“What caused the opioid epidemic?”
This is a question I frequently get asked as a physician who works on the front lines of the opioid crisis. For the past several decades, our country has been waging a War on Drugs. The strategy on its face seems logical: If we eliminate the source of recreational drugs by incarcerating users and traffickers, we can eliminate the plague of addiction. Thus far this war has been an unmitigated disaster. It has cost billions of dollars, drug use rates remain the same or have increased, and millions of people, disproportionately those from poor and minority communities, have been incarcerated, destroying the social fabric in many parts of our country. All in an attempt to squelch drug use, a behavior that has existed across all societies since the dawn of humanity.
While the war on drugs has been around for several decades, the opioid epidemic in its current form started about 20 years ago. It began with aggressive attempts by pharmaceutical companies to promote use of prescription opioids. These companies lobbied regulatory organizations to encourage physicians to treat pain more aggressively. At the same time, physicians were not educated about the true risks of opioids and how to use them judiciously. When you factor in cultural expectations that we treat pain to the point of eradication—despite the fact that this is not always possible—and an over-reliance on pills to remedy all that ails us, everything was in place to create a dramatic increase in the prescribing of opioids. This led to increased availability in medicine cabinets and, eventually, on the streets. To put a global perspective on our opioid consumption, consider that while the US makes up only 5% percent of the world’s population, it consumes 80 percent of the opioid supply. Are we in the U.S. in that much more pain then the rest of the world?
To make sense of this perhaps it helps to know that emotional and physical pain are processed in the same part of the brain. And opioids relieve both types of pain. A study on rats conducted in the 1970s by psychologist Bruce K. Alexander helped us to understand the complex interaction between addiction and emotional stress. Previous studies looking at the behavior of rats in solitary confinement produced consistent results: A rat in this environment, given the choice between plain water and water laced with opioids, will most often choose the drugged water until it kills itself.
Alexander then asked, “What if a rat was placed in a ‘rat utopia’ with plenty of adequate food, space, recreation, social interaction and mating opportunities and given the same choice?” The results were provocative. His rats preferred plain water to drugged water. Furthermore, rats in solitary confinement that had been imbibing opioid- laced water for weeks chose plain water after being moved to “rat utopia,” even if that meant enduring withdrawal symptoms. Alexander’s research team concluded that isolation, boredom, alienation and a lack of connection appear to be the most important contributors to drug addiction. When one lives in an enriched environment with minimal stress and where one’s basic needs are met, one would be unlikely to use drugs. To the contrary, one would likely avoid them.
This leads me to wonder: As our society’s rates of opioid use increase, is it our environment and its effect on our sense of well-being that is the major contributor to this increase? The World Happiness Report 2017 states, “The USA is a story of reduced happiness. In 2007 the USA ranked 3rd among the OECD countries; in 2016 it came in 19th. The reasons are declining social support and increased corruption….” Could the opioid epidemic be the result of a perfect storm: increased drug availability and an unhappy, stressed, disconnected populous doing what they can to cope? Are we in a situation very similar to that of rats deprived of their basic needs?
It seems that for most of my patients, drug use starts out as a solution to problems of living. I would argue that part of that problem is the disconnect between how we currently exist and how we as human beings evolved to exist. We are social animals that have evolved to gather in communities, not to live increasingly isolated lives. We are supposed to follow natural rhythms of wake and sleep instead of burning candles at both ends. We are supposed to have time to rest and play instead of working longer and longer in order to meet basic material needs. And while many other factors contribute to the development of addiction, including genetics, socioeconomic status and exposure to trauma, most of these factors are deeply influenced and intertwined with the environmental factors I have already mentioned.
Given the enormity and complexity of the opioid epidemic and its root causes, it can be difficult to know where to begin when addressing it. In the next issue of The Charlotte News, I will outline a series of possible remedies for this devastating problem.
Carina Cartelli, M.D., is a Charlotte resident and a physician practicing at Howard Center’s Chittenden Clinic in South Burlington.