“The Invisible Pandemic within the
Pandemic” July 26, 2020
Drs Stephen Christiansen, Roger Ray, and Paul
Thomlinson
Top Trump administration officials say drug
overdose deaths are surging amid the coronavirus pandemic, driven by increased
substance use due to anxiety, social isolation and depression.
A White House drug policy office analysis shows
an 11.4 percent year-over-year increase in fatalities for the first four months
of 2020, confirming experts’ early fears that precautions like quarantines and
lockdowns combined with economic uncertainty would exacerbate the addiction
crisis.
ROGER: I am not the sort of
person to ever say that I am tired of being right about things but at this
moment, I am. When the pandemic began I publicly expressed concern about the
spread of the virus among imprisoned populations and especially among the
children being held by ICE on our border. I did not mention nursing homes but,
those in prison and in detention, and those housed in long term care facilities
have been the hardest hit in the pandemic, accounting for more than half of the
fatalities in America.
At the end of March, when we
first began our lock down, I posted some
meditations online warning
those who had a proclivity for drug abuse, depression, or who suffered with suicidal
ideation out of a fear that since all three of those problems are either caused
or made worse by social isolation, that the pandemic would likely make all
three a more serious concern.
I have been actively supportive
of AA and AlAnon meetings for the past 40 years and I have never seen a
holiday, or an event of weather ever cancel a meeting, but a pandemic is
different. In person AA meetings have almost entirely ceased and online
alternatives just don’t work for everyone. So, I expected addiction to be a
growing problem. But I was not prepared for what I read in the Washington Post
a few weeks ago when they published that: Nationally overdoses in the
United States jumped 18 percent in March, 29 percent in April and 42 percent in
May according to the Overdose Detection Mapping Application Program, a federal
initiative that collects data from ambulance teams, hospitals and
police.”
Data for June and July are not
currently available to me but given this meteoric rise, in spite of a relative
silence in the media, deaths from overdoses, primarily a synthetic fentanyl,
must be rivaling the fatality rate from Covid-19, literally, a silent pandemic
within the viral pandemic.
I have invited two friends,
both of whom I have known for more than 25 years, to join me today. Dr. Paul
Thomlinson has two PhD’s in psychology and is a leading researcher in suicide’s
causes and prevention. Dr. Stephen Christiansen is a former trauma surgeon who
evolved into being an addiction treatment physician.
Speaking first as a member of
the clergy, I have been painfully aware, as Viktor Frankl noted nearly 75 years
ago, that addiction, depression and suicide are primarily caused by social
isolation . . . and not mere loneliness, because many of the people we have
seen have lots of social connections, but more an isolation from meaningful
connection.
Frankl could not have imagined
the emergence of the internet and certainly not social media, but he did
chronical the breakdown of social norms and customs which once kept families
and friendships knit together at a more substantive and meaningful level.
I have always believed that the
two most meaningful reasons for churches to exist in this modern and largely
post-theistic age, is to create meaningful community connection and to organize
well-intended people into opportunities for community service and action. Now,
in the midst of the pandemic, we are nearly entirely prevented from in-person
community gatherings and a non-compliant community makes community service or
public demonstration a potentially life-threatening situation. We do
what we can to make progressive faith relevant to our viewers online, but I
know that the lack of contact is undermining our effectiveness. Let me ask you,
Paul and Steve, for your reactions to this sudden escalation of addiction over
the past three months.
STEVE: Let me begin by thanking you
for asking me to participate. A great deal has changed in our understanding of
the "use disorders", the present idiom for what used to be called
abuse or addiction. There is a growing realization that all of these
"disorders" represent self medication of what is usually a inherited
problem with producing brain chemicals. These disorders can broadly be grouped
into self treatment for anxiety(nicotine, alcohol, marijuana, bento's, and
barbiturates) or self treatment for depression(amphetamines,ketamine, peyote).
Since these are inherited diseases, they are best treated by restoring the
deficient brain chemicals to a better balance by using medication , exercise,
counciling, or other social interventions so that the patient can be the best
person that they can be. I believe that the increase in deaths we are seeing
related to OD is caused by the increased stress we have been experiencing due
to the Covid-19 pandemic and the social unrest related to the polarization of
society. Stress requires increased coping skills which are already stretched
thin in people already self medicating to cope. Obviously, it doesn't
help that fentanyl has arrived and is incredibly potent. Any failure to
appropriately mix it with base leads to overdose. As an aside, overdose from
stimulants have been on the rise and are now nearly as large as opioid deaths.
Of interest is the most recent
press release from the Mo governors office stating that opioid death rates have
fallen in Missouri. I am not sure that rings true and it does not speak about
the surge in stimulant deaths in the last year that no one is talking about.
Today, the accepted most effective therapy for opioid use disorder is
MMT(monitored maintenance therapy, medication maitainence therapy). The success
rates for abstinence based therapies are about 10%(meaning 10% remain off of
opiates at the end of a year) while the success rates for MMT programs(which
combine a closely monitored maintenance dose of an opiate and counciling) are
about 70%(meaning that 70% of those who began the program remain on it and off
street drugs a the end of a year). The documented reduction in mortality is
also impressive. A IV drug user has an apx 13x increased risk of dying compared
to an non-user. An oral opiate user has a 4x risk. MMT reduces those risks to
about 1.7x a non-user. In practice, safety is the last selling point for the
programs but the easiest for a non-user to understand. MMT is safer, cheaper,
and legal. The average price of oxycodone on the street is about a dollar a
milligram(a 10mg oxycodone retails for about $10). Most oral users use 60-120mg
a day. Most MMT programs cost about $10/day including drug costs and
monitoring. It further allows a user to qualify fro jobs that demand a urine
drug screen pre-hire. This opens up a large range of employment opportunities
that otherwise would be closed. Once the daily search for money and supplies
has ended, social relationships that have been damaged or destroyed by years of
lying and stealing can be repaired.
While the only currently approved replacement
therapies are for nicotine and opiates, there is interest in extending the
replacement and counciling model to stimulants. The most challenging and common
problem is the anxiety driven use disorders. The ugly truth is that we do not
have a good medical treatment for excess anxiety. Benzodiazapams(Valium, Xanax,
ativan, klonipin, etc) are effective in the short term but habituation occurs
making them less than desirable long term choices. Gabapentin is marginally
effective for anxiety though is often used in an attempt to avoid the benzo's.
Commonly used drugs like VIstaril(which is an antihistamine) do not target the
GABA receptor at all and just make people sleepy. SSRI's and SNRI's have some
anxiety relieving effects but are not reliable or rapidly effective. Alcohol
works rapidly and is effective but in susceptible individuals, can lead to
overuse and a long lis too problems. Nicotine is the only anti-anxiety drug I
am aware of that has a rapid onset, tolerable habituation, and makes you more
alert, not less. Unfortunately, the delivery system(inhaled smoke or chewing)
leads to a whole host of problems which are well publicized.
I wish that there was higher availability of
counciling services and the they were much better coordinated with the services
I provide. In my experience, finding a good councilor is difficult and once
found, getting insurance to pay for any councilor, let alone the good one is
very difficult. Counciling is an investment in oneself and requires time to be
effective. For those reasons, my schedule is always full of people struggling
with anxiety, depression, or fatigue and wanting relief.
Paul:
Thanks for the invitation, Roger…always a pleasure and my honor to share
this panel with you and Steve. As you know, I’ve also been concerned about this
from the jump as well, and have done a couple of podcast pieces on it through Compass
Health Network.
Dr.
Nora Volkow, Director of NIH’s National Institute on Drug Abuse has recently
written in the Annals of Internal
Medicine of how the global COVID-19 pandemic is colliding with the more
familiar public health crisis of substance use disorders. By that, she meant that we were already struggling with the wildfire opioid
epidemic and the fatalities related to that, and then the COVID tsunami hit us.
As Dr. Volkow points out, we can easily see how COVID-19 can
make things even more difficult for people with addictions…for example, the
healthcare system may not prepared to take care of them in the midst of the
demands created by COVID. There are also stigma and social issues created by
this crisis: so-called social distancing may make these people even more
vulnerable because it interferes with many of the support systems that can help
them to reach and maintain recovery. Add to that the fact that drugs themselves
negatively impact our physiology and make us more susceptible to infection and
more prone to poor outcomes and it becomes very obvious why we should be
concerned about the collision of these public health crises.
As I’ve noted before, the lack of a sense of mission, the lack
of a purpose in life, has been identified as one of the major factors that make
people more vulnerable to taking drugs. We know that feeling irrelevant,
feeling that no one cares about you, is probably one of the most devastating
feelings a human being can have. Epidemiological studies show that social
isolation and neglect increase dramatically the risk of taking drugs, and, if
you are trying to stop taking drugs, it increases that risk of relapse. So, as
Dr. Volkow has put it, the challenge is “How do we provide social support for
people at risk of substance abuse during the COVID-19 pandemic?” This got me
thinking about what we’ve learned about substance use in the past few decades. Some of you may remember a series of anti-drug messages from the
1980’s including one PSA, based on studies from the 1960’s, showing rats in a
cage dying from consuming heroin. You see, in those studies scientists put rats
in cages with two water bottles. One bottle had water; the other bottle had
water laced with either cocaine or heroin. In virtually every case, in this
free choice situation, the rats would keep going back to the drug-laced water
bottle and fairly quickly die of an overdose. The conclusions are clear, right?
Drugs have an inherent hook in them, they are addictive, and if you start them,
they will kill you.
Kind of ironically, those
messages and the underlying studies became an inspiration for a psychology
researcher named Dr. Bruce Alexander at Simon Fraser University. This clever
psychologist wondered, what else is going on here, and maybe it’s not really
the drugs themselves that explain what’s happening. He wondered if it might be
the cage, the environment in which these rats were placed—a bleak and solitary
existence in which they only thing there was to do was…drink water or take
drugs. So, Alexander repeated the experiments, but rather than putting one rat
in a small cage, he created what he called “rat park.” Famously now, this cage
was filled with lots of good things to eat, other rats for socialization and
plenty of physical intimacy, and toys and colored balls for recreation. Rat
park also had two water bottles: one with water, and one with drugged water.
The rats tried both, but given the choice between good food, enjoyable
activities, and playful friends, none of the rats became addicted or overdosed.
Not a single death by overdose. They, in fact, didn’t like the drugged water.
Does this study have any
relevance to humans? Of course it does. Pesky research ethics prevent us from
putting humans in cages for extended periods of time with ad libitum drug
consumption…but as Johann Hari beautifully describes in his book Chasing the
Scream, in the Vietnam War and it’s aftermath, we have something of a natural
human experiment that illustrates the principles very well. At one point, a
huge number, upwards of ten percent of American soldiers stationed in a
miserable jungle, where they didn’t want to be and where they might be killed
at any moment, were using heroin. It was feared that when these soldiers came
home, we would have hoards of vacant-eyed heroin addicts roaming our
streets—but that’s not what happened, thankfully. When they were removed from
their virtual rat cages in the jungles of Vietnam, and were able to come home
to the embrace of family, the meaningful activities of employment and school, most
were no longer interested in heroin and simply quit. They were not criminal nor
physically addicted. They just changed their cages.
As the great Hungarian born,
Canadian physician Dr. Gabor Mate has put it, “All substances of abuse will
either treat pain or distract from pain. So the question is not, why the
addiction, but why the pain?” This question is a haunting one…it is what we
must answer if we are to make long-term, sustainable recovery possible for people
with addictions. The sources of the pain that humans treat with whiskey and
Oxycontin, with cocaine and benzodiazapines, are many—chronic physical pain
from injuries and illnesses, for sure. But I’m convinced it is much more likely
to include psychic pain from trauma (either in childhood or later), from
interpersonal alienation from primary relationships, from family disconnection
and conflict, from shame and guilt heaped upon us, from abject loneliness, from
having not found a guiding passion or a meaningful purpose for one’s life.
These are the real sources of pain that lead so many to find connection with
alcohol or other drugs. These are the sources of pain that lead to
self-medication. These are the sources of pain we can and must find ways and
means of treating.
I’ll conclude with an
all-too-obvious application of all this to our current circumstances, the
COVID-19 crisis. Under quarantine, we may all begin to feel like rats in cages,
right? What if our cage is feeling pretty desolate, and we have two bottles from
which to choose? We might begin to choose the whiskey bottle, or the bottle of
pills, rather than the healthier water bottle if we don’t take care to enrich
our environment. Rat park was an enriched environment that included, not
insignificantly, other rats with whom to play, socialize, have sex…be close to.
So we need to enrich our environments by bringing our offline supports online
through regular phone calls, FaceTime, Zoom, syncing up Netflix accounts. Getting
and/or staying connected with others is really the most important thing we can
do for ourselves right now. We need to enrich our environments by refusing to
drink from the firehose and restricting the flow of bad news and
misinformation—make sure we are getting good information, and balance it with
stories of human kindness and resilience. We need to enrich our environments by
developing and demonstrating mastery—learn something new or practice something
old. To be most helpful and hopeful, make sure it is something that provides
meaning and purpose to life—some way of adding beauty to your own life or those
of others, some way of contributing joy to someone who may desperately need
your light. Let’s all enrich these cages we are living in, together.
I also want to speak
specifically to a potential perfect storm for a rapid spike in suicides as
well. Clearly, there are major risk factors afoot these days: economic stress,
social isolation, loss of community and religious contacts, barriers to mental
health treatment, other medical problems not getting proper treatment, and
social media influences. So far, we don’t know what the impact is on
suicide…but we are worried, obviously. Yet, there is cause for some optimism on
this point. Suicide rates have declined in the period after past national
disasters (eg, the September 11, 2001, terrorist attacks). One hypothesis is
the so-called pulling-together effect, whereby individuals undergoing a shared
experience might support one another, thus strengthening social connectedness.
Recent advancements in technology (eg, video conferencing) might facilitate
pulling together. Epidemics and pandemics may also alter one’s views on health
and mortality, making life more precious, death more fearsome, and suicide less
likely. But, clearly, we are not pulling together to the extent that we could
or should in order to make this a real protective factor against suicide. Wear
a mask…it’s a tangible sign that you care about someone other than yourself…and
that maybe, just maybe, we can pull together.
