COMMENTARY POINT OF VIEW

The changing landscape of drug abuse What’s new? What can we do?

BY CAROL FALKOWSKI

Editor’s note: This is the first of four articles day’s counterfeit opioid pills often include Currently, more adolescents smoke in this issue, spanning pages 30-39, that highly potent synthetic fentanyl manu- marijuana than smoke cigarettes. Ac- address topics related to drug abuse and ad- factured in China. The powerful drug is cording to the National Survey on Drug diction. responsible for clusters of overdoses and Use and Health conducted by the Sub- deaths that have occurred throughout the stance Abuse and Mental Health Services very corner of the country is touched U.S. Last year in Minnesota, the drug was Administration, more than 111 million by drug abuse and addiction—Min- implicated in the death of the musician Americans have used marijuana at least Enesota is no exception. Drug-induced Prince. Synthetic fentanyl also has ap- once during their lifetime; 22 million are deaths have tripled since 1990 and now peared in powdered form in street drugs current users (i.e., they used it during the outnumber fatalities from motor vehicle such as heroin and cocaine. past month); and 8 million are daily users. accidents. Deaths from opioid overdoses in In 2014, an estimated 4.2 million people particular have skyrocketed; they now out- Methamphetamine makes a aged 12 or older had had a marijuana-use number cocaine and methamphetamine comeback disorder during the past year. overdose deaths, combined. The numbers of known methamphetamine Today, 29 states and Washington, D.C., labs—and rates of methamphetamine Guam and Puerto Rico have compre- Opioid epidemic stems from abuse—significantly declined after passage hensive medical marijuana programs, several sources of a 2005 federal law restricting retail sales according to the National Conference of The opioid epidemic is fueled by non- of over-the-counter products containing State Legislatures. In addition, 21 states medical use of prescription opioids and pseudoephedrine. But in recent years, and Washington, D.C., have decriminal- a record-high supply of high-purity, low- Mexican-produced methamphetamine has ized small amounts of marijuana, and cost heroin. These substances have high flooded the market, and law enforcement eight states and Washington, D.C., have liability for abuse, addiction and overdose. seizures of the drug now surpass previ- legalized adult recreational use of the They produce pain relief, euphoria, respi- ous peak levels reached in 2005. Last year, drug. Voters in Colorado and Washington ratory depression, mental clouding, physi- more than 11,000 methamphetamine- started this movement in 2012, followed cal tolerance and dependence. As a result, addicted patients received addiction treat- by citizens of Oregon, Alaska and Wash- addiction, hospitalizations, overdoses and ment services in Minnesota, a record-high ington, D.C., two years later. In November funerals are enveloping communities and number reflecting a 72 percent increase 2016, California, Maine, Massachusetts families like a dense fog—one that seem- over the total for 2005. and Nevada were added to the list. ingly won’t lift. Meanwhile, sales of other imported syn- In spite of these largely voter-initiated, Compounding the problem are counter- thetic chemical compounds persist in spite state-level changes, marijuana remains feit pills. Sold on the black market, these of federal and state bans. Such substances a Schedule I drug under the Federal “knock-offs” are clandestinely produced include products marketed as bath salts, Controlled Substances Act of 1970, a with inconsistent ingredients of varied— research chemicals or synthetic THC. designation reaffirmed in 2016. Voters, sometimes lethal—potency. These prod- not scientists or medical practitioners, ucts are not made in controlled laboratory Marijuana’s popularity grows have determined medical practice and settings. Their manufacture includes no The emerging hazardous drug-abuse pat- implemented systems that successfully cir- quality control. The pills look exactly like terns we see today occur against a back- cumvent both the usual FDA-driven drug their legitimately prescribed counterparts, drop of ever-popular—and increasingly approval process and federal law. Pro- but often, even the people selling them acceptable—marijuana use. According to a marijuana advocates are well-organized, have no specific information about their 2016 Gallup poll, 60 percent of Americans and entrepreneurs within the burgeoning composition. favor the drug’s legalization. In 1969, just marijuana industry have prospered despite In recent years, one mystery ingredient 12 percent of the population expressed numerous obstacles. has become increasingly prevalent. To- such approval.

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Abuse and addiction require a tion frequently goes unnoticed, undiag- (Suboxone, Subutex, Probuphine) and na- multifaceted response nosed and untreated. ltrexone (Vivitrol). The FDA has approved So where does this leave us? Practitioners must learn how to initiate two prescription medications for nicotine Historically, addressing a drug abuse conversations with patients about high- addiction: bupropion (Zyban) and var- epidemic has relied upon three prongs: risk drinking and drug use behaviors that, enicline (Chantix). Three medications are prevention, law enforcement and treat- left unchecked, can progress to addiction FDA-approved for treating alcohol addic- ment. or produce other adverse effects. And tion: naltrexone, acamprosate (Campral) Effective prevention boils down to screening for addiction must be integrated and disulfiram (Antabuse). Yet some consistent messages delivered by different within primary care settings in the same doctors are unaware of these options, and messengers: families, schools and com- manner that routine screening is used many addiction treatment providers re- munities. Yet too often, these messengers main reluctant to use them. fall short of exercising their greatest po- tential influence. Parents, uncertain how Online resources Action is overdue to broach the topic, often say nothing at for medical For decades epidemiologists have sounded all. To many adolescents, this silence is professionals alarms about the changing nature and perceived as implicit approval. Schools • National Institute on Drug extent of substance abuse and addiction. cover the topic of drugs in class, but often Abuse Yet concerted improvements have been leave discussions beyond that up to their NIDAMED: Medical & Health slow to materialize within homes, schools, Professionals students’ parents. Communities can be communities, legislative chambers and drugabuse.gov/nidamed- reluctant to step up and actively address medical-health-professionals doctors’ offices. drug abuse problems due to fear of being When it comes to marijuana, many • National Institute on Alcohol labeled a drug abuse epicenter. Abuse and Alcoholism consider its use “no big deal,” and state Law enforcement curtails the supply of Helping Patients Who Drink Too and federal laws collide on an ongoing illegal drugs. Prescription monitoring pro- Much: A Clinician’s Guide basis. Concerning opioids, some policy- grams curtail “doctor shopping”—patients niaaa.nih.gov/guide makers are so befuddled they take little obtaining the same prescriptions from • Substance Abuse and action at all, while parents cling to the no- multiple providers. Mental Health Services tion that it can’t happen in their family— Treatment for substance use disorders, Administration until it does. As for addiction treatment, SBIRT: Screening, Brief sometimes including medications, helps models based on ideology, not science, Intervention, and Referral to many addicts modify their attitudes and Treatment abound, and many providers routinely behaviors, develop responses to life stress- integration.samhsa.gov/ fail to use effective medications. When ors that do not involve substance abuse, clinical-practice/SBIRT pursuing pain management, many doctors and adopt healthier life skills. still struggle to find viable options to help long-term opioid patients for whom func- Medicine must broaden its role to identify other chronic diseases with tionality has steeply declined. When it comes to addressing the opioid behavioral components, such as diabetes, The bottom line? Problems surround- crisis, however, our efforts need to ex- hypertension and asthma. Screening, Brief ing drug abuse are serious, complicated tend beyond traditional tactics. We must Intervention and Referral to Treatment and widespread. And the more we pro- examine the practice of medicine—and (SBIRT) is an evidence-based practice ceed with business as usual, the more the acknowledge that our prescribing prac- used to identify, prevent and reduce prob- body counts will continue to rise. There tices aren’t all that require scrutiny and lematic use of—and dependence on—al- are small steps people on many fronts can improvement. cohol and illicit drugs. take today to contribute to more effective Medical education, for example, must To help patients access effective treat- solutions. expand beyond the immediately obvious ment, doctors must maintain an up-to- What are we waiting for? MM topics of pain management tools and new date knowledge base about the range and opioid prescribing guidelines. Long-stand- efficacy of various addiction treatment Carol Falkowski is CEO of Drug Abuse ing inadequacies in medical training about options. It is still true today that most Dialogues, former director of the Alcohol and Drug Abuse Division of the Minnesota addiction must be remedied. Current and addiction goes untreated, and very few Department of Human Services, and former future medical practitioners need compre- referrals to treatment come from medical director of research communications at Hazelden Betty Ford Foundation. For 30 hensive, formal training about addiction practitioners. years she has represented the Twin Cities in a that is on par with training they receive Medication-assisted treatments for opi- nationwide drug abuse epidemiology network of the National Institute on Drug Abuse. about other chronic diseases. When doc- oid addiction include use of methadone She also is the author of the reference book tors are not adequately educated, addic- (Dolophine, Methadose), buprenorphine Dangerous Drugs.

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