June 12, 2019 News » Cover Story

What if our opioid crisis is really about isolation? 


click to enlarge SHUTTERSTOCK
  • Shutterstock

When Brittany Pettersen was 6 years old, her mother slipped on a skateboard and injured her back.

Stacy Pettersen was prescribed opioids for her pain. Scarred from an abusive childhood, still living with an abusive, alcoholic husband, Stacy was a perfect nesting ground for addiction. 

“She liked escaping,” Brittany remembers. “She liked that feeling — it made it go away.”

It didn’t take long for Stacy to develop a dependence on the drugs. When she could no longer get prescriptions, she moved to heroin.

A few years back — some 30 years into her addiction — Stacy was overdosing at least once a month, and sometimes more than once in a day. Brittany, who was elected a state representative in 2012, didn’t talk to her colleagues about her mother. Instead, she’d rush out of the state Capitol when Stacy was fighting for her life — and pleading for help to get clean.

Since she knew top experts “who helped me navigate the high barriers in the system,” Brittany was able to do something that most families in similar straits find impossible: secure a court order to have Stacy involuntarily committed to inpatient treatment on the state’s dime.

“It was the first time in 30 years that she was actually treated for the disease that she had,” Brittany remembers.

It proved a turning point for Stacy — and also Brittany, who had always felt like a powerless witness to her mother’s story. If she could help her mom, Brittany thought, maybe she could also help others with opioid addiction.

This past session, now-Sen. Brittany Pettersen, D-Lakewood, sponsored bills to give recovering addicts access to housing vouchers, make it easier for people to find treatment, provide medication-assisted treatment for addiction in jails, and allow schools to carry naloxone and hospitals to serve as syringe exchanges. 

Her approach is simple: destigmatize addiction; make treatment accessible; and — this is key — help addicts build new lives and relationships. 

click to enlarge Sen. Pete Lee is a champion of criminal justice reform. - CASEY BRADLEY GENT
  • Casey Bradley Gent
  • Sen. Pete Lee is a champion of criminal justice reform.

Back in 2015, journalist Johann Hari gave a TEDGlobalLondon talk called “Everything you know about addiction is wrong.” Over 11.5 million people watched it.

While Hari delved into a lot of studies, statistics and theories, the meat of the story had to do with a scientist named Dr. Bruce Alexander, and an experiment he conducted in the 1970s — popularly referred to simply as “Rat Park.” 

Born in 1939 in New York, Alexander, now 80, renounced his citizenship in the 1970s during the turmoil of the Vietnam War, and became a Canadian citizen. We reached him by phone, while he was at his local community garden in Vancouver, British Columbia.

Alexander explained that he conceived of his famous Rat Park experiment while he was employed at Simon Fraser University in British Columbia. At the time, experiments on addiction were straightforward: Put a rat in a cage with two water bottles, one of plain water, one of water laced with a drug (like morphine). Watch the rat suck down the drugged water and (probably) die.

Conclusion: Drugs are dangerous because they cause physical addiction and we lose control over our choices. 

Alexander wasn’t buying it. What does a rat in a cage with two water bottles have to live for anyway, he wondered? So he and his colleagues built Rat Park — a comparably giant enclosure replete with all the luxuries a rat could ask for: fresh wood chips, nesting areas, toys, mates, food, even a little conflict with other rats.

Then he added the two water bottles.

Rat Park rats shunned water laced with morphine, even though it was also sweetened. Alexander tried different scenarios, including dropping addicted rats, once kept in isolated cages, into Rat Park. He found that once moved to the better environment, the addicted rats preferred water. 

Alexander and his colleagues weren’t surprised. “We thought it’s better to be a rat in a colony, which is not a totally peaceful place, but it’s real.”

The findings seemed to explain some of the facts we know about drugs: The National Institute on Drug Abuse notes that only 8-12 percent of people who are given opioids will develop a use disorder. And, of course, many people who grow addicted to opioids, or any drug, simply quit at some point. If the drugs are irresistible, why doesn’t everyone become irreversibly addicted?

To Alexander the results meant that, when it comes to addiction, drugs aren’t really the problem. He offers an analogy.

“I’ve been standing watching this parade my whole life and all these floats are going by and each float that goes by is a new drug panic,” he says. “... In our gut we feel the fear — and each of the floats is telling us: ‘This is what the fear should be directed at’... But each float is just a gaudy representation of a far, far deeper problem... Until we deal with the problem, we’re going to have to keep dealing with the float.”

click to enlarge Dr. Nathaniel Granger: Drug users want to fill a void. - NATE ALEXANDER
  • Nate Alexander
  • Dr. Nathaniel Granger: Drug users want to fill a void.

And what is the deeper problem? Alienation. Angst. Modern society.

After he studied rats, Alexander says, he studied humans: Native tribes in Canada that had only been displaced from ancestral lands in the last century. Before moving to reservations, he says, the tribes had most of the woes that are common to humans: wars, violence, torture, insanity. But you didn’t see addiction, even though the drugs were available.

After the move, when the structure of the tribes was damaged, addiction came in like a cancer — in some cases addiction rates in adults reached nearly 100 percent.

Alexander is quick to point out that not everyone agrees with his theory of addiction. And he notes that some replications of Rat Park produced different results. But he says that after decades of study, he at least feels confident that he knows what’s going on when addiction takes hold.

“You create cages,” he says, “by destroying culture.”

According to the National Institute on Drug Abuse, 130-plus people die every day in America from an opioid-related drug overdose.

In 2017, more than 47,000 Americans died from an opioid overdose, an estimated 1.7 million Americans were addicted to prescription opioid painkillers, and 652,000 were addicted to heroin. That same year, 578 people died in Colorado from an opioid-related overdose, a figure that included a five-fold increase in heroin ODs, from 46 in 2010 to 224 that year. While Colorado’s drug-overdose deaths dropped slightly from 1,012 in 2017 to 974 last year, deaths associated with the deadly opioid fentanyl increased 21 percent, the Colorado Department of Public Health and Environment found. 

The opioid epidemic is widely blamed on the rise in pain-killer prescriptions in the 1990s, which led to physical opioid addiction in many patients, some of whom turned to street drugs when the pills were no longer available. 

In response, opioid prescription has been greatly reduced across the country due to new insurance policies and regulations, including strict management of the drugs by government insurers like Medicare.

Many states and local governments have also sued Big Pharma companies in an attempt to get drug manufacturers to pay for the costly crisis 

Meanwhile, in 2017, the same year that so many Coloradans died from overdoses, the Colorado Health Institute found that a record 1,175 Coloradans took their own lives. Twenty-three of them were between the ages of 10 and 14, and another 169 were between 15 and 24 years old. The American Foundation for Suicide Prevention found 47,173 Americans died by suicide in 2017, and it was the 10th leading cause of death. 

The problem wasn’t confined to Colorado: In 2008, the suicide rate in the United States was 11.6 per 100,000 individuals. In 2017, that rate was 14.

Suicide isn’t the only sign of declining mental health in the country. The Anxiety and Depression Association of America has found that anxiety disorders are now the most common mental illness in the United States, with 18.1 percent of the population suffering with them in a given year. Another 6.7 percent have Major Depressive Disorder. 

And the Harvard Business Review wrote that rates of loneliness in the United States have doubled in the last 50 years and show no relationship to any particular demographic. A big part of that may be our tech obsession. Surveys have found that those who spend more daily time on social media felt lonelier, and those who checked it more in a given week, more isolated.

So how bad is it to simply be lonely? Well, we know that solitary confinement leads to permanent mental scars, right? The Harvard Business Review notes, “Research shows that loneliness has the same effect as 15 cigarettes a day in terms of health care outcomes and health care costs.”

Here’s another interesting nugget: A story in Psychology Today notes that Erik Peper, Associate Professor of Health Education at San Francisco State University, has said your smartphone causes connections in your brain that look remarkably similar to the ones caused by opioid addiction.

“Further,” the article notes, “in a study of 135 individuals, Peper and his colleagues found that people who utilize their phones more often were more likely to report feeling anxious, depressed, isolated, and lonely.”

Professionals have come to recognize strong ties between substance abuse and mental health, and now use the umbrella term “behavioral health” to encompass both sets of disorders. Dr. Nathaniel Granger, a local psychologist who also teaches at Saybrook University in Oakland, says, “Addictions stem from individuals wanting or needing something to fill a void. But that’s just the tip of the iceberg.”

Some people get high to temper their mania, he notes, others to escape busy, but fulfilling, lives.

Psychologists often look for ways to help patients reconnect, he says. In his own practice, Granger uses poetry to help his patients. In fact, he and Louis Hoffman compiled the book, Silent Screams: Poetic Journeys Through Addiction and Recovery, a collection of poems from people struggling to get clean. Granger says that poetry helps people connect with emotions that might otherwise be hard to confront. That strengthens a person’s connection to themselves.

“It’s all about relationship — relationship with others and relationship with self,” he says of recovery. “Relationships can really make you or break you, especially on that road from addiction to recovery.”

In his experience, treating addiction is not a “one size fits all” issue — different approaches work for different people. But the breakdown of social connection is a huge factor for a lot of people, Granger says.

“We don’t know our neighbors, we lack the social connection,” he says. “And we’re social creatures. When we meet each other, oxytocin is released [in the brain].”

In the 1980s, Portugal experienced a drug problem that makes our current crisis look small. It’s believed that one in every 100 people in Portugal was addicted to heroin at one point.

In 2001, Portugal took a bold step: It decriminalized drugs. Those caught with heroin were referred to a doctor or social worker, or given support services. And the country’s attitude about drug users changed, from one of condemnation to one of empathy.

“The opioid crisis soon stabilized, and the ensuing years saw dramatic drops in problematic drug use, HIV and hepatitis infection rates, overdose deaths, drug-related crime and incarceration rates,” The Guardian writes. “HIV infection plummeted from an all-time high in 2000 of 104.2 new cases per million to 4.2 cases per million in 2015.”

And sure, like all things addiction-related, what happened (and is happening) in Portugal is complicated. But it does show that people can stop using addictive drugs, and that certain strategies work better on that front than others. 

Lauren Snyder, state policy director for the nonprofit Mental Health Colorado, says one of her organization’s big pushes is to end the bifurcation of mental health and substance abuse. It happens in insurance billing, making seeking treatment difficult for patients. It happens at the state’s 24-hour crisis centers, which have been known to turn people away if they have been drinking or using drugs — even if they are suicidal. (A new contractor will take over the clinics this summer and will treat intoxicated people in crisis.)

Snyder says she’s excited about the passage of Colorado’s Senate Bill 222, whose sponsors included local legislators Sen. Pete Lee, a Democrat, and Rep. Lois Landgraf, a Republican. The bill offers incentives to providers who treat more challenging patients and creates outreach programs to meet people with behavioral health issues where they are — even if that’s under a bridge. 

And there have been other transformative ideas in recent years. The 2017 Justice Reinvestment Crime Prevention Initiative — sponsored by locals Lee and Sen. Bob Gardner, a Republican, along with Sen. Daniel Kagan, D-Arapahoe County — might be the most visionary. The bill reformed the parole system, and used the subsequent savings to create grant programs in crime-challenged Aurora and Southeast Colorado Springs. The grants are used by the communities to fund programs and opportunities that enrich the communities, and hopefully prevent crime. 

Of course, a lot of those programs may also help people to find a community and a sense of purpose. Which, when you think about it, isn’t that much different from the camaraderie felt by a bunch of small, furry creatures back in the 1970s in Rat Park.

In his golden years, Dr. Alexander sees things from the 10,000-foot level. He sees how first-world countries — invested in war and competition in order to remain superpowers — neglect the basic needs of human beings, including health care. He sees how that feels even more poignant in “a declining empire” like America. 

Not religious himself, he still believes we must liberalize religion, make it more ecumenical, include more people. He sees the intense loneliness rooted in cities with high population densities, packed with people who spend their time on their phones. He sees cultural shifts that have left many isolated and unsure where they might belong.

“We can tell stories about rats,” he says, “which kind of illustrate the larger truth. And I think the truth is that we have an opioid crisis that is, in fact, totally tied up with the mental health crisis and that it’s a systemic problem of these times globally.”

click to enlarge Sen. Brittany Pettersen has transformed a personal experience into legislation. - BRITTANY PETTERSEN CAMPAIGN
  • Brittany Pettersen Campaign
  • Sen. Brittany Pettersen has transformed a personal experience into legislation.

Sen. Brittany Pettersen says that while most of her years with her mom were strained at best, she always remembered the mother of her early childhood. She calls her, “the most amazing person in the world.”

“When she would walk into a room, I have heard, everyone would just stop — she just shined.” 

Now, she says, that mother has returned. Stacy lives with other recovering addicts, and works at the home welcoming new patients. She has friends, a purpose, and is healing her relationships with her kids. Her two-year sober anniversary approaches at the end of the summer. Her shine is back.

“It’s just crazy to see what’s possible when we change people’s environment,” Brittany says. “... I still pinch myself that I’m able to have a relationship with my mom.” 

The difference, she says, isn’t just the absence of the drugs. Her mom feels rooted in a real life again — the void in her heart is full. It’s the type of healing that doesn’t come from a bottle or a doctor. 

Pettersen says that as Colorado moves forward in its battle against the opioid crisis, lawmakers would do well to remember that the epidemic is ultimately about people.

“I think if we’re not addressing that continuum of care and really helping people rebuild their lives,” she says, “then we’re lighting money on fire.”

Welcome to the clubhouse

In 1943, patients at Rockland Psychiatric Center in New York formed a group. When they were discharged, they continued meeting and decided to formalize the situation with a drop-in space they called Fountain House. The patients helped support each other, forming a symbiotic community. In the 1950s, they hired staff to help them create treatment programs.

Fountain House is the basis for the “clubhouse model” — now complete with standards and accreditation and adopted by clinics around the world, including at North Range Behavioral Health in Weld County.

Larry Pottorff, executive director of North Range, says he does believe that isolation and a lack of connection play into addiction, but he also says there’s good science to show that addiction changes the brain physically. North Range offers the full range of services, from therapy to medication-assisted treatment to the clubhouse program, which was started 29 years ago and now sees about 45 “members” every day.

At the clubhouse, members — who join voluntarily — are given work on days they choose to show up. It can be anything from cooking a meal to writing a newsletter. As they advance in skills, they are connected with local businesses, which move them into jobs.

The people at the clubhouse form lasting friendships, and also learn to work through relationship struggles in healthy ways. For instance, clubhouse members and staff (who refer to each other as “colleagues”) make decisions about the clubhouse together. Sometimes someone disagrees with the majority.

“It’s adulthood,” Pottorff says. “It’s life, and how do you cope with life when things don’t go your way?”

Pottorff says it’s important to note that the clubhouse isn’t really treatment — it’s considered a part of a continuum of care — but he thinks it’s incredibly helpful. In fact, he says, other effective models also provide these types of services that work to connect people, help them rebuild healthy lives and give them a say in their future.

“The difference is they feel empowered, they feel heard, they feel their opinion matters and their voice matters,” he says.

Lauren Snyder, the state policy director for the nonprofit Mental Health Colorado, says she’s been impressed with the clubhouse model.

“It has incredible results because it’s really community-focused, not treatment-focused,” she says. “And that’s what I think a lot of people need.”

— J. Adrian Stanley

Coroner: Deaths drop

  • Courtesy Coroner’s Office

A bit of good news emerged from El Paso County Coroner Dr. Leon Kelly’s annual report for 2018: a reduction in drug-related accidental deaths. Last year, 133 perished due to drugs, compared to 147 in 2017. Notably, opioid deaths, which include accidents and suicides, fell by nearly 15 percent, to 87 in 2018 from 102 in 2017.

Kelly credits those declines to “progress by our medical community and public health officials.”

But the 2018 annual report also contains a disturbing fact: fentanyl, a deadly synthetic opioid, is on the ascent, taking nine lives in 2018, compared to only five in 2017.

Still, Kelly called it “progress” that only 12 percent of total opioid deaths involved medication prescribed by the decedent’s physician.

In 2018, methamphetamine led the way as the drug most often seen in accidental deaths involving drugs — in 36 out of 133 deaths, followed by heroin (22 deaths) and a combination of the two (18 deaths). Prescription opioids were a factor in 21 deaths, either alone or when combined with other drugs. Cocaine, fentanyl and ethanol were among other substances found in those who died accidentally from overdoses.

Turning to suicides, in 2017, according to Kelly’s annual report, 23 deaths stemmed from drug intoxication, but that report goes no further in breaking down which drugs were used.

In 2018, 18 suicide deaths were linked to drugs, of which nine involved opioids.

It’s worth noting that 73 percent of all those who completed suicide in 2018 had drugs (39 percent), alcohol (36 percent) or THC (15 percent) in their systems at the time of death. Three quarters of those who died from suicide were male.

Teen suicides fell to seven in 2018 (three males and four females) from 15 in 2017 (10 males and five females).

Some other drug-related facts from the 2018 report:

• 70 percent of those whose deaths were drug-related had a history of substance abuse or addiction.
• 23 percent had a known history of mental illness.
• 60 percent of the accidental opioid deaths were from heroin.

— Pam Zubeck


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