Eben Alexander III, MD Addresses the Opioid Crisis

1. Background on who you are and your experience in this industry.

I spent over 25 years as an academic neurosurgeon, including 15 years at the Brigham & Women’s Hospital and the Children’s Hospital in Boston. During this time, I taught neurosurgery at Harvard Medical School (Associate Professor) and performed over 4,000 neurosurgical operations. I authored or co-authored over 150 chapters and papers in peer-reviewed journals, authored or edited five books on radiosurgery and neurosurgery, and made over 230 presentations at conferences and medical centers around the world. Much of my focus was on advanced management of brain tumors, cerebrovascular disorders such as aneurysms and vascular malformations, and the stereotactic and functional neurosurgical management of refractory pain syndromes, as well as movement disorders and spine surgery.

Although the performance of surgery occupied much of my time, such a practice also involved patient care outside of the operating room. And, while most neurosurgery addresses physical symptoms/conditions, those in my profession inevitably encounter the effects on health from addictions of all types. Further, because of post-surgical pain, I am very familiar with protocols for prescribing the opioids used to control patients’ acute pain – such as oxycodone, hydrocodone, and morphine – so that they can recover comfortably in good time. Pharmaceutical representatives educated us through regular marketing efforts on the benefits and risks of such medications, although, in retrospect, it appears that much of that effort did not fully acknowledge the risks of addiction and overdosage.

Looking back, prescriptions for opioids quadrupled from 1999 to 2014 and increased in parallel with overdoses involving the most commonly used opioid pain relievers.(1) Since this marked increase in opioid addiction, the U.S. Centers for Disease Control and Prevention (CDC) has issued more restrictive recommended guidelines for prescribing, and physicians and nurses have had access to training on how to better communicate with patients concerning their pain levels and to monitor drug dispensing in-hospital.
Even so, once patients are discharged, they often feel the added stress from work and family, adding to their perceived pain. Much of the formal training information distributed by opioid manufacturers in the 1990s and early 2000s failed to acknowledge the highly addictive potential of some opioids; the potentially lethal dangers of their use, especially for the management of chronic pain, were minimized. It’s now clear that if patients stay on opioids too long, they greatly increase their risk of becoming addicted. Without appropriate support for getting off the drugs, they might also move from physician-prescribed and monitored meds to unregulated products on the street (including black market prescription opioids).

2. Give an overview of the story and what is happening.

The scale of the burgeoning opioid crisis is staggering: over 600,000 Americans have died of opioid overdoses in the 18 years since 2000, almost twelve times the number of Americans killed during the decade of the Viet Nam War. Each year witnesses an alarming increase in the number of fatalities. Sadly, much of the dynamic has been through misinformation and deliberate marketing by the pharmaceutical industry, and by some less ethical physicians who have operated “pill farms” to flood their communities with alarmingly overwhelming supplies of these dangerous and potentially deadly substances.

Unlike most issues involving the physician-patient relationship, the opioid crisis has been greatly inflamed by the breakdown in trust commonly assumed to be a major determinant in that relationship – addictive behavior involves less-than-honest discussions, such as fabrication of symptoms and histories, all in an effort to satisfy the addiction, but at the great expense of trust between doctor and patient. The ultimate victims are the addicts and their family and social circles, and yet the travesty of this epidemic reaches all corners of modern society.

3. Who will this impact and how?

With opioid addiction and overdose fatalities now at epidemic levels, the misuse of prescription opioids and use of heroin make this one of the most significant public health issues in the history of the United States. Opioid abuse now claims more lives than motor vehicle accidents. This is no longer someone else’s problem – it can be found in every zip code in our nation, affecting every age, cultural and socio-economic group. Too often the stigma of drug abuse keeps people from reporting their problems, compounding the situation. And, like most addictions, there is no one clear cause or remedy, which means the community as a whole must get involved.

According to data from the CDC, over 2.5 million people are dealing with opioid addiction involving pain relievers or heroin, and approximately 3,900 people initiate the nonmedical use of a prescription opioid every day.

In 2016, over 70,000 Americans died from drug overdoses that included illicit drugs and prescription opioids – that represents a 2.8-fold increase in total deaths from 2002 to 2015. And, during this same period, there was a 6.2-fold increase in the total number of deaths due to heroin overdose. Here is a breakdown of the causes of 71,614 total drug overdose deaths in the United States in 2016: synthetic opioids including methadone 23,459 (33%); heroin 15,446 (22%); natural/semi-synthetic opioids 14,427 (20%); methamphetamine/cocaine 18,282 (26%). The sharpest recent increase involved deaths related to fentanyl and fentanyl analogs (synthetic opioids) with 20,145 overdose deaths reported in 2016 (2)

Heroin use has increased significantly, by 63% in the years 2002-2013, and even more so in recent years. Increases are seen across all age groups and income levels with the largest increases in groups with historically lower rates of heroin use such as women and those with higher incomes. (3)

As one’s addiction progresses, the dose required for a given high increases, decreasing the margin of safety between the required dose and lethal suppression of respiration. Teenagers can often gain access to heroin more easily than a six-pack of beer. But opioids are more dangerous than alcohol, varying widely in purity, often contaminated with lethal substances on their journey from distant countries where they are grown and manufactured. “Cutting” street drugs with fentanyl, which is roughly 100 times more potent by weight than morphine, delivers a lethal mix for those unaware of its presence.

If these statistics of human life do not alarm you, then consider the financial cost to our nation. Government studies from 2013 showed that the abuse of tobacco, alcohol and illicit drugs had associated costs of more than $740 billion annually due to crime, lost work productivity and direct health care expenses. While costs related to tobacco were highest at $300 billion, prescription opioid abuse alone cost the country $78.5 billion overall, of which $26 billion was spent directly on health care issues. (4)

4. What are the short-term and long-term implications?

In the short-term, families are in crisis and people continue to die needlessly at alarming rates. Addiction is related to the brain’s chemistry, and the root causes can vary widely. A patient who comes in for routine surgery might be more susceptible to a chemical dependency through no fault of will power, but simply because their pain threshold is low and he or she needs pain relief for a longer period. The neuroreceptors in the brain require higher doses over time for the same effect, so that without the constant or increasing delivery, pain returns. Some pain patients develop hyperalgesia, where they are more sensitive to pain stimuli due to their long-term opioid treatment – the solution to their pain problem is to actually wean them off of the opioid.

For others in the general population, the feeling of euphoria derived from an opioid quickly becomes habit forming through the same pathway, turning a recreational pleasure into a formidable foe that ravages the body and brain and destroys relationships and families. The personality changes and the focus of all activity can turn on the next delivery of opioid rather than living life without such a burden as addiction.
As with any public health crisis, the risk of a significant number of deaths and a large number of people dealing with long-term disability is great. This situation further burdens those who remain relatively healthy and must support or provide caregiving for those afflicted. The health care system – already struggling under its present structure, the rising costs, and a growing number of baby boomers reaching an age that requires more healthcare services – is ill-equipped to deal with the present and impending crises where both mental and physical healing will require long-term strategies and community-wide cooperation. I submit that spiritual healing is also greatly wanting in our world, and that may be an area where my current life’s work can make a difference.

During my own struggles while recovering from alcoholism, I came to realize that a sense of spiritual emptiness, represented by isolation or separation from loving connections, seemed to be a root cause of addiction in general. As discussed in my most recent book, Living in a Mindful Universe, a culture such as ours is steeped in materialism, the idea that physical matter is all that exists, and as a result, it places very little value on spiritual matters. Far from being the result of brain chemistry alone, the drive to “get high” is an effort to fill a void of spiritual emptiness with something in the physical world. We must also address the root cause of our separation anxiety by acknowledging that we are primarily spiritual beings, inherently interconnected in the rich tapestry of life.

We can rally together today to address this existential challenge. Medical research facilities here and abroad are making remarkable strides in treatments for cancer and heart disease. With a national directive and federal budget allocation to fast-track research for addiction treatments and recovery, we can hopefully stem the tide of this devastating addiction crisis to staunch the hemorrhage from further loss of workforce talent and motivation, family infrastructure and other pillars of society. I believe one of the most powerful correctives will be an enhanced focus on the spiritual aspects of our existence – a rich sense of meaning and purpose, and of interconnectedness through spiritual awareness and cultivation of deeper relationships with our world.

6. How will things in your industry change from this?

Some in government approach this crisis through talk of more aggressive criminal legislation, including expanded incarceration not only of drug dealers but of addicts, which only further damages our social fabric. Medical professionals have begun to acknowledge the crisis by reevaluating prescription practices and developing better treatment protocols for those in addiction. But, ultimately, I believe the long-term solution will involve an enrichment of the spiritual core of our society. Religions have served as a formal base for much of human spirituality over the last few millennia, but religious orthodoxies sometimes tend to obscure an individual’s beneficial relationship with the spiritual universe, as opposed to enhancing it.
Looking again at some statistics for perspective, the CDC reported in 2010 that enough opioids had been sold to medicate every adult in the United States with 5 mg of hydrocodone every four hours for a month. (5) Although evidence shows that prescriptions for opioids have now waned slightly since peaking in 2011, efforts to curb supply (and demand from prescriptions) remain an essential part of combatting the opioid epidemic. (6) Physicians continue to modify protocols in pain medications, even as new clinical practices focused exclusively on pain management have emerged.

Meanwhile, our emergency rooms are dealing with extraordinary numbers of overdoses, from various substances, often endangering the lives of EMTs and hospital staff who come in contact with lethal substances while trying to triage patients. Protocols normally reserved for the most contagious diseases are being adapted to the ER, while drugs that can be used in the short-term to counter an overdose are not always in stock. Adaptive training has been instituted in many communities to meet the changing times.
New methods of longer-term treatment have thus far been relegated to rehabilitation and recovery centers that specialize in addiction treatment and recovery, although there are not enough such facilities and most are out of financial reach for many people or their insurance plans. Creative ways to follow a patient from crisis to recovery need to be developed, and soon.

7. What needs to be done or focused on that is currently being neglected?

In the Continuum of Care Approach report issued by the University of Pittsburgh in 2016, researchers claimed that although substance-use disorder (SUD) is a brain disease that is potentially fatal, research shows that it also is treatable. The disease is best treated through a holistic approach along the continuum of care, where SUD can be addressed through prevention, treatment, and ongoing maintenance/recovery to prevent relapse. Critical to the treatment of SUD is addressing both the needs of the person suffering and also the needs of the victim’s family. Families can provide important support for the victim, and they may also require services themselves to address the collateral harm of having a loved one suffering from SUD. (7)

Prevention, treatment, and maintenance/recovery are not quick fixes, especially with this condition. Each component requires a separate type of focus. Prevention has been shown effective in other areas such as in efforts to curb tobacco smoking through publicity campaigns and the surgeon general’s warning, among other tactics. And, we have reduced or prevented accidental deaths in this country by wearing seat belts, but not without a substantial promotional campaign and new legislation. But such massive promotion has not yet been undertaken in regards to opioid addiction. We are just getting started, and the stigma still lingers, as for many mental health initiatives in this country. New strategies, especially using social media, may prove invaluable. The treatment phase is fairly standard in terms of initial counter measures. Drugs such as naloxone, suboxone, and vivitrol are currently in use. The treatment is by no means easy on the patient, but is better than the alternative.

Maintenance and recovery are areas that can have a range of variables and will likely succeed with an individualized approach. Some will need a structured residency recovery center as a first stop after the hospital, to prevent a relapse to old habits and surroundings. Family members may need training and education about what changes need to be made in the home environment. And, as we all know from experience, making new healthy habits can be a big challenge. So, good support mechanisms of many kinds will be important, from continuing and monitoring anti-opioid drug therapy (if indicated) to diet and lifestyle changes, to group therapy, etc.

As part of the lifestyle changes, we must become more open to alternative methods of managing pain that are mind-based. The mind has tremendous power in shaping our emergent reality, as the placebo effect so consistently demonstrates. Addiction points to underlying unresolved emotional (and spiritual) issues, not solely chemical imbalances in the brain. Despite their advantages, social media and modern technologies have continued to separate us from one another. These conveniences may well be contributing factors in the rising suicide rate and sense of loneliness especially in young people. Having real-time connection with others is a vital part of living that cannot be ignored. We need to develop ways to reduce that isolation and lack of social contact, while encouraging mindfulness practices, as we work together to promote a healthier society.

8. What can be done to improve our current approach to the crisis, and what can one individual do to make a difference?

So much of my work since my near-death experience (NDE) in 2008 (as described in Proof of Heaven [2012], The Map of Heaven [2014] and most recently Living in a Mindful Universe [2017]) has centered on the realization that consciousness is fundamental in the universe. We are in the midst of a paradigm shift that I believe will outshine the Copernican revolution as science and spirituality come together in unprecedented fashion. The binding force of love is prevalent in our universe and our souls outlive the death of the physical body. What a revelation this is, and one not dependent on adopting a particular religious belief.

It is simply based on the empirical data concerning the nature of consciousness, and expanded worldviews emerging to accommodate them (as opposed to the simple dismissal and denial of such experiences typical of materialist scientists). We are all interconnected and share great personal responsibility for our every action and thought. If more people realized this fundamental truth, it would offer a higher perspective on their lives. Such a perspective would provide constant support in the addict’s determination to overcome the addiction and live a life with a higher level of fulfillment.

The false notion of physicalist neuroscience that we have no free will, and thus no such responsibility, has been very damaging for our stewardship of planet Earth, not to mention of our individual lives. It is time to take full responsibility for our behavior, thoughts and actions. Warfare and senseless violence, ecological mayhem, economic polarization, and mindless addiction – all these and more are consequences of the false sense of separation from each other that scientific materialism and societal materialism at large have foisted upon the world. It’s time for all of us to wake up!

As an individual, these perspectives can open us to new thinking, but we also need practical tools. What I have found very effective is developing a daily habit of meditation – going within my own consciousness using the support of differential frequency brain entrainment sound recordings created by Sacred Acoustics [http://www.sacredacoustics.com]. Meditation has been proven for centuries to be effective for physical, mental, emotional and spiritual health. This and other mindfulness practices do not require much money (if any) or special abilities, and they can benefit the entire family as well as the individual.

Quieting the mind becomes an invaluable practice, so that we can hear that voice within, and there find our answers. By getting in touch with the neutral inner observer, anxieties and problems are viewed with a fresh perspective, allowing for clearer choices and a more directed future. Developing a relationship with expanded consciousness from within is akin to being in touch with your “higher self” or “higher power.” Trusting in that higher power is a bastion of Alcoholics Anonymous. No matter what the nature of such a higher power, the important thing is to acknowledge we are not alone in the universe and everything happens for the purpose of learning and teaching important life lessons – and, we are not slave to all of the demands of our ego.

As Einstein famously said, a problem cannot be solved through the kind of thinking that resulted in the problem in the first place. To solve this unprecedented public health crisis, we must step outside our usual paradigm and reckon with some deep societal changes.

From a big picture viewpoint, the prevailing paradigm of materialism in medicine and overall society must be reevaluated. Far from being physical beings under the control of random fluctuations of hormones and neurons, we are spiritual beings having a physical experience. Most importantly, we are responsible for all of our choices in life, and our current crisis around drug addiction and overdose has its roots in our deepest sense of existence and our relationship with the universe at large. We must adapt more comfortably to our roles as spiritual beings in a spiritual universe. This bigger picture view will allow more facile resolution, both for individuals and for society at large, of an evolving crisis as grand as our current opioid addiction crisis.

[1. Paulozzi LJ, Jones C, Mack K, Rudd R. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep 2011;60:1487–92]
[2. CDC http://wonder.cdc.gov]
[3. Vital Signs, CDC http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm]
[4. https://www.drugabuse.gov/related-topics/trends-statistics]
[5. CDC’s Vital Signs Sept 2016, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm]
[7. http://d-scholarship.pitt.edu/29950/1/IOPOpioidReport2016.pdf]

Here are a few of the many resources available in the United States.

Substance Abuse and Mental Health Services Administration (SAMHSA)
http://www.samhsa.gov/find-help –resources and locator for physician/treatment
1-800-662-HELP (4357) – 24/7 FREE and CONFIDENTIAL helpline
https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-Updated-2016/All-New-Products/SMA16-4742 FREE prevention toolkit

US Department of Health & Human Services
https://www.hhs.gov/opioids/prevention/index.html – guide to opioid addiction treatment

Partnership for Drug-Free Kids
1-855-DRUGFREE (378-4373) – Bilingual parent support, 9a-5p ET, Mon-Fri

Narcotics Anonymous
http://www.na.org/ – information and how to find local meetings

The National Institute on Drug Abuse

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