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“With clarity and keen insight, Drs. Olsen and Dr. Sharfstein trace the opioid overdose epidemic back to its roots, and lay out the steps that every community needs to take going forward to prevent overdoses and save lives. The Opioid Epidemic is absolutely essential reading for those who are just getting up to speed on this national health crisis and for seasoned public health and policy professionals alike.”
Nicole Alexander-Scott, Commissioner of Health for Rhode Island and President, Association of State and Territorial Health Officials
“Understanding the addiction epidemic in the US today is a daunting task. This is a complex issue crossing many disciplines–health services, criminal justice, law enforcement, and family systems. This book is excellent in offering the most up-to-date orientation of the history of the disease, laws, causes, treatment, and, most of all, hope. I wish this book had been available when my son was struggling for his life. A must read for those who suffer and those who love them. Great primer for medical professionals, law enforcement and any others who want to be part of the solution of healing and hope.”
Barbara Allen, Executive Director and Founder, James Place and Chair, Howard County Opioid Council
“As two of the most distinguished experts on addiction and the opioid epidemic, Drs. Olsen and Sharfstein have written a definitive guide to understanding the epidemic and arming readers with information backed by science and evidence to help themselves, their loved ones, and their communities.”
Michael Botticelli, Executive Director, Grayken Center for Addiction Medicine and former Director, White House Office of National Drug Control Policy
“This is a one-of-a-kind, comprehensive review of everything to know about the opioid epidemic. Drs. Olsen and Sharfstein have made complex issues accessible and digestible to the reader. This book should be read by everyone involved in the opioid epidemic— especially patients, family members, health care providers, and policy makers.”
Chinazo
Cunningham, Addiction Medicine Physician, Albert Einstein School of Medicine
“Years into our nation’s lethal and unrelenting opioid epidemic, we are still missing a level-setting work that equips us with the language, concepts, science, and tools to truly tackle the crisis together. Drs. Olsen and Sharfstein have given us just that: an accessible and compelling account of the opioid epidemic in all of its dimensions, including the best path out of it. It should be required reading for everyone contending with the crisis, in other words, for all of us.”
Brandon del Pozo, Chief of Police, Burlington, Vermont
“In highlighting the worst public health disaster facing Americans in a generation, Olsen and Sharfstein methodically provide riveting insights in a relentlessly logical manner. The book is the most comprehensive and insightful look at the opioid crisis from its origins to what it will take to solve this epidemic, written in a clear and concise manner. A must read for everyone.”
Rahul Gupta, Former Commissioner and State Health Officer for West Virginia
“In this pragmatic and accessible book Drs. Olsen and Sharfstein unrelentingly explain and hew to the science behind opioid addiction and related public policy. Their book will help people who use drugs and their families, health professionals, and policy makers make wiser and safer choices for themselves and their communities”
Hilary Kunins, Assistant Commissioner, Bureau of Alcohol and Drug Use, New York City Department of Health and Mental Hygiene
“This highly informative book is a valuable resource to help families truly understand addiction. Most, if not all, of your questions will be answered.”
Toni Torsch, Director, Daniel Carl Torsch Foundation
“The Opioid Epidemic offers insightful life-saving educational information not only for health professionals but for the millions of individuals and families struggling to find answers in a sea of confusion and conflicting information. An important contribution from two of the most informed and practiced thought-leaders on solving the opioid crisis.”
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This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.
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To Our Parents
Section 2:Â Individuals and Families
6 Treatment for Opioid Addiction
Section 3:Â Communities and Policy
APPENDIX
PREFACE
The taps on the shoulder are discreet, the words whispered in shame. “My son is in jail again.” “I worry every day that my daughter might die.” “Why is my husband behaving like this?” “My wife overdosed last night.” “I think I might have a problem.”
For a crisis that has landed on millions of doorsteps across the country, the opioid epidemic has left many individuals and families in a state of isolation—as well as in a state of confusion. Confusion about what opioids are. About how addiction develops. About which treatments work. About how best to support the process of recovery. Out of desperation, many Americans have spent their savings on worthless programs and false cures.
Misunderstanding about opioids also pervades community meeting rooms, town councils, city and state agencies, and the halls of power in Washington, D.C. It permeates emergency departments, physician offices, and hospital wards. More than 70,000 Americans each year are dying of overdose, the majority from opioids. The crisis is responsible for a decline in life expectancy in America over the past three years. Yet many responses are constructed with little awareness of evidence or history. The result is that many of the actions taken to address the opioid epidemic have made little difference—or even made the problem worse.
This state of confusion on opioids is, in its own way, a national crisis.
In our own careers, the two of us spend many hours answering questions about opioids from individuals with addiction, friends and family members, clinicians, agency officials, and elected leaders. Some of these conversations happen in person during work hours; others in urgent calls late at night.
One of us is a doctor specializing in addiction medicine; the other is a former public health official. We have witnessed the devastating consequences of the opioid epidemic. But we have also seen many people heal and recover.
We share this conviction:Â The fog that surrounds the opioid epidemic is not impenetrable.
With effective treatment, people can feel better, reunite with their families, and regain faith in themselves. With greater understanding, families can become an essential source of support to their loved ones. With an informed perspective, communities can tackle the opioid crisis as a solvable problem. With a public health approach, measuring results at each step, our nation can turn the corner on the opioid epidemic.
Our purpose in writing this book is to document the lessons of science and history, to replace myths with facts, and to help individuals, families, and policymakers tell the difference between wishful thinking and what really works. Of course, there is much unknown about opioid addiction. But what is known can be put to great use.
It starts with the basics: What are opioids, and how do they affect the human brain and body. The book’s first section explains the essential concepts of tolerance, withdrawal, and physical dependence—and how these differ from addiction. This section discusses effective treatment and recovery and ends with an overview of the opioid epidemic and what can be done.
Individuals and families need straightforward answers. The book’s second section addresses when to use opioids for pain and why opioids are misused. It answers questions on
addiction and treatment, including for teenagers and pregnant women. It covers how to stop an overdose in progress and how to assist a loved one in recovery.
Why did the opioid epidemic start, and how can it be stopped? The third section addresses urgent questions facing local communities, cities and counties, and states,—as well as the federal government. This section reviews the evidence on which programs and policies work for prevention and treatment—and which do not. It also addresses sensitive issues, including the “not in my backyard” syndrome, the “war on drugs,” and the evidence about harm reduction approaches such as naloxone distribution, syringe services programs, and overdose prevention sites (also known as supervised consumption spaces). It closes with specific recommendations to save lives.
At times, it may seem that opioids leave us all powerless to resist their devastation. But this is not true. “Knowledge is power,” wrote philosopher Francis Bacon more than 400 years ago. With greater understanding can come strength, resolve, and hope.
ACKNOWLEDGMENTS
This is a book two careers in the making. We thank everyone who made these careers possible, from our earliest mentors to our many amazing colleagues at IBR/REACH, the Maryland Department of Health, Behavioral Health System Baltimore, the American Society of Addiction Medicine, and the Johns Hopkins Bloomberg School of Public Health.
Individuals with opioid addiction, along with their friends and family members, have been our greatest teachers. We are profoundly grateful to have shared in their journeys. We also deeply appreciate the community leaders and policymakers who have trusted us amid crisis.
We appreciate the tireless efforts of our research assistant Jenny Wen and the helpful comments of Kathleen RebbertFranklin, Sarah Despres, Sean Allen, and Colleen Barry. This book would not have been possible without the able assistance of Chloe Layman and the expert guidance and generous encouragement of our editor Chad Zimmerman, both at Oxford University Press.
Finally, we thank Sam and Isak, two remarkable young men who keep us hopeful for the future (and grounded in the present). In writing this book, we are honoring the tradition of our parents, Marie, Bjorn, Margaret, and Steven. All four are physicians devoted to improving the lives of others through science, care, and compassion. This book is for them.
Section 1 THE BASICS
1
THE BASICS OFÂ OPIOIDS AND OPIOID ADDICTION
What are opioids?
Opioids are a group of chemical compounds that can reduce pain, cause sensations of pleasure, and induce sleep. To have these and other effects on the human body, all opioids interact with specific receptors on the surface of cells called opioid receptors.
How are opioids made?
There are four sources of opioids.
Agriculture
The oldest known opioids come directly from the seeds of the poppy plant, Papaver Somniferum. The history of the poppy plant stretches back more than 5,000 years to a time when ancient Sumerians, the earliest known civilization in today’s Iraq, discovered the “Hul Gil” or “joy plant.”1
Today, poppy plants are grown for the pharmaceutical production of opioids under the supervision of the United Nations in Australia, France, Hungary, India, Spain, and Turkey.2 Poppies are also grown illicitly in Afghanistan, Mexico, and other warm and dry areas of Central Asia and Latin America.
