So how did the epidemic start?

I asked Dr. Rigg if overprescription of opioids contributed to the problem. In short, his answer was "yes", but the issue is a little more complicated than that and has changed over the decades. According to Dr. Rigg, "the epidemic was really started through overprescribing." In the 1990s, when OxyContin was first being introduced, doctors were quick to prescribe it, mostly because they were misled by the companies manufacturing the drug. In fact, Dr. Rigg states that "pharmaceutical companies knew how addictive opioids were, but purposefully hid it." Another reason these drugs became so problematic, is because they were "aggressively marketed", especially to people living in low-income areas, rural communities, people living with chronic pain, as well as to older adults. Prescription painkillers, in particular, Oxycontin, were largely responsible for most of the opioid overdose deaths in the late 1990s. However, once deaths started rapidly rising, society took notice. The prescribing of these drugs became much more closely monitored, the media launched campaigns to raise awareness, "pill mills" (clinics which distributed these prescriptions, no-questions-asked), were being shut down by law enforcement, and doctors received more education on the safe prescribing of opioids. Because of this corrective action,  prescription-related opioid deaths tapered, but heroin (a street-level opioid) deaths began to sharply increase. Starting in 2015, we saw fentanyl, a synthetic opioid, being responsible for the most overdose deaths across the nation.

What poses a greater threat- prescription medications or street drugs?

Prescription drugs are given supposed to be given to a patient under the supervision of a doctor and there is a great amount of research on the effects of these drugs in order for them to be FDA-approved, so surely they are safer than street drugs, right? Not so fast! Many people think there is no harm in taking an extra Xanax or Percocet, or borrowing some pills from a friend's prescription. However, according to Dr. Rigg, "in some cases, prescription drugs can be just as dangerous, as street drugs." Why? Well for starters, if you take a drug that is not meant for you, you are not under that doctor's supervision. That drug was prescribed for the other person, with his or her unique medical history in mind. So while a dose may be safe for your friend, it may not be safe for you. Also, you should never take more than the prescribed dose. Doing so could lead to overdose. Also, it is important for people to remember that using prescription drugs that are not yours- or giving a drug prescribed for you to someone else- could result in legal trouble- both criminal and civil. While you may be arrested on a felony charge for the illegal use of a prescription, you could also be held liable if the person you gave the drug to overdosed. So say you give the rest of your prescription for a painkiller to a friend and that friend ends up overdosing and dying. If the prescription can be traced back to you, you can be held liable for his or her death. Dr. Rigg stresses that "no drug use comes without risk." The moral of the story, is never share prescriptions, and never take more than the recommended dose.

How does misuse of these drugs lead to addiction?

It is important to remember that there is no one set pathway to addiction- it depends on the individual and his or her unique situation. However, there are risk factors, commonly found in people's backgrounds when they begin using. Dr. Rigg, for his research, has interviewed roughly a thousand individuals who suffer from drug addiction. What is the most common pathway he found? "The most common pathway was through a friend or family member." Others start using to cope with trauma, stress, or emotional turmoil. Others want to experiment or explore a new sensation. We would like to think that it would never happen to us. Dr. Rigg's response to this false belief is that "addiction doesn't discriminate and that no one is immune to the disease of addiction". He continues by adding that "almost every demographic group has been touched by this." We even see it in celebrities- Demi Lovato and Robert Downey Jr. are examples of some celebrities who have gone public with their histories of addictions. Sadly, Mac Miller, the famous music artist, died from an overdose. Cocaine and fentanyl were found in his system at the time of his death. However, it is critical that we understand that this issue is not just affecting white, middle or upper-class people. The media tends to heavily cover these cases, but there are other communities not receiving media coverage. There is a dramatic increase in the opioid deaths of African-American and Latinx citizens. This is not being discussed enough. Despite the large number of deaths that is happening in these minority communities, there are very little resources, such as drug treatment centers or providers of mental health care. We also see the elderly being affected by this issue. Older people often have to take a lot of prescriptions, and may undergo painful medical procedures or live with chronic pain as a result of their age. Whenever there is a large number of medications- there is the danger of overdose. People almost never overdose on a single drug- rather, it is an interaction of drugs that creates a dangerous situation. One of the most dangerous combinations is of two or more depressants. Depressants are drugs that slow down our central nervous system- our breathing, our heart rate, and our blood pressure. Opioids are depressants, but so is alcohol, Xanax, and drugs taken to treat anxiety. If taken in excess, or along with another drug, these drugs can stop or dangerously slow people's breathing. While some groups may have a higher risk of addiction than others, Dr. Rigg emphasizes that, "addiction can happen to anyone."

What sort of questions should we ask if a doctor prescribes an opioid?

Here is some advice from Dr. Rigg on the type of questions to ask or information to bear in mind if you are given an opioid prescription:

Ask: "What medications should not be taken with prescription opioids?"

Advice: "Benzodiazepines, such as Xanax, are the most dangerous to take with opioids, but substances, like alcohol, sleeping medications, or anti-anxiety medications may also interact poorly with opioids and may result in respiratory depression. Have your doctor to give you a list of substances to avoid when taking opioids for pain."

Ask: "How do I safely store my opioid medications and dispose of it?"

Advice: "It's probably best to store opioids in their original packaging. Also, don't keep them in the same location where over the counter medications like Advil are stored. Rather, be sure to keep them in a locked cabinet or other location where people (especially children) can't easily access them. Also, it is advisable to dispose of opioids after your pain is gone. The most ideal option for disposal is to find a collection site at a local pharmacy or police station. If this is not possible, then it is acceptable to flush some opioids down the toilet like Percocet or Vicodin. However, if your opioid medication is not approved to be flushed, place the pills in a sealed Ziploc bag with either coffee grounds or dirt and throw it in your trash. To find out if your pills are safe to flush, visit fda.gov"

Ask: "If I have a substance use disorder or mental illness, can I take prescription opioids?"

Advice: Yes, you can, but discuss it thoroughly with your doctor before deciding to use prescription opioids. Research shows that individuals with these conditions are at higher risk for developing opioid-related problems. Patients should also be aware that there are a wide array of pain management techniques that do not involve the use of opioids. Some of these include cognitive behavioral therapy, acupuncture, and non-opioid medications.

"If your doctor is not aware that you have a history of mental health illness or addictive disorders, please tell them."

Do not be afraid or ashamed, it is an important factor for your care provider to consider when selecting the safest and most beneficial treatment option for you.

How can we help a friend or loved one we are concerned about?

If substance use is negatively affecting someone you love (impairing their ability to function at work, school, or fulfill other responsibilities), or their use is high-risk, then that is a problem. If you are concerned, approach that person from a place of love for them. Express your concern without judgement and offer your support and resources if needed. If your friend or loved one resists treatment, then propose using harm-reduction strategies. Included at the end of this article is a list of resources.

What are some harmful myths about the opioid crisis?

There is a pervasive myth circulating, that opioid use is only affecting white people. Dr. Rigg states that "this myth is largely perpetuated by the uneven coverage of the epidemic in the media." In fact, the demographic group that is experiencing the fastest increase in the opioid epidemic is African Americans and Hispanics. Native Americans also have a high percentage of involvement in opioids for their population, but none of these demographics are receiving attention from the media or politicians. These people in these demographics deserve awareness, resources, and media attention. We cannot forget that Americans of every race and ethnicity are being affected by this tragedy. Furthermore, the opioid epidemic is not just confined to pharmaceuticals anymore. Now most deaths are associated with street drugs, such as heroin and fentanyl. People who use intravenously are at an extremely high risk for contracting disease, such as HIV or Hepatitis C and developing other health issues. We have to stop using terms like "junkie" to refer to people who use these drugs. They are people who have addictions, and they are every as bit deserving of help as the people who are addicted to prescription drugs. A successful, evidence-based practice in lowering the risk of transmitting these diseases, are clean needle exchange programs, also called syringe service programs. Unfortunately, this is controversial, as some people view this harm reduction strategy as enabling drug use. The CDC, along with other federal agencies, have reached the conclusion (based off extensive studies) that clean needle exchanges create safer communities by reducing prevalence of HIV. Clean needle exchanges do not increase crime or drug use- they just make it safer for people who for whatever reason, are not in treatment. It is actually more cost-effective, as well. The evidence backing these claims is strong.

The single most important piece of information about this issue:

"We've got to stop this war on drugs." Dr. Rigg says. The war on drugs, launched in the 1980s, has proven to be ineffective. This war has lasted far too long and is creating more problems than solutions, such as the waste of billions of dollars and the ballooning of the prison population. Most people who finally get help for their addictions, end up doing so as a result of involvement in the criminal justice system. People are serving very long sentences in prison for possession charges. Yet, drug use is still prevalent. Our perspective needs to shift if we want to resolve this issue. People who are addicted to drugs are not bad people- they are in the words of Dr. Rigg, are "people who deserve to be treated with dignity and we should be doing everything within our power to keep them alive and healthy". Dr. Rigg wants to remind readers that addiction and substance use is a health issue and it is absolutely imperative that it be treated as such. "We need to be fighting the opioid epidemic through public health interventions" says Dr. Rigg. Dr. Rigg concludes by saying that this is "not a criminal problem, and we should be fighting this epidemic with better prevention, treatment, and harm reduction solutions, rather than with more police and outdated drug policy." As for myself, I want everyone to know that we have to end the stigma and judgement surrounding substance use and addiction.

For more resources:

If you are concerned that you or someone else is experiencing substance use, do not be ashamed and look into the following resources:

https://www.samhsa.gov/find-help/national-helpline

https://www.na.org/meetingsearch/

https://www.drug-rehabs.org/

To learn more about the opioid epidemic:

https://www.hhs.gov/opioids/about-the-epidemic/index.html

https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

You can follow Dr. Rigg on Twitter (@krigg01) or read his blog:

https://www.psychologytoday.com/us/experts/khary-rigg-phd