Introduction
“Presently she cast a drug into the wine of which they drank to lull all pain and anger and bring forgetfulness of every sorrow.”1
The inebriant described in Homer’s “Odyssey” depicts the equivalent drug experience currently overwhelming the United States: opioids. This class of drug has taken many forms throughout history, from opium to fentanyl and has played a major role in influencing civilization. This is by virtue of the neurobiological affinity humans have for it’s euphoric and pain-reducing effects. The over reliance on opioids as tools has lead to millions in the clutches of addiction and an current estimated average of 115 people a day dying of accidental overdose in the United States.2,3 From an epidemiological perspective, the current problems associated with opiate abuse are not affecting all demographics equally. Consequently the current political approach being taken has a different rhetoric compared to other drug epidemics, like that of the crack-cocaine epidemic of the 1980’s.4 Nevertheless, with President Trump’s declaration of this as a public health emergency and more recent grim threats for traffickers,5 legislators, community leaders, and health care providers are looking for answers. It is imperative to look at failings of past drug crises as solutions are formulated. Revised tools for pain and addiction are needed to help the thousands desperate for help, many of which are offered by integrative medicine. Traditional Chinese Medicine and other modalities of integrative medicine offer many tools for pain management and addiction treatment. In order for these modalities to be successful in decreasing opioid use and dependence, they must be embedded in larger public health efforts and aligned with key public health principles: prevention, equitable access, and compassion.
According to the Center for Disease Control, one out of every five people diagnosed with a pain disorder is prescribed opioids.2 An estimated 2.1 million people suffered from substance abuse related to opioids in 2012.2 According to the Kaiser Family Foundation, the number of accidental opioid overdoses doubled in five years between 2011 to 2016.6 The American Society of Addiction Medicine cites drug related overdoses as the leading cause of accidental death in the United States, surpassing car accidents. Furthermore, four out of five heroin users start with the misuse of prescription painkillers.7
ETHNOBOTANICAL HISTORY
Humans’ relationship with opioids spans millennia. To understand the issue in the broader scope of history, it’s worthwhile to look at the relationship humans have had with this drug over time. Opioid drugs may be derived from the opium poppy (Papaver somniferum) as either natural drug isolates like morphine or semi-synthetic compounds like oxycodone; or they may be fully synthetic like fentanyl. Opium poppy cultivation dates back to 3400 B.C.E., in the first known human civilization of Mesopotamia.8 It was then passed down to major ancient civilization, including the Egyptians, Babylonians, and Chinese.9 Opium was introduced to modern Western medicine in the 16th century in the form of laudanum, an alcohol extract of the poppy by Swiss doctor and alchemist, Paracelsus.10 Morphine, one of its active alkaloid constituents was first isolated in 1805 in Germany and has been used by physicians ever since.11 Shortly after, the United Kingdom went to war with China over the trade of the poppy in the first of two Opium Wars from 1839-1842.12 Around this time, thousands of pounds of opium were annually imported into the United States and the famed “Opium Dens” of San Francisco were prevalent. In 1973, the Drug Enforcement Agency (DEA) was created by President Nixon to address the growing rise of heroin use.9 In present day, the United Nations reported the production of opium poppies in Afghanistan reached a record high in 2017, causing alarm for its implications on the ongoing wars and global drug trade.13 Meanwhile, in the United States, pharmaceutical companies who produce and distribute opioid medications, like McKesson, are some of the most profitable in the world, reporting $198.5 billion revenue in 2017.14
This timeline illustrates Papaver somniferum’s far-reaching impact on history. The value and significance this plant has played culturally is hard to fathom. Anthropologist, P.G. Kritikos, described how the poppy was used in religious ritual by the ancient Greeks as a euphoriant.15 16 By the Sumerians, it was known as “hul gil” or joy plant.15 Meanwhile, it was valued as a medicine all over the world as it traveled along the Silk Road. Though different cultures may have had distinct medical applications, it is clear P. somniferum’s most compelling effects are on shifting consciousness and alleviating pain.
BASIC NEUROSCIENCE OF OPIOIDS
To understand why this medicine is so powerfully effective, it is helpful to understand its basic mechanism in the brain. Endorphins (short for endogenous morphine) are a class of neurotransmitters naturally produced by the body that elicit pleasure and are involved in pain mediation. Endorphins are structurally related to exogenous opioids, and both work at the same receptor sites in the central nervous system.17 These receptors are like a lock that fits the keys of both the endogenous (endorphins: Beta endorphin and enkelphins) and exogenous opioids (oxycodone and heroin). However, the pharmacological profile of the exogenous opiates are stronger and consequently they have severe side effects.17
The side effects of these exogenous opiates have been noted throughout history. According to ethnobotanist MJ Brownstein, “Starting in the 16th century, manuscripts can be found describing drug abuse and tolerance [to opium] in Turkey, Egypt, Germany, and England.”15 Tolerance is the crux of the current crisis, as one of the expected side effects of taking medications like Vicodin and OxyContin. With repeated use, the pain relieving effects of opioids are diminished due in part to a decreased sensitivity at the receptor site, and users increase the dose in order to get results.18 This escalates the risks of dependence, addiction, and adverse effects like constipation, nausea, and respiratory depression.19
Abuse of an opioid often begins when an individual experiences the sense of euphoria brought on by the drug and then tries try re-create these feelings. This may be done with techniques like nasal inhalation, injection, or increasing the dosage.20 Opioid abuse also changes the level of dopamine in the brain, associated with feelings of excitement, and provides positive reinforcement for continued abuse.17 Long-term opioid use causes the brain to produce less of the various neurotransmitters, including dopamine, serotonin, GABA, and endorphins due to the overwhelming surge caused by using the drug.17 18 When the brain stops producing its own neurotransmitters to feel good, the user feels more drawn to continue using opioids. As these biological processes occur and levels of dependence become severe, users become desperate to maintain this new level of baseline. Also seen in this current crisis is when access to prescription opioids becomes unavailable, people struggling with addiction will turn to the relatively inexpensive and readily available alternative heroin.7, 13 According to the CDC, the rate of heroin overdoses increased five fold between 2010 to 2016.21 Those being sold heroin are often given a concoction of different opioids, sometimes containing the highly potent synthetic opiate Fentanyl, which has led to staggering overdose rates.22
EASY ACCESS
Until recently, opioids have been a primary treatment for a wide variety of pain disorders by biomedical health care providers. In response to the current crisis, the CDC issued new guidelines for safer practices in prescribing these medications in order to curb problematic over-prescription by doctors.23 Between 1998 and 2010, the amount of opioids dispensed by pharmacies in the U.S. doubled.24 In 2013, there were enough prescriptions written for every American to have their own bottle of pills.2 Some states have more painkiller prescriptions than there are people living in that state.2 25 Nonetheless, over 75% of people abusing opioid painkillers are not getting it directly from their doctors, but from either a friend, relative, drug dealer, or off the internet. 25 Though the problem may originate in the doctor’s office, the pleasurable and addictive nature of this substance lends itself to proliferate out into communities.
In 2015, while law enforcement efforts continued on street drugs, legislators eased regulations on incoming opioids from the pharmaceutical industry under the pressure of highly affluent lobbyists.26 The law is called the “Ensuring Patient Access and Effective Drug Enforcement Act”27 and effectively weakens DEA restrictions on the top companies who produce and distribute opioids like Cardinal Health, McKesson, and AmerisourceBergen. This along with the surplus of Mexican and Afghan produced heroin,13 resulted in an explosion in availability of opioids in the country.28, 29
AVAILABLE TREATMENT OPTIONS
The U.S. now finds itself with the major question of how to address the thousands of newfound addicts. While there are programs in existence for many suffering for addiction, some treatment options are simply out of reach. For example, the average cost of an inpatient privately run rehab program can range between $6000-$20,000 a month.30 The Affordable Care Act of 2010 requires insurance providers to cover addiction services, though very few treatment centers actually accept this type of insurance, including Medicaid.31 Alternative treatment centers are available. For example, the Salvation Army offers services for those with low to no income or insurance, yet these are state-funded or non-profit entities relying on donations or government allocated resources.
The primary medical treatment for opioid addiction is Methadone and Buprenorphine, drugs that act as a replacement for prescription opioids or heroin. Methadone, a full opioid receptor agonist, is the gold standard for treating addiction, however this substance is also a highly addictive substance and it’s use is stigmatized.32 Buprenorphine on the other hand, is only a partial opioid receptor agonist and therefore does not have the same euphoric effects of methadone. However, Buprenorphine is not as readily accessible as Methadone.33 Other medical treatment options like Naltrexone and Vivitrol, opioid antagonists that prevent effects of opiates, have not been shown to be effective when compared to placebo.33 Psycho-social interventions like working with a psychotherapist, joining a peer support group like Narcotics Anonymous, and having supportive social network also play a critical role in treatment,.33
INTEGRATIVE MEDICINE SOLUTIONS
The medical community continues looking for solutions for this crisis both downstream for treating patients addicted opioids and upstream in helping patients manage pain. With the new stricter CDC opioid prescribing guidelines, providers have fewer options to support their patients. Thus integrative medicine may play an integral role in providing alternative approaches to treatment and pain management. Chinese philosophy’s classic axiom on pain states: “If there is free flow, there is no pain; if there is no free flow, there is pain.” Traditional Chinese Medicine (TCM) has a broad lexicon for describing the origins of pain; for example it can be due to: blood stasis, qi stagnation, cold congealing, heat, and Bi syndrome. With this breadth of etiology and sophisticated diagnostic lens, acupuncturists have a large toolbox for managing pain with acupuncture and herbs. Acupuncture analgesia is supported by many randomized controlled trials on both on humans as well as animals: one of the well researched theories on it’s mechanisms of action is by working on the endorphin system. 34, 35, 36, 37, 38 Along with the growing body of evidence, acupuncture has thousands of years of empirical practice showing its safety, efficacy, and minimal side effects.
In addition to acupuncture, there are many herbal medicine therapies from both Eastern and Western traditions that can be implemented for managing pain. Yan Hu Suo (Corydalis chinesis) and California poppy (Eschscholzia californica) are both herbs in the Papveracea family, the same as the Opium poppy, that act at the same opioid receptor sites to reduce pain.39 Curcumin, an active compound in Turmeric, has recently gained major popularity in the West for pain and inflammation. In a systematic review when Curcumin was put in a head to head against NSAIDS (Ibuprofen,) the results found similar significant pain reduction over the 4-6 weeks of the study’s duration.40 There are several classic Chinese herbal formulas like Shen Tong Zhu Yu Tang and Shao Yao Gan Cao Tang, which are traditionally used to move the blood, have been shown in to be effective for decreasing pain.41,42 The latter formula contains Bai Shao (Paeonia lactiflora,) high in anti-inflammatory, pain modulating polyphenols,43 and Gan Cao (Glycyrrhizia glabra) which contains pre-cursors to corticosteroids that have anti-inflammatory effects44. Even cannabis (Cannabis sativa) though perhaps laden with it’s own potential for abuse, may be a helpful harm reduction tool for mediating chronic pain.45 There is also interesting research suggesting the co-administration of cannabis with opioids is safe and increases analgesic effects, and may allow prescribers to decrease opioid dosing.46 Additionally, in states where medical cannabis is legalized compared to states without these laws showed a reduction in opioid overdose mortality by 24.8% that increased over time.47
Additionally, integrative medicine has many tools to offer patients withdrawing and trying to overcome struggles with addition. Acupuncture is a great modality for supporting opioid detoxification and reducing cravings, particularly using the auricular National Acupuncture Detoxication Association (NADA) protocol.48 Acupuncture and herbs, including Chinese formulas, can be helpful for managing the side effects of withdrawal: insomnia, body aches, diarrhea, muscle spasms, and nausea.49 Many herbs used to support the nervous system, or “Spirit” as is described in TCM, also play a vital role in supporting the emotional aspect often integral in addition and recovery.50
HEALTH INEQUITIES IN THE OPIOID CRISIS
Integrative medicine, acupuncture in particular, finds itself in an influential position in this crisis, as it is able to treat both pain and the complications of addiction. As these modalities continue gaining popularity and recognition, the hope is that access also continues to expand. This is essential as the burden of the crisis falls on those who have the least availability of alternative options.51 This is where policy could play a critical role: ensuring these treatments are accessible for anyone on the socio-economic scale and that barriers to entry are removed. Several surveys have shown that aside from Asian communities, minority patients and those of lower socioeconomic status are not as likely to use acupuncture.52 A disparity exists across all health services for minority patients53, and especially for pain management. The disparity in the case of acupuncture use is often due to cost52. However, one study looking at use rates by minority adolescents at free acupuncture clinic in an urban hospital setting showed that when this barrier is removed, diverse communities are more likely to use acupuncture.52
Interestingly, the current opioid crisis is not equally divided along racial lines: it is primarily a problem for White Americans. In 2015, according to the Kaiser Family Foundation, of the 33,091 people who died of an opioid related overdose, 27,056 were White, non-Hispanic.6 This means less than 20% of the total overdose deaths are people of color (POC). Interpretations of this data have pointed the cause to be from racial and ethnic disparities in pain management53. POC are less likely to receive opioid prescriptions than non-hispanic white patients for a variety of pain conditions.54 This differential behavior by prescribers is linked to inherent biases and stereotyping minority patients55; for example being concerned pain complaints are merely for seeking drugs or that POC patients may sell their pills.56 Though this prejudice may be having a protective effect for POC, this may also mean they are getting less than adequate treatment for their pain.
Being that the opioid crisis is primarily affecting white Americans, the political language used to describe the problem shifts, as well as how to deal with the drug users. Since the advent of the government-led “War on Drugs” in the 1970’s, the use or abuse of specific drugs has been seen as a criminal justice issue, implementing harsh sentences such as the three strikes policy and mandatory minimum sentences for illegal drugs. This approach not only fell short of its promise to reduce drug use, it also resulted in severe racial injustice in our prisons. Men of color are disproportionately targeted by police for drug crimes, at a rate of five to one.57 Furthermore, even though the current numbers show a disproportionate number of white abusers in this opioid crisis, there are still more POC being charged with opioid and heroin related offenses.58 However, with the white face of the current drug crisis, the view of drug user shifts from criminal requiring punishment to patient needing rehabilitation. Legislators are hit hard to find treatment for the people struggling with addiction in their districts, as hundreds die monthly; most of whom look like them.59 However, the numbers of this current crisis could be compared to those of the crack cocaine crisis of the 1980’s and 90’s60, affecting mostly urban black communities; though the approach of this era was not one of compassion. 4 This is again mirrored in the heroin crisis of the 1970’s, “with a punitive approach to black heroin users coinciding with a great expansion of methadone maintenance programs — for mainly white “patients.”61 These racial double standards result in health inequities, from the doctor’s office, to how law is enforced, to how people with drug addiction are treated.
POLITICAL APPROACHES
With President Trump’s announcement in October 2017 of the epidemic being a national public health emergency,62 there was a familiar Reagan era moralistic tone: responsible citizens should abstain from the evils of drugs under all circumstances and “Just Say No.” Like the Nancy Reagan campaign of 1980’s, this not only is ineffective63 but it undermines how and why people are using opioids in the first place.2 However, President Trump did mention of some public health measures: like access to rehabilitation programs, funding research for non-addictive pain medication, requiring more training for prescribers of these medications, and increasing availability and community trainings for Naloxone, a harm reduction medication used to reverse overdose. While there has been skepticism on if these promises can take effect64, the administration’s two-year budget proposes to allocate a substantial amount of resources into research, prevention, and treatment services. However, it also aims to cut government funded health insurance programs like Medicare and Medicaid, leaving many without coverage.65
The Trump administration has also made it very clear that they are taking a strong punitive criminal justice approach to the crisis. In President Trump’s more recent speech regarding the crisis, he declared that those prosecuted trafficking opioids are deserving of capital punishment and praised President Rodrigo Duterte of the Philippines for having taken a similar approach66 This is radically different from moving towards a public health approach. This is especially true with Attorney General Jeff Sessions at the helm of the Department of Justice, who has a history of racially hostile comments and voting record67, as well as recently reinstating longer sentences for drug prosecutions.68 As history has shown57, unless significant changes are made within the nation’s criminal justice system, this punitive approach will likely not solve the problem but continue to result in disproportionally more POC incarcerated.
A radical public health resolution is decriminalization. Both the World Health Organization69 and United Nations70 have advocated for this approach. This follows the major successes of Portugal’s decriminalization and public health campaign of 2001, decriminalizing drug use and expanded its public health efforts to more compassionately help addicts. The Health Ministry of Portugal estimates that 25,000 Portuguese currently use heroin, down from 100,000; and the opioid overdose rate has decreased 85% since the policy began.71 While drug dealers continue to be sentenced to prison, when someone is found with a personal possession of drugs, they are instead sent to a meeting with social workers who provide resources for addiction and mental health support. Another important part of the public health campaign is the government-funded outreach vans, which make rounds on the streets of Portugal giving out free methadone to allow addicts to gain stability instead of relying on street heroin.71 The crisis in the United States is fundamentally different from Portugal, as it did not start from over-prescriptions. However this serves as country a model in how harm reduction and public health efforts work.
INTEGRATIVE MEDICINE AND PUBLIC HEALTH
It is unlikely the United States will be taking a decimalization approach to the current opioid crisis. Instead the push must continue to be on allocating resources into public health measures to see any far reaching and equitable changes in this opioid crisis. Moreover, a decisive way for patients to get the improved care for pain and addiction is having integrative medicine fused into these programs. Once informed of the benefits of integrative medicine like acupuncture, patients most often do not choose use these modalities because of cost barriers.52 Many integrative medicine interventions are evidenced-based and would be powerful complements to current programs or those being crafted to meet the needs of the crisis. Some examples of this could be acupuncture offered at more Methadone clinics and free needle exchange sites, or integrative medicine offered as part of county mental health facility programs. The inclusion of Integrative Medicine as it’s own department in primary care settings would make it easy for patients coming in for pain management to access these services, like at Kaiser Oakland72, or in hospitals like Highland Hospital in Oakland, California.73 Additional research is critical to continue building the evidence base for these modalities, particularly herbal medicine.74 With the allocation of resources for researching treatments for addiction and non-addictive therapies for pain, now is an excellent time to fund research on integrative medicine approaches.65 Practitioners already offering accessible treatments, like community style acupuncture might be able to apply for state grants to continue offering these services to support opioid dependent patients. Also critical is advocating for acupuncture coverage and adequate practitioner compensation by insurance companies, from both government programs and private companies. Insurance coverage compels patients to use these services when out-of-pocket expenses are minimized. Advocates and lobbyists who straddle the intersection of public health and integrative medicine are essential for advancing these kinds of integrative solutions at the upstream policy level.
The current opioid epidemic echoes a recurring pattern throughout human history: a physiological susceptibility to falling under the spell of Papaver somniferum and its derivates. With an so many under this spell in the United States in the current crisis, alternatives to opioids and solutions for their side effects are needed. Integrative medicine, like acupuncture and herbal medicine, offers remarkable tools that can become an integral part of pain management and opioid addiction solutions. However, for these modalities to be available to those who need them most, they must be part of larger public health policies aimed at prevention and access. Other countries like Portugal have shown that an approach based in public health and compassion can reduce the numbers of opioid related overdose deaths.71 On the other hand, the punitive approach taken by the United States in past drug epidemics resulted in exacerbated racial disparities in health and in the criminal justice system.57, 75 Therefore as policy makers debate how to approach this crisis, attention must be paid to which groups these policies serve and who is left with no options. Practitioners must work together to continue building the research base and creating inclusive programs to offer the best integrative medical care to patients. Ultimate success could be measured in a number of ways including: reduction of opiate overdose deaths, successful treatment of pain with safe alternatives, more people in addiction recovery, improved equitable access to healthcare, and resiliency in communities. As practitioners and policy makers come into alignment on how to address this complex issue, compassion is critical in creating sustainable solutions for those in desperate need.
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