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Beyond Binary: Rethinking Opioid Crisis Solutions

In shifting the opioid crisis conversation toward solutions, one recurrent obstacle is our binary way of thinking. Healthcare policy, like media coverage, favors “either/or” categorization of all problems and solutions. We love stories with clear heroes and villains. (If you doubt this, follow the coverage of Purdue Pharma, Insys, or other drugmakers these days.) It makes sense that our media is sometimes forced to simplify stories in this way. After all, when things get more complex, viewers tune out. What has been disheartening to me is waking up to the reality that our policy discourse falls into the same trap. This binary approach in actively unhelpful in shaping the discussion of addiction, recovery, and wellness.

Opioid Prescribing

The recent history of opioid prescribing is marked by vacillations. As I detail in The United States of Opioids, in the late 1800s, the standard of care for doctors prescribing opioids extended to preventing addicted patients to avoid withdrawal. By the 1920s, the Federal Bureau of Narcotics was arresting doctors by the hundreds for this practice. As the memory of this crackdown faded, the “pain as the vital sign” movement gained steam in the early 2000s. I found myself defending doctors who were being prosecuted by state medical boards for undertreating pain. The pain doctors I advise these days are so afraid of DEA and medical board response that they would rather turn away patients in pain than prescribe more than minuscule doses of opioids.

These swings from one polarity to the other – and back again – have been brutal for patients and providers alike. People in chronic pain are living in misery. In the worst cases, untreated pain is driving an increase in suicides. Rather than contributing to solving the opioid crisis, the binary approach has added another dimension to the crisis. Not only are overdose and substance use disorder rates rising but now doctors cannot treat pain effectively and people in pain cannot get the medications they need. The same dynamic predominates discussions of cannabis and psychedelics. They are the bogeyman to some, and a silver bullet to others. Part of the solution to the crisis is finding a middle ground where doctors can treat pain without fear and people who need medications can actually get them.

Biomedical and Socioemotional Models of Addiction

Of late, I have been struck by the extent to which binary thinking is obstructing the pursuit of more effective addiction treatment. Is addiction a biomedical condition? Or is it primarily socioemotional? For policymakers these days, the conversation is strictly biomedical: addiction, in this view, is no different than heart disease or diabetes, a chronic condition to be managed through ongoing medication. In some corners of the addiction treatment field, the conversation is strictly socioemotional: the path out of addiction is counseling, psychosocial support from a peer community, and a spiritual path.

The bifurcation gets in the way. Several months ago, I was meeting with a senior policymaker in a key government agency dealing with opioid addiction, listening to why medication-assisted treatment (MAT), i.e. Suboxone, is the only solution to the crisis that is actually backed up by the data (number of overdoses). When I asked about funding for counseling and social model recovery, the answer was “social model (e.g. 12-step) is nice, but where’s the data to prove that it works?” A few weeks later, I was at a conference explaining the implications of new laws prohibiting addiction treatment providers from turning away patients on Suboxone. The room was full of dedicated providers, many veterans of the recovery journey. The frustration over new anti-MAT discrimination laws was palpable. “Why,” one person asked me, “are insurance companies and government shoving an opioid substitute down our throats?”

As a lawyer navigating through clinical, regulatory, and reimbursement challenges in addiction treatment, the answer should be obvious: addiction simultaneously has biomedical and socioemotional features. Our genes and neurobiology put us at risk for substance use disorders, as do socioemotional factors like family history, and childhood trauma. Why do we have to choose? it seems the answer is that, in an environment of scarce funding, the two models of care are forced into a nonsensical competition. I frequently meet people who share stories of their children who would not be alive but for MAT. I have many friends who swear they are only alive because they went through the hard work of recovery because they found both a community and a spiritual path. We need to find a model of care that makes room for and provides access to both approaches.

Wellness and Eliminating Shame

In thinking through solutions to the opioid crisis, a recurrent issue that comes up is the way that shame and stigma keep people needing help—in prevention before, and intervention after addiction or mental health challenges arise—from reaching out. In looking for ways to normalize the challenges that lead to substance use and mental health issues, one critical item is to reframe wellness away from the binary model. In going around the country talking about addiction, I constantly get asked, “Are you in recovery?” People are quick to label themselves as being well. Addiction and mental health are problems that we talk about through other people in our lives like family, friends, neighbors, and co-workers. The underlying assumption is binary; “I am fine,” we reflexively answer when asked. My daughter is addicted. Listen to conversations and the recurring message is the same: I don’t have a problem. My friend has an anxiety disorder.

Part of the solution to the problem forces us to get rid of this binary way of thinking. We are all broken, just in different ways. Acknowledging our brokenness is what creates the space to make it safe for us to talk to each other. As I travel the country talking about The United States of Opioids, I have begun to make a point of sharing my connection to recovery and addiction. I talk about my daily work—social connection, prayer, exercise—to address my own mental health issues. I have found that being vulnerable about my own brokenness is an important way to change the conversation. Addictive behavior and mental health challenges occur on a continuum. We need to stop treating them as binary states of being addicted or not, of being mentally ill or well. By acknowledging that we are all dealing with these challenges in various forms, with different degrees of severity at different times for different people, with different coping mechanisms, we reduce and hopefully eliminate the shame for everyone. We can begin to move toward rethinking wellness as encompassing dimensions beyond smoking and weight. We must begin including our needs for human connection, spiritual meaning, and financial security. In the process, we expand the conversation and increase the chances of people who need resources are able to get them in a timely and effective way.

My goal in The United States of Opioids was two-fold: first, to think through the numerous points of system failure beyond bad behavior by drug companies. Second, to call attention to the deep social crisis beneath the surface. The first step in rethinking the crisis with more complexity is to pay attention to the countless ways that binary modes of thinking predominate and confine the conversation. I hope you will join me in moving beyond a binary mindset.

Harry Nelson is the founder of Nelson Hardiman, the largest healthcare/life sciences law firm in Los Angeles, and author of The United States of Opioids: A Prescription for Liberating a Nation in Pain (2019)

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Read Harry Nelson on Forbes: People in Pain: Navigating Opioid Crisis Politics

If you told me that I would get a barrage of angry emails and social media posts for writing The United States of Opioids: A Prescription for Liberating a Nation in Pain,  I would not have believed you . Who could possibly have a problem with my trying to change the conversation to solving the opioid crisis?

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Death-by-Opioid: How many Opioid Deaths are Suicides? Does It Matter?

We often speak about the opioid crisis and the suicide crisis – the parallel rises in the rate at which people are overdosing and taking their own lives – as if they are separate and distinct problems. According to Centers for Disease Control (CDC) data, the rate of fatal drug overdoses for 2017 was over 70,000, with 2/3 being opioid-related (49,000). The number of overdose deaths from all drugs and opioid, in particular, continues to break a new record every year. Meanwhile, suicides numbered over 47,000, a one-third increase over the past two decades. The demographic data hold all kinds of troubling trends, including suicide among the young and among women.

Many people’s overriding image of the opioid crisis is distinct from suicide: the patient in severe pain who gets prescribed too high a dose by a doctor or takes more than the doctor ordered to compensate for pain, accidentally overdosing as a result. Or the those who overdose from the lacing of “party drugs” with fentanyl. A 2015 study (reviewing hospital emergency room data) found that more than half of opioid deaths are, in fact, unintentional.

But is death by opioids a form of suicide? The same study found that over a quarter of overdoses were unambiguously suicides. The same study found that, in 20% of overdose deaths, it was impossible to determine. If we assume that the ambiguous cases stratify similarly to the clear accidents and clear suicides, then the rate is even higher: roughly 1/3 of overdoses as suicides and 2/3 as accidental.  Assuming that 20,000 drug overdoses are suicides, then the 47,000 figure is undercounting the totality of America’ s suicide problem.

What can we learn from this data? Does it really matter why people are dying?  While all of it is bad news, it’s critical to take some lessons away from how we respond to both public health challenges. The most basic takeaway is that the suicide crisis is embedded within the opioid crisis. This should not surprise anyone: between easy public access to heroin and fentanyl (just visit Craigslist) and the biochemical process of opioid overdose (a trifecta of euphoria, pain relief, and respiratory depression to the point of brain death), opioids are a relatively easy way to go. Some of the suicides might be people who are suffering from depression or other mental health issues and see opioids as an alternative, effective of taking their own lives (Growing recognition of opioids’ effectiveness as a means of death led  Nebraska to become the first state to use opioids to carry out a death sentence in July 2018). Perhaps the most bitter irony of the denial of prescription opioids to people in severe chronic pain is that some people are taking their own lives with illegal opioids when they are denied access to legal ones.

If as many as a third of opioid overdoses are intentional, then another takeaway should be greater policy focus on addressing the underlying social and mental health issues driving the problem. When we examine the opioid policy response, much of the action has been focused on cracking down on doctors or biochemical response (drugs to prevent overdoses, like Narcan). These policy initiatives make sense if the central problem was unintentional overdoses. Based on the intentionality of some overdose deaths, however, these solutions are less relevant (in the case of Narcan) or actively harmful, in the case of the crackdown on doctor prescribing.

Meanwhile, it is hard to find much in the way of a policy response addressing the deep social crisis underlying intentional overdoses. Having sat at the table with federal policymakers, I am deeply troubled by the minimal level of attention spent examining how we address pervasive isolation, stress, and trauma, rising reported rates of anxiety and depression, and despair across America. Focusing on the opioid crisis as part of the suicide crisis and the suicide crisis as part of the opioid crisis means exploring how we address these underlying drivers. In The United States of Opioids, I argue that we cannot afford to wait for the government or our healthcare system to make this pivot. It is time for a grassroots action to address this within our homes, workplaces, school, religious communities, and in civic life.

What do we need to do? The more you study the data, it becomes clear that these crises are not easily reduced to one simple problem. They reflect multiple things going on at once. In a 2014 study of suicide and chronic pain, just under 9% of patients with suicide had evidence of chronic pain, but nearly 19% of patients without chronic pain tested positive for opioids. Mental health issues such as depression were a much more significant factor (present in over half of the suicides studied). The bottom line is that the decision a person makes to end his or her own life, and the interplay between pain and mental health issues is complicated. The important thing for us to remember is that the opioid crisis is not just about the people dying accidentally. It’s also people ending their own lives with opioids. Some of these are people cut off by their doctors. Many are people not getting access to effective social support and mental health resources. We have plenty of work ahead of us.

 

Harry Nelson is the author of The United States of Opioids: A Prescription for Liberating a Nation in Pain (2019) and co-author of From ObamaCare to TrumpCare: Why You Should Care. He is the founder of Nelson Hardiman, L.A.’s largest healthcare/life science law firm, where he advises on health regulatory and reimbursement issues.

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Read Harry Nelson on Forbes: Time to Stop Gawping and Start Doing Something About the Opioid Crisis

For over a year now, media coverage of the opioid crisis has been a steady drumbeat. Almost every day, we see variations on the same stories; another overdose death; the latest lawsuit over deceptive drug marketing; or another story on the Sacklers, founders of Purdue Pharma, and the billions they earned trafficking opioids. For all of the attention it gets, the opioid crisis just keeps getting worse…

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Taking on the Opioid Crisis in Schools: A New Vision

Earlier this week, I was lecturing to public policy students about The United States of Opioids: A Prescription for Liberating a Nation in Pain at USC, when a student shared that, as a 9th grader, she and her Boston high school had gotten trained on how to administer Narcan (naloxone), the overdose drugs. The school supplied syringes onsite, she said, for overdose response.

Listening to her, I was struck by what a different world it is for students today. One of my messages about the roadmap out of the opioid crisis in the book is that we need to rethink the opportunity for schools and educators to play a role in combating the opioid crisis. I’ve got to be honest that I didn’t have in mind Naloxone administration training when I wrote the book. It is a sad reality that we need this kind of crisis response training. What I’m interested in is: how far can we go to transforming the school curriculum nationwide from the youngest ages through high school to give age-appropriate training to create new awareness, new language, and new skills that will support greater resilience in facing a new world of pervasive environmental and emotional challenges (that, among other things, are underlying the opioid crisis).

While the idea of focusing on schools as a battlefront in taking on the opioid crisis showed up in the 2017 President’s Commission on Combating Drug Addiction and the Opioid Crisis, my view is that we are thinking too narrowly. The three highlights on this issue from the Commission were:

At Risk Behavior starts in Middle School: since drug use and at-risk behavior is beginning in middle school (6th grade forward), we need to start earlier than we have been in addressing the issues and provide resources through high school college.
More Prevention and Early Intervention: we need evidence-based prevention outreach programs in schools, including tools for teachers and parents to enhance awareness of the dangers of drug use, early intervention strategies for kids with environmental and individual risk factors (trauma, foster care, developmental challenges); and
SBIRT: we need to train counselors and school staff to utilize Screening, Brief Intervention, and Referral to Treatment (SBIRT), in schools to screen for substance use, provide counseling and make referrals as appropriate.

Amen to all of the above. But in The United States of Opioids, I ALSO argue that we need to think about even bigger opportunities:

Don’t wait for middle school: One of my messages in the  book  is that middle schoolers may be the earliest age group at which at-risk opioid-related behavior behinds, but the work needs to start right the beginning in early education and elementary school to lay the foundation for a next generation of kids who are more resilient, and less at risk of stress-driven emotional responses.
Mindfulness and Response Flexibility: As it becomes clearer that the modern environment of technology and nonstop media are not suited for how we as human beings are built (and that the opioid use among the young is being fueled in part by stress-driven emotional responses), we need to teach children how to focus their concentration and assert control over their attention, to notice distraction, and to take time for rest and recovery. Rather than waiting for kids to experience and cope with the inevitable exhaustion and mental and emotional stress resulting from all of the demands on our attention and the many sources of distraction, we need to prepare them. Embedding mindfulness and response flexibility training into the school curriculum means teaching children to be more resilient and help them develop neural pathways for good health. (Note: thank you to Judith Gordon, a human design facilitator, for sharing her important work on this subject with law students with me.)
The Normalcy of Emotional Stress: The stories of opioid crisis victims are full of children who grew up feeling all alone in a sense of worthlessness, anxiety, depression, and isolation. These are stories of emotional stress and pain that is wrapped in a layer of shame that keeps kids from sharing what they are experiencing with parents, teachers, and friends. We need to teach children that they are not alone — that these feelings are pervasive and part of life (especially in a time of information onslaught). We need to teach awareness, so that no more children make the mistake of thinking they are the only ones who are all alone in feeling worthless or hopeless or living in shame. We need a curriculum that teaches not just self-awareness, but coping skills for mental wellness, including the importance of communal activity, healthy peer group communication, and the way that exercise, sleep, good nutrition are part of wellness. Too many children are at either the extreme of suffering in silence out of shame or being pathologized and prescribed for. While everyone’s experience is different and some cases call for intervention by health professionals, the pervasive nature of these issues calls for an education curriculum to raise self-aware children.
Skills of Engagement, Prevention, and Intervention: At the broadest level, the opioid crisis is a symptom of how disconnected so many people are. We ought to be teaching the skills of engagement and requiring service opportunities to instill in children a sense of their own power and capacity to be a positive force for change. One of the things that became clear to me in writing  The United States of Opioids  is how often we are unaware that our expressions of concern are laden with judgment and shame for the recipient. We need to be teaching and learning not just new awareness, but new language and new skills to raise a generation that understand and are motivated to be agents of prevention and intervention in the lives of everyone around them.

What will this look like? I am inviting educators and parents to join me in a new conversation about how we might retool our schools to take on the opioid crisis in these ways. I’ve made a similar case for a new approach to parenting on many of these same issues. What do you think? I look forward to hearing from you.

Harry Nelson is the author of  The United States of Opioids: A Prescription for Liberating a Nation in Pain . Harry’s #NotAnotherStat campaign is raising money to support vitally important work in filling gaps in our response to the crisis, including:

-development of standards to require psychosocial counseling and support participation in recovery for patients receiving medication assisted treatment

-developing resources for employers of all sizes to support SUD and mental health in workplace wellness

– supporting the work of other critically important advocacy groups, including the National Association of Recovery Residences and Young People in Recovery, who are working with Harry on resource development

-convening conversations to bring together important voices on tackling the opioid crisis, and supporting the resources to do so.

Harry has pledged to donate $1 million from sales of the book to this effort.

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Can Religious Communities Be A New Battlefront for Tackling the Opioid Crisis?

This past weekend, I visited Saddleback Church, the Baptist evangelical megachurch founded by Pastor Rick Warren, the author of, among many other books, The Purpose Driven Life (2002). It was my first time in a church in a long time, and, honestly, blew me away with its powerful, inclusive, and healing message.

I came to Saddleback at the invitation of Dr. Ron Wolfson, author of God’s To Do List, to talk with church leaders about the potential as a religious community for catalyzing a grassroots campaign to address the opioid crisis. I have been a big fan of The Purpose Driven Life since I first read it 15 years ago, and particularly of Warren’s articulation that the path to a life of personal fulfillment, happiness, and purpose runs through being of service to others.

Perhaps the central problem of our era may be the vast numbers of people who are suffering because they don’t feel they are part of anything. In Chapter 6 of The United State of Opioids, I examine how the opioid crisis parallels a crisis of suicidality (as much as one-third of overdoses may be suicides) and reflects the anxiety, depression, isolation, chronic stress, and lost sense of purpose of the present and recent decades. These sources of pain explain why the crisis keeps getting worse. A 2018 study by researchers at the University of Pittsburgh identified a 40-year exponential rise in the overdose death rate (a majority accidental and a minority suicides) across all types of drugs—underscoring that the solution does not lie in drug policy, but rather in attention to the social crisis manifesting across America. We are a society in pain, with too many people whose needs are going unmet turning to self-medicating as a solution.

The thing that frustrates me most is the way that most of the coverage of the crisis amounts to “rubbernecking”. We watch the latest news story passively. Nothing seems to move us out of shock and into action.

One of my overarching messages in the book is that the real challenge in front of us — to bring down the exponentially increasing overdose rates and the scary rates of addiction and chronic pain — demands a new conversation, one that eradicates the shame that keeps people disconnected. To me, a critical part of the “work” of beating back the opioid crisis is developing awareness, skills, and resources to empower people to be agents of engagement, connection, prevention and intervention.

Saddleback, with its volunteer infrastructure, reach, and ministries that already focus on key elements of the crisis (including Celebrate Recovery, Grief Support, and Chronic Pain) seemed like a perfect place to test my theory that religious communities are uniquely positioned to lead when it comes to the work in front of us. Imagine how many people could be reached if we enlisted more people who walk through the doors of churches and synagogues to reach out to the people who are just one degrees of separation away. I have been heartened to find allies in the church leadership who have put the opioid crisis on their agenda and are eager to think about and begin implementing the work ahead.

Beyond Saddleback, I am looking forward to sharing more in the weeks ahead about my dialogue with a wide range of Christian, Jewish, and other religious communal leaders about potential collaboration and the role religious communities can play in this crisis. One takeaway in these conversations so far has been a different sense of urgency in some places. The first challenge of awareness is getting people to realize that this crisis is happening everywhere. There may be more overdose deaths in one community than another, but people are dying everywhere, and the rest of the suffering — the addiction, the chronic pain, the emotional pain, which we know from the data are pervasive — are disturbingly unseen. If you are interested in finding out how you and your community can play a role, I invite you to order a copy of The United States of Opioids and email me to discuss next steps. I look forward to hearing from you.

 

Harry Nelson can be reached at hnelson@nelsonhardiman.com.

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Cannabis and Opioids: Yes, we need more research, but that’s not an excuse to slow expansion of access

Last week’s New York Times talks about New Hampshire’s hesitancy to join other states in decriminalizing and expanding access to marijuana because of fears of the public health risks in the midst of still reckoning with the harm caused by opioids. For my fuller perspective on this issues, read Chapter 9 of The United States of Opioids, where I address the risks and promise of cannabis in detail, including some of the following ideas:

The Data is that Cannabis Access Reduces Overdose Deaths: The critical data point that New Hampshire and other states hesitating to expand access to cannabis should be paying attention to is that, in decriminalized states like Colorado,  the rates of opioid overdose deaths have gone down . According to a 2014 study published in JAMA Internal Medicine, between 1999 and 2010, states that made marijuana legally available for medical purposes had nearly a 25% lower annual rate of opioid analgesic overdose deaths. In 2010, that translated to 1,729 fewer people dying. Even after suicides are excluded from the data and heroin overdoses were added in, the data shows the same association–more access to cannabis means fewer opioid-related deaths. Period.
How Marijuana Access Impacts Opioid Use: In  The United States of Opioids , I share insights from a September 2018 University of Pittsburgh studythat identified that, over the past 40 years, when you combine together all of the various sub-epidemics of drug abuse (heroin, prescription opioids, cocaine, methamphetamine, etc.), the resulting data forms a tight, linear, exponentially rising curve of overdose deaths. What this data signifies, among other things, is that illegal drug use operates with market efficiency. Whether use is recreational or self-medication, whenever government pushes down on the availability of one kind of drug, suppliers and user demand simply shifts to another drug. We see this playing out in opioid use. The government cracked down on prescription opioids, and traffickers filled the void with black tar heroin. The government cracked down on heroin, and traffickers increased their importation of fentanyl. It makes perfect sense that giving users access to marijuana means some people will choose an option other than opioids. If expanded marijuana access saves lives, that should be the end of the conversation.
Enough Already With the “Reefer Madness” Propaganda: People opposed to cannabis decriminalization are excited about Alex Berenson’s book,  Talk to Your Children ,decrying the menace of marijuana. Berenson’s book links cannabis use to psychosis. While there is no question that cannabis raises multiple health concerns that demand attention, this alarmist message is hard to take seriously. Thanks to a growing body research done outside of the United States (in places where the government has not obstructed research), we now have evidence that, along with the risks, cannabis has numerous valuable therapeutic applications. Moreover, as I write about in  The United States of Opioids , in striking contrast to opioids, there is  no dosage at which c a nnabis kills people.  That difference is why we have an opioid crisis and not a cannabis crisis. 
Thinking about Cannabis as Similar to Alcohol: In light of that growing body of research about the promise of marijuana, Berenson’s book represents a return to scare tactics from the “Reefer Madness” era, which were used to deny access and maintain the criminalized status of cannabis.

No one is denying health risks around cannabis use and the need to study them. The better way to think about cannabis access is parallel to how we think about alcohol. Alcohol addiction is a problem. Alcohol has extensive risks and related social harms. As we learned in the Prohibition Era, however, the bottom line is that we are better off as a society when we decriminalize it, apply standards to its production and marketing, and focus on limiting access for kids and expanding public health education and awareness. ironically, cannabis appears to be distinguishable from alcohol, both for its extensive therapeutic potential and for a lower level of harm. As with alcohol, the rational path forward for cannabis involves (a) expanding access; (b) opening up research; and (c) putting into place controls to prevent use by children, and (d) education campaigns to increase awareness of risks, and (e) developing treatment resources for people with use disorders.

For more on this topic, please check out The United States of Opioids.

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Recognizing, Reconnecting, Doing Something: A Prescription for America’s Pain

In this week’s New York Times, David Brooks offers a hopeful vision of what we can do with America’s pain — not just the literal chronic pain (afflicting 50 million Americans, 1 in 5 adults), but the pain caused by the opioid crisis and all of America’s other social problems. Parents losing teenagers to overdoses. People feeling isolated, caught up in their own perceived worthlessness. Brooks identifies a “common thread” that I address in Chapter 6 of The United States of Opioids, the “Deeper Roots” of the opioid crisis.

My original vision in writing the book was my sense that the conversation around the opioid crisis was like ships passing in the night: the public health policy community focusing on containing a spiraling overdose death rate was not having meaningful dialogue with the addiction treatment community. The community treating and suffering from chronic pain were left out of the conversation altogether. Despite the fact that this crisis is a series of interwoven problems that need attention in a unified conversation, our discourse has not been addressing the issues comprehensively. I felt uniquely positioned to tie up many loose ends and misperceptions by virtue of working across numerous segments of the healthcare world and participating in both high level discussions and on-the-ground work.

One of my biggest frustrations has been the oversimplification of the issues. We villainize Big Pharma for their central role in the opioid crisis, but we ignore many other broader points of health system failure — and the way that Pharma continues to be a bad actor. (Earlier this month, the Academy for Integrative Pain Management announced that it was shutting down, its funding suffocated because it was making the case for ways to treat pain other than pharmacology. We continue to have perhaps the most powerful lobby in America hobbling our efforts to improve care.)

But in writing the book, I got to the same point that Brooks alludes to in his article, the overwhelming sense that, when you look at the 40 year crisis of exponentially rising overdose death rates across all drugs, the issue is not any particular drug but the social crisis running through American life: deep anxiety about the future, a lost sense of purpose, despair, a sense of isolation, and chronic stress. Brooks gets to a similar point via different route. He diagnoses the “common thread” of America’s deeper pain as “our lack of healthy connection to each other, our inability to see the full dignity of each other, and the resulting culture of fear, distrust, tribalism, shaming and strife.” Amen.

I believe that, if we don’t begin to address these challenges, then all of the healthcare reform in the world amounts to “rearranging deck chairs on the Titanic.” So what can we actually do? In Chapter 10 of The United States of Opioids, I make the case that we need to start a new conversation about not just fixing healthcare, but changing ourselves: how we parent, how we engage in supporting wellness in the workplace, what we teach in our schools, what we do in our religious communities, and, above all, how we interrelate in our broader communal spaces — getting rid of the shame in order to get people to talk about the pain. Expressing concern without judgment to get people the help they need.

In his article, Brooks likens the overdose crisis to Pearl Harbor and asks “Aren’t we called at moments like these to do something extra?” Amen, David! In sharing the message of my book, I keep meeting people coming at the problem with different perspectives and different prescriptions than my own — people who are doing something. I met with Media Policy Center founder Harry Wiland, one of the filmmakers behind “Do No Harm-The Opioid Epidemic.” Wiland and his co-founder of MPC, Dale Bell, are filmmakers and journalists who are focusing, among other things, on creating accessible video educational content that kids and schools can access and use for prevention. Their work, in turn, highlights other people making a difference.

Brooks shares his own involvement in the Aspen Institute’s Weave: The Social Fabric Project, which is trying to understand the issue of America’s social isolation by looking at problem-solvers around the country who are “building community and weaving the social fabric.” He talks about a bunch of inspiring examples: a vet helping other vets dealing with mental illness in New Orleans, a boxing gym owner in Ohio teaching young men about life through boxing, a woman in Florida who spends her week looking out for local kids and visiting people in the hospital.

For me, the irony about what Brooks describes and that runs through The United States of Opioids is that, in a time when there is much to discourage us, to make us think we are facing insoluble problems and an existential crisis, there is also much to be hopeful about. There isn’t one solution to the opioid crisis and the interrelated problems we face: there are 330 million potential solutions, each waiting for one more person to commit themselves to some action to make a difference. If you’re already on the same page, I’d love to hear about what you’re doing. If you are wondering how to get involved, I’m glad to share ideas as well. Ultimately, the prescription for liberating a nation in pain is all of us doing something.

Harry Nelson is the author of The United States of Opioids: A Prescription for Liberating a Nation in Pain (ForbesBooks 2019). To learn about how you can contribute to Harry’s projects to tackle the opioid crisis, visit https://notanotherstat.com and https://bhap.us/force/.

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