How To Solve the Opioid Epidemic
Q: What can therapists do about the Opioid Epidemic?
A: You can’t avoid the news without hearing that opioid use has become an epidemic in the United States. Drug overdose is now responsible for more deaths than automobile accidents. The president declared it a public health emergency and numerous government officials and treatment providers have made it a key issue.
Ask anyone who has become addicted to heroin, loves someone who uses it, or works with people who are trying to quit and they will tell you heroin and opiate addiction is horrific. It’s a living hell. After one of my clients had gone through withdrawal, he said, “I did not think I could feel that bad and still be alive.” But, I am telling you: we are focusing on the wrong issue. There is another way to solve the opioid epidemic.
I’ve been a therapist working with those struggling with dual diagnoses (both drug/alcohol and mental health disorders) for nearly a quarter of a century.
I am a trained Narcan provider. If I see someone who is overdosing on an opioid, I can spray this drug and reverse their overdose, potentially saving their life. But guess what, I have never had to do this. And, of the thousands of clients I have worked with during my career, I can probably count less than one hundred people who have been dependent on heroin or painkillers. I am the co-founder and Clinical Director of an outpatient private practice. I would likely see more opioid dependent clients if I worked in a detoxification unit, emergency department, or an inpatient addiction center. However, most psychotherapists are in an outpatient setting like me.
Take a moment and ask yourself about the clients you see and the members of your community:
Parents: are you more likely to find an empty beer bottle or a needle in your child’s room?
School administrators: do kids get sent to your office for smelling like marijuana or nodding out in class from opioid use?
Legal professionals: are you more likely to see a Driving Under the Influence or a possession of heroin?
Therapists: will someone come to you for help with for depression and anxiety or injecting heroin?
Colleges: are you more likely to break up a keg party or a trap house?
Spiritual leaders: do your parishioners come to you because of drinking too much or taking too many pills?
The National Survey on Drug Use and Health (NSDUH) reports that marijuana is the most widely used illicit drug. Approximately 37 million people in the United States admit to it. That’s the about the amount of people who live in California. Yet only 948,000 people are using heroin—the population of San Francisco. Yes, this number is too large and too many people’s lives are ruined, but I still say that we are focusing on the wrong drug issue.
The Centers for Disease Control and Prevention (CDC) found that more than nine of ten people who used heroin also used at least one other drug. And that heroin rarely is the first drug of abuse. The CDC also notes that one of the main risks factors for using heroin is first being addicted to marijuana and alcohol.
Are you beginning to see the problem? There is a clear connection between alcohol and marijuana use that can lead to the more lethal addiction of heroin. The earlier it starts, the more serious it becomes. Why are we not treating marijuana and alcohol use as the epidemic waiting instead until people are hooked on opioids?
The evidence shows that we need to intervene much earlier. As we know from the number of lethal overdoses from heroin and fentanyl by the time in gets to this point, it may be too late. We have to do something sooner.
Here is how I handled a family who called me when they found a homemade bong in their 16-year-old son’s room. I met with the parents without their son as he refused to attend the session. The soft-spoken mother voiced her concerns that had seen changes in his attitude at home and who he spent time with, along with finding the bong and empty beer bottles. The father was angry at having to come to my office, saying that he had smoked pot as a kid and turned out fine, and that his wife just “babied” their son. He argued that his son still got good grades and played lacrosse. Then he said the two most common rationalizations I hear: “It’s not like he is shooting heroin and weed is practically legal.”
Now any good therapist knows not to argue back with a client about the flaws in his statements. There was no point in arguing with his defenses. This told me where he stood and gave me clues of how to intervene with him. The mother was already more on board, as she knew something was not okay with her son, thus would be more open to recommendations.
I first acknowledged how much they must love their son to spend the time and money to meet with me. I was very careful not to side with either parent as the child was already taking advantage of their different viewpoints. I asked questions about their son, making sure to focus on changes to what was normal for him. Stereotypes still show “pot heads” as listening to a certain type of music, talking slow, and not doing well in school. It can be hard to distinguish between what is the normal separation and individuation of an adolescent and the developing signs of a marijuana use disorder.
In my years of experience, I have found that one of the most telling signs of regular substance use is having paraphernalia or being in possession of alcohol. This young man had made his own bong. This signals a red flag to me that he is likely using it frequently, has probably purchased it, and may be using it alone. When probed the parents also admitted that they had noticed him smelling strongly of cologne (to hide the smell of marijuana smoke), heard a rumor that a new teen he was spending time with was a “bad kid”, and allowed him to have beer with his friends, thinking it was better to know where he was and that he was not driving. The couple also found vomit in the backyard a few weekends ago. While adolescence is a period of testing limits, taking risks, and rebelling against authority, regular drug or alcohol use is not.
Trying marijuana or alcohol at a party junior or senior year is within normal limits. I find it critical for the parents and adults in kids’ lives to send the message that drug and alcohol use is not acceptable. Teens often see things in black and white. Their pre-frontal cortex— a part of the brain that forms judgments, weighs outcomes, and controls impulses and emotions— is not fully developed until around age 26. Biologically adolescents are not able to see the shades of grey that an adult can.
For example, if healthy adults chose to consume alcohol (I have many thoughts on marijuana, but will not get into them here!) they assess their responsibilities, make sure those are taken care of, find a ride home, etc. These actions reduce the likelihood of significant consequences. Additionally, alcohol is more activating for adolescents while more sedating for adults. This mean that the more a teen drinks, the more likely he or she is to become aggressive or reckless, while an adult typically gets sleepier. At this age, teenagers’ brains are wired to seek pleasure and not think through consequences. These skills we develop with age and experience.
Once I gathered additional information from the parents about the young man, I suspected that he might be experiencing a mild to moderate marijuana use disorder. But I also needed to meet with him. I wanted to know why he was making the choices he was. Could there be trauma? An underlying mood disorder? Problems at home or school that would explain what he was hoping the drug would do for him? Oftentimes when kids are using chemicals “just to have fun” they generally stop after the first or second time they get caught and consequenced. This young man’s behaviors had been found out on several occasions.
Now remember that this young man refused to attend the session. No problem, rarely do my clients voluntarily come to see me. It is a myth that people have to “hit bottom” before they get help. Most often the reason people are in my office are because of external reasons like getting caught by a parent, spouse, employer, school, or law enforcement.
With adolescents, I prefer to first offer options. I recommended to these parents that they go home and let their son know that they spent the session talking about him. Most people are uncomfortable with this and want to be able to tell their side of the story. I told them to say that I wanted to meet him before I ever gave any direction on what to do; that they might even being doing something wrong (this has hooked many adolescents). He knew his parents had differing views on how to handle consequences. When the father was angry he had threatened military school or a wilderness program. The mother cried and wondered if he needed to go into rehab.
I prefer parents offer reluctant teens incentives for therapy. Parents of most kids over the age of twelve know their most powerful weapon: the cell phone. “Son, you can have your phone back once you have your appointment.”
Lastly, if the teen still refuses, we give consequences. “You can’t drive the car, go out, and get your allowance, etc. until you complete your evaluation.”
Many times by the time I see an adolescent in my office, their substance use has been occurring between six months and two years. They are not kids who got caught on their first use. There are often behavioral, academic, interpersonal and sometimes mental health and legal issues that are occurring. A typical recommendation I give in this situation is once a week individual and group therapy for the teen with random drug and alcohol screening. I also educate parents on the signs and symptoms and how to provide consistent, predictable, and fair consequences. I rarely recommend an out of home placement unless there is a severe substance use disorder that includes multiple daily drug use and a mental health diagnosis that interrupts activities of daily living. We have to be careful of using the most intensive treatment option as a first choice unless there is a life threatening symptom or behavior. To be a dual diagnosis therapist you have to be comfortable high-risk actions, resistant behaviors, and confrontation.
Research has repeatedly shown that the younger someone starts using a substance, the greater likelihood there is that they will become addicted to it. In fact, if someone begins using before age 15, they have about a 50% chance of developing a severe substance use disorder—addiction. It is also well documentedthat 90 percent of people who develop a substance use disorder began using chemicals in their teens.
We need to take adolescents’ drinking alcohol and smoking marijuana seriously because these can be the early warning signs of a developing addiction. It may not just be “kids being kids”, “experimentation” or “everybody doing it.” This use may be the first symptoms of heroin addiction. We need to address it.
When I am meeting with concerned adults I often use shock value to get their attention. I ask parents again how many children they have. Often it is two. I then look them both clearly in their eyes, “Which one are you willing to give up?”
This may sound extreme, but I need families to hear how dangerous early drug use is.
I tell parents that they will never regret meeting with a licensed therapist who is credentialed in substance use disorders and has experience in treating adolescents. Just like talking about sex is not going to make them go out and have relations, talking about substance use is not going to make them suddenly take a drink or take a hit. Requesting a drug screen from a teen who is already using substances is going to yield a very different response that one from a teen who has not been under the influence.
The majority of adolescents are not experiencing addiction. Yet.
Don’t wait to do something until it is out of control.
Yes, there is a heroin epidemic. But that epidemic usually starts with alcohol and marijuana use. As a community we have the opportunity and responsibility to prevent one more overdose by taking action sooner.
