I’m the editorial page editor of USA TODAY, and I recently lost a son to the opioid epidemic. I’m joined by Dr. Marc Fishman, medical director at Maryland Treatment Centers in Baltimore. AMA!

My sister and father are addicts, heroin and oxy. I've already lost my mother, aunt, brother and friend to heroin.

Thank you for writing your article. It was good for to hear that hitting rock bottom isn't the answer. Sometimes I tell myself it is so I feel ok about the distance I have to take with those that I love, but I agree MAT is the direction to push them if they'll let me.

With all that said, as the mother of three teenagers, what can I do to help prevent or catch it in the beginning? We have open discussions and try not to let my family influence what's seen as normal and acceptable but like most parents I often feel like I don't know what I'm doing.

Any advice for parents to help see signs of use or concern in teenagers?

Very sorry to hear about your losses.

So important as a parent to look for warning signs and act on them. Hope alone is not an adequate response, as things usually will not get better on their own. Important not to "explain away" early use as something that "all the kids are doing." When parents are concerned they should talk openly with their children and seek professional evaluation.

​

One of the most messages for the prevention of opioid addiction is to prevent initiation by addressing earlier forms of substance use problems, most commonly alcohol and cannabis.

​

--Marc Fishman

Very sorry for your loss.

Although I agree there is a problem but, Do you think the blanket change is punishment for pain patients? Also, when people can’t get legal meds do you think it pushes them to street drugs which make the problem bigger?

Thank you very much for your time to tackle this issue

Yes, this is trickiest part of the crisis. We don't want to deny legal meds to people who legitimately need them for pain. And without enough access to treatment, people who are addicted to pain pill are going to turn to street drugs that are easier to get, cheaper and give a better high. I'm not sure the system is capable of such a highly calibrated response.

-- B. Sternberg

I’m gutted for you, and all the other families this has happened to. It just seems like there is no end in sight to this, that it keeps getting worse. Tell me there’s a glimmer of hope, that the tide might be showing signs of at least slowing?

Thank you. You're right, the overdose death data continues to get grimmer. If there's a glimmer of hope, it's on the prevention side, where prescriptions of opioid painkillers are falling rather dramatically. Also, the scope of the crisis -- nearly 200 people a day dying of drug overdoses -- has mobilized a public policy response.

-- B. Sternberg

​

Does it bother you that the DEA doesn't use simple auditing techniques to identify and prosecute "pill mills"?

Important question, but I'm not well informed on the techniques that the DEA and other law enforcement uses to identify sources of illicit opioids. II do know that many pill mills have been identified and shut down --- which I think is a good thing, but I don't know how they are identified.

​

--Marc Fishman

I'm not American. We don't have an opioid crisis in our country. What has caused the massive acceptance of prescribing addictive substances?

Stage one of the crisis is that drugmakers, distributors and doctors flooded the USA with prescription painkillers that turned out to be far more addictive than the manufacturers claimed. This hasn't happened to the same degree in other nations.

-- B. Sternberg

We have seen a 2 decade process of concern about the under-treatment of pain, in which the medical community took the mis-direction of excessive use of opioid pain medications as a response. As it turns out there are the non obvious consequences of overuse of opioids. This is the problem that has been well-publicized of getting 60 pills and 3 refills for a wisdom tooth extraction. Further, it turns out that opioids don't really even work that well to relieve chronic non-cancer pain to begin with.

​

-- Marc Fishman

After kicking withdrawal from opiates how long does it take the brain to ‘heal’ (for lack of a better word)? Are there any nonaddictive medications someone could take to help them through the process?

I recently took myself off of them and have been in a funk ever since (it’s been a bit over a month)

We don't really know exactly, but our best estimate is at least months and in some cases years for the lingering chronic effects.

​

The question of how to help restoration of normal function is one of active research. Certainly vigorous active pursuit of alternative pleasurable activities and stress relief tool is critical. Some doctors recommend antidepressants, certainly for those that have significant depression or anxiety. Some researchers are wondering whether there might be medications that can help restore "normal" dopamine balance or restore healthy function of the opioid receptors, but these remain hypothetical and unproven.

​

-- Marc Fishman

My brother is in treatment for fentanyl addiction and is on suboxone. His treatment plan is to keep him on suboxone forever. The idea is that detox, rehab, and other treatment have dismal track records and are are costly to hospitals, shelters, cities/towns - basically society.

What do you think of this approach?

Buprenorphine (suboxone) is one of the effective relapse prevention medications for opioid addiction. Our best information is that although some people can be successful after discontinuing the medications, most people do better the longer they stay on them.

​

-- Marc Fishman

I am so sorry for your loss. Thank you for sharing your story. Hopefully others will learn from your tragedy. How did you learn your son was addicted to opioids?

For pain pills, when we confronted him for stealing from us to support his habit.

For heroin, the track marks in his arm were a dead giveaway.

- B. Sternberg

Since the crisis came to the forefront have the numbers stabilized or are they trending in one direction or another? Or is it simply too early to tell?

Also, I am saddened over the loss of your son. As a Dad myself it guts me to think of my own little boy someday being lost.

I appreciate the kind thoughts. Unfortunately, the trend lines are grim. Last year, according to preliminary numbers from the CDC, there were nearly 50,000 opioid-related deaths, up 16% from the year before. This is being driven by heroin and counterfeit pain pills being laced with powerful synthetic opioids known as fentanyls.

- B. Sternberg

Dr. Fishman, as a psychiatrist, how do you think mental health plays into opioid addiction and abuse?

Concurrent mental health problems with addiction are the rule rather than the exception. We have clear evidence that treatment of co-morbid psychiatric illness improves addiction treatment outcomes.

​

--Marc Fishman

Why are opioids so addictive?

It's the fundamental biology of opioids and their effect on the brain. We are hard-wired to be very reinforced by opioid, and most people find them pleasurable. What's worse is that after a time of steady use, stopping opioids becomes difficult because of the physiologic withdrawal that happens, and the effect in relieving stress.

​

- Marc Fishman

how much of this was caused by drug companies lobbying doctors to prescribe their products?

why is there not legislation to curb such practices, as well as limit advertising prescription drugs on tv?

Probably a significant amount. Doctors were told there was less than a 1% chance of addiction for prescription opioids. In reality, the number is probably between 10% and 25%. There has been some legislation to limit initial prescriptions to 3 or 5 or 7 days, which should help.

-- B. Sternberg

I agree that drug companies were part of the problem. But there were other sources of influence as well. As doctors we are motivated to try to relieve suffering, but in our attempts at compassion we sometimes make mistakes. Organizations like the profession medical societies and the Joint Commission (that accredits health care providers) also pushed the agenda of better stronger paint treatment. We tend to swing to extremes in general. And now although we recognize we vastly overdid that agenda, I think we are swinging too far the other way, and some patients who really need opioid pain medications are being limited by the new restrictions.

​

Can you speak to the efficacy of Drug Courts in the US in curtailing narcotics use?

What should our legal policy be toward users?

I've seen drug courts in action and think they can be very helpful in providing incentives and alternatives to incarceration for non-violent abusers.

-- B. Sternberg

What can family members do to help someone with an addiction even if they don’t want help?

The key message is never give up, it's a marathon not a sprint. The idea is to keep engaging, trying to persuade a child (or any loved one) that they have changed for the worse and their own personal goals are being derailed. Use natural reinforcers for positive behaviors (like accessing treatment) and "active ignoring" for negative behaviors. You don't have to commit to a full course of treatment (like "rehab"), how about just starting with an evaluation --"let's see what the professional has to say..."

​

​

-- Marc Fishman

​

Do you feel responsible for his death by enabling his lifestyle choices?

As I wrote, the line between supportive and enabling isn't bright or clear. It can shift by the hour or by the day. But addiction is a chronic brain disorder, not a "lifestyle choice."

-- B. Sternberg

When treatment providers talk to parents about "enabling" we are often heard as send a message that this is your fault as a parent. That is the WRONG message. We need to do a much better job communicating with parents and helping understand that they can't control everything but we can educate them and empower them to use their natural leverage over the long haul to make a difference in monitoring and supervision. But there are no easy answers, and no predicting the future.

​

-- Marc Fishman