliment the principal active ingredient by virtue of their synergistic interaction within our body.
There's something calming about sipping a cup of green tea, and it may be the L-theanine. An amino acid found naturally in green tea and some mushrooms, L-theanine is said to alleviate anxiety, improve sleep, and reduce stress. We don't consider green tea a drug and doctors are not prescribing it to their patients, although some may recommend it. Basically, “the dose makes the medicine, the dose makes the poison”.
Cannabis and MarijuanaWhen we think of cannabis, well - it is more complicated. ● We know that cannabis is a plant and don’t consider it a drug. It’s a plant. It’s a recreational drug. It seems to have medical advantages. It is still illegal.● Even in states with approved ‘medical marijuana’, doctors are not prescribing it to their patients, but rather recommending it for medicinal purposes. This is because cannabis contains cannabinoids, such as THC and CBD, which have a biological effect on the body and may treat a variety of diseases and disorders. ● There are four approved prescription drugs made with cannabinoids: Marinol, Syndros, Cesamet and Epidiolex. Sativex, a mixture of THC and cannabidiol, is a mucosal spray approved in Canada for pain in multiple sclerosis.Three have been approved by the U.S. FDA, one has been approved globally. ○ Two are based on THC ○ One is based on CBD, and ○ One containing a combination of CBD and THC. ● These products have demonstrated safety and efficacy based on FDA approved, double blind placebo-controlled studies, the gold standard for clinical research. It should be noted that these products do not completely reflect the potential of cannabinoids due to a limited source and limited variety of whole leaf cannabinoids.
For many most people that use cannabis, it is used either as needed. This is where the line gets blurry and where individuals are ultimately responsible for their use. Cannabis is generally considered to be safe and well tolerated, in low to moderate amounts. But there must be clinical trials to clearly establish safety and efficacy. And clinical trials can’t happen until the federal government changes its illegal status or, at least, allows controlled clinical research to inform patients and clinicians.
Although cannabis is not without side effects and at higher doses may be habit forming, current testing and quality control address a lot of these issues. Consumers should ask for information about the products they are buying, such as the certificate of analysis to know the potency. A better understanding of how people use cannabis to better manage pain, related symptoms, and reduce dependency on opioids and other prescription medications, can help us to improve access to cannabis as a complementary alternative to opioids for chronic pain relief and addiction.
Perspectives #9—Legally Speaking: When Does A Natural Product Become A Drug?
Oct. 22, 2020
Perspectives #8 - Opioid Overdose and Dependence: What it Looks Like, What to Do
October 8, 2020
What are the signs of opioid dependence?
People who are dependent on opioids experience withdrawal symptoms when they stop takingthem. People may become nervous or cranky particularly when they're unable to use their painmeds. Their movements may become erratic and they're sleeping habits may change.What should I do if I or someone I know becomes dependent on opioids? If you or someone you know becomes dependent on opioids and is ready to seek help, the firststep is to find a physician or other healthcare professional who can help. Getting support foryourself as well as a loved one is essential for recovery. It's important to acknowledge that itmay take several attempts at treatment to find the best approach. If you or someone you knowis not ready to seek treatment, a confrontational approach or an intervention is notrecommended and can escalate to violence or backfire in other ways. A loving and compassionate approach is the best way to encourage and support their recovery.
Perspectives #7: Opioids 101 - Everything you want to know but are afraid to ask.
October 1, 2020
Opioids are highly addictive and people can become addicted or dependent on them for many reasons. The more you use and the longer you use, the more your brain and body come to believe that the drug is necessary for survival. As your tolerance for the pain-relieving effects increases, you may find you need even more to relieve the pain or achieve well-being, which can lead to dependency.
The opioid epidemic refers to the increase in both prescription and non-prescription opioid drug use for non-medical purposes. The statistics are sobering:● According to the national survey on drug use and health, 19.7 million American adults over the age of 12 battled a substance use disorder in 2017.● One out of every eight adults struggled with both alcohol and drug use disorders.● 8.5 million Americans suffered from both a mental health disorder and a substance use disorder.● Drug use disorders cost American society more than 740 billion dollars a year in lost productivity, health care expenses, and crime-related costs.
Despite these sobering facts, it's important to remember that prescription opioids can be used responsibly to help relieve pain and when they are prescribed by doctors following surgery or serious injury and other health conditions. These medications can be an important part of treatment but also come with serious risks.
What are the side effects of opioid use?Prescription opioids carry serious risk of addiction and overdose, especially with prolonged use. Side effects may include;● Tolerance, meaning that you need more of a medication to get the same pain relief● Physical dependence, meaning you have symptoms of withdrawal when medication is stopped● Increased sensitivity to pain● Constipation● Sleepiness, dizziness, and confusion● Depression● Itchiness and sweating● Affect on hormones including testosterone resulting in lower sex drive, energy, and strength.
Remember, with knowledge comes personal responsibility. Use it well.
Perspectives #6: Cannabis As Harm Reduction for Opioid Dependency and Addiction
September 30, 2020
When it comes to dependencies, wouldn’t it be nice if everyone suffering from opioid dependency could embrace abstinence. We all know that abstinence or going “cold turkey” isn’t easy and is not always an effective treatment option. You may have tried to go cold turkey when you tossed the full cigarette pack into the trash or emptied all the alcohol into your sink. Not very successful you say!
So instead of abstinence, we should consider substituting a safer substance for a more harmful one. This is the basic principle of harm reduction. The American Medical Association is greatly concerned with the increases in opioid-related mortality, specifically related to fentanyl. Suppressing opioid use with Methadone or Buprenorphine may be helpful but they are not without risk and side effects.
Cannabis, on the other hand, is more effective, has fewer side effects, and less risk of dependence and addiction. There are currently over 30,000 patient-years of data, mostly from randomized control trials using a cannabis extract, a sublingual spray called Nabiximols, tested for the treatment of pain. Nabiximols is a combination drug standardized in composition, formulation, and dose. Its principal active cannabinoid components are the cannabinoids: tetrahydrocannabinol (THC) and cannabidiol (CBD). Each spray delivers a dose of 2.7 mg THC and 2.5 mg CBD. Nabiximols has been approved in 27 countries. In that huge data set, there’s been no evidence of abuse or diversion. What’s more, most people who stop using cannabis are able to do so without any formal treatment.
Perspectives #5 Facing the unknown…without opioids
September 16, 2020
The COVID-19 pandemic, and the resulting economic recession, have negatively affected many people’s mental health and created new barriers for people already suffering from mental illness and substance use disorders. In a KFF Tracking Poll conducted in mid-July, 53% of adults in the United States reported that their mental health has been negatively impacted due to worry and stress over the coronavirus. This is significantly higher than the 32% reported in March, the first time this question was included in KFF polling. Many adults are also reporting specific negative impacts on their mental health and wellbeing, such as difficulty sleeping (36%) or eating (32%), increases in alcohol consumption or substance use (12%), and worsening chronic conditions (12%), due to worry and stress over the coronavirus.
Recognizing the stress is the first step. Clearing the body of stress hormones, such as cortisol and adrenaline, is the next step. This can be facilitated with physical exercise, yoga, Tai Chi, or stretching. Mindfulness and/or mediation, including breathing techniques, can also help us to relax and focus. Instead of turning the pills or alcohol, the controlled use of non-addictive cannabis products helps me to relax and focus on the positive elements of my life. —Linda Strause
Perspectives #4. Losing Family Members
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Perspectives' Guest Contributor Elliot Bostick: "The Life Triangle"
This model does not decide who you are—it explains your actions. You can be a great person. A nice person. A loving person. A successful person. However at one point, you might have made a bad decision that has negatively affected yourself and others. I know I have.
I will give you a look into my own life experiences but please explore this yourself:
Negative action scenario: —Pressure - Your are working your butt off to finish your shift at work and are stressed—Opportunity - Maybe a friend wants to hangout and get high afterwards—Rationale - You deserve this. You have done a lot of good work
Positive action scenario:—Pressure - Your are working your butt off to finish your shift at work and are stressed—Opportunity - A loved one wants to grab dinner and watch a movie —Rationale - You deserve this and earned it
There is greatness in our future. We should choose the life triangle! —Elliot Bodtick
3. Becoming a Mom, and a Caregiver
Before children, I slept through the night; that uninterrupted bliss of a good rest. With young children I worried about them falling, choking, or getting lost. With age the anxiety grew. When my sons got their driver's license and became more independent, I wouldn’t really sleep until they got home. I wasn't so much worried about them as I was worried for them. I found comfort from others, that loving touch that says, “everything will be ok” or being reminded that “bad news travels fast,” all helped me to manage my worrying and decrease the associated anxiety.
Having a community means that there is someone there to listen and comfort you. When one child is facing his or her own demons, seeking resources beyond those immediately impacted can provide help not only to the child but to the rest of the family. Much has been written about the stress of caregiving - whether for a spouse, an aging parent, or a child/young adult with an addiction. Learning to cope with being a caregiver means being aware of changes in your level of “compassion fatigue”, making self-care a priority, spending time with friends or with a support group, writing in a journal, and/or speaking with a counselor or therapist. Caring for oneself results in a healthier relationship with your family, a healthier relationship with your friends, and a healthier relationship with yourself. —Linda Strause
2. Experiencing Addiction:
Cannabis As Harm Reduction In Recovery
When you are suffering from addiction you often find yourself in the company of addicts, surrounded by people whose compulsive addictive behavior encourages and reinforces your own. One of the ways that I have found success in my recovery is by connecting with the cannabis plant in the same way as I connected with my dealer. I realize that at some level I'm substituting one addiction for another. However, I realized the potential harm is so much less. I'll never overdose from cannabis, I'll never have to compromise myself to get more, and if I want, I can grow my own cannabis each year.
Cannabis has been the key to my recovery. Not only does it help address the issues that drove my addiction but it also provides a community of like minded people who have all found their peace through this plant. I'm always amazed at how much this plant can do for humanity and for the planet. For me, it's part of my harm reduction strategy to be successful in my recovery and continue to feel like I'm a part of a community. —Linda Strause
1. The Evolution of Hope: Managing Hope in Recovery
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Dr. Strause combines over 30 years in clinical research and as a professor of nutrition at UC San Diego, with her peronal journey: her husband's diagnosis and death from brain cancer. She has been interviewed by KCBQ and by Dr. Jamie Corron of the Center for Medical Cannabis Education. She was recently selected to be interviewed by Authority Magazine for their series, Women Leaders in Cannabis.