Opioids and why we call it ‘substance use disorder’

Maine Drug Death Stats
Chart Courtesy of Portland Press Herald

The current opioid epidemic is the deadliest drug crisis in American history. Overdoses, fueled by opioids, are the leading cause of death for Americans under 50 years old, killing roughly 64,000 people last year, more than guns or car accidents, and at faster velocity than the H.I.V. epidemic.

The extent of the opioid crisis is astounding. Opioid addiction affects people of both genders, all racial and socioeconomic groups, from rural areas to big cities and everywhere in between. State resources are strained by overwhelmed emergency rooms and first responders, crowded morgues, jam-packed jail cells and mounting foster care caseloads, which are now at their highest level since 2009. Babies under age 1, sometimes dependent at birth (you cannot be addicted at birth, only dependent), comprise around 17 percent of children entering foster care as parents either die or have their children taken away. Our school departments are stressed as unstable home lives manifest themselves during the school day. There are about 32 babies born in Maine each day and 8 of them are born dependent. The stereotypes are many, but in fact the majority of people who use drugs are educated, and the average age is almost 40.

Over the course of the next two columns, I will explore the sources of the problem and propose some solutions. Let’s start with the basics.

Sometimes you hear the terms opioid and opiate used interchangeably, but the terms have different meanings. Opiate is specific to natural derivatives of the opium poppy, like codeine, opium, and morphine. Opioid is the more comprehensive term and includes natural derivatives, as well as, man-made synthetics like oxycodone, heroin, and fentanyl.

From a chemistry point of view, the entire class of drugs works the same way, natural or synthetic. They numb and reduce pain by bonding to opioid receptors in the brain and central nervous system. And in fact, the brain contains miniscule amounts of opioid-like molecules called endogenous opioids that regulate digestion and mood in the body.

In someone using opioids, tolerance can build. A higher tolerance lessens effect of the drug over time. The dosage needed to re-create the initial relief must increase. This creates a cycle of physical dependence. If you quit, you’ll go into immediate withdrawal. Withdrawal isn’t fatal, but it is extremely uncomfortable.

Long-time opioid users generally do not overdose if they know the source and dosage of the drugs they are taking. However, people often overdose on opioids from the illegal marketplace that are cut with unknown drugs, or are used in combination with other prescription drugs, which often results in death.

In Biddeford, in 2016, we had 14 opioid overdose deaths, out of 376 statewide (numbers for 2017 will be available soon, but the disturbing trend is expected to continue). It is a public health crisis.

Addiction is a disease, properly referred to as substance use disorder (SUD). Those in the recovery community would like to get away from the term substance abuse. Abuse has a legal definition, meaning willful misconduct, and it also carries violent connotations. Substance Use Disorder is a disease and should be treated as such.

It is widely asserted that the current drug crisis started with an over-reliance on prescription opioids, in pill form, for pain. However, the national trends have shown that prescription opioids have been steadily declining for years. The availability of pills has now been dramatically reduced by greater awareness among doctors, tighter regulations, and expired medication takeback programs. The State of Maine has been a leader in this area, having passed effective and strict regulations against overprescribing. In fact, some think prescription drugs are actually too hard to prescribe now for those in chronic pain. This is also a tremendous problem, as those who legitimately use opioids and who need them are now more likely to be denied them.

As those struggling with a substance use disorder seek the next dose, they are driven away from pills to injectable street drugs. It’s possible we may also see this shift in people with chronic pain because of under-treatment of pain from tighter prescribing guidelines.

Injecting the drug produces a stronger, quicker high, and street drugs are often much cheaper to buy than pills. However, there is considerable risk. You don’t know what you’re getting. The product is unstable and unknown. Those struggling with SUD know that the drugs are poison, and even use the term ‘chasing the dragon’, a reference to the risk of getting too close to the edge. But the force of the disorder is so strong, they set aside the risk. People who misuse substances will say, “It’s not like I want to die, but I don’t care if I do.”

Having the disease of substance use disorder is not cheap. Staying high costs about forty to eighty dollars a day. That’s why it inevitably leads to crime. Anecdotally, about 8 out of 10 offenders currently housed in our county jails are there because of drug related activity.

Locally, among many others, the Saco-Biddeford Opioid Outreach Initiative is doing great work. I am fighting hard for continued state funding for this effort, as I think it is the right approach to helping recovery happen, so critical in so many ways for our community.

But funding is only part of the solution. Next week I’ll explore in more depth what is being done and what more I think it will take. In the meantime, please reach out to me with your thoughts and suggestions of all kinds, positive or negative, and any connections I can make for you with employment or recovery services. I believe recovery happens in the community and am committed to supporting it.

Rep. Martin Grohman of Biddeford is an Independent State Representative serving his second term in the Maine Legislature and is a member of the Criminal Justice and Public Safety Committee. Outside the legislature, he is chair of the Biddeford Solid Waste Commission. Marty hosts a podcast for Maine entrepreneurs called The Grow Maine Show. Find it on Apple Podcasts and Google Play, sign up for legislative updates at www.growmaine.com or facebook.com/repgrohman or call 207-283-1476.