Welcome to the first day of our two-day discussion on the impact of the opioid epidemic on adult education. We’re fortunate to be joined by long-time adult educator, Paul Jurmo, Ed.D., family & preventive medicine physician, Richard Bruno, M.D., and corrections specialist, Jeffrey Abramowitz, J.D. in examining the issues impacting our learners, families, and programs.
To begin, I’d ask our panelists to share more on their background as it relates to the topic, and ask them to respond to the two questions below. For those interested in a little background information on opioids, we have provided a brief overview of the different types of opioids, both medically prescribed and non-prescribed, and their impact on the body. These are provided from resources available from the National Institute on Drug Abuse.
Questions:
1. What is unique about opioid addiction, in its short and long-term impacts on individuals, that is different from other types of addiction, such as alcoholism? What is different in the approach to treating opioid addiction than other forms of addiction?
2. Opioid addiction is a disease that alters the structure and function of the brain. Understanding how this disease impacts the brain is important for educators working with persons with a history of opioid use. What should adult educators know, and what training do you recommend programs offer their staff to help them better understand these impacts?
Background information on Opioids:
Opioids are naturally found in the opium poppy plant. Some opioid medications are made from this plant while others are made by scientists in labs. Opioids have been used for hundreds of years to treat pain.
Heroin is also an opioid but is not classified as a prescription medication. Fentanyl is a powerful prescription pain reliever that is 50 times more powerful than heroin. It is sometimes added to heroin, leading many users to overdose. One of the ways opioids work to relax your body is by slowing down your breathing. When misused, opioids can slow your breathing too much. This can cause you to stop breathing entirely and lead to an overdose. For some people, just one dose is enough to make them stop breathing.
Naloxone is used to counteract an overdose. It works to quickly block the effects of opioids. It is available as an injectable solution, an auto-injector, and a nasal spray. Some states require a doctor to prescribe naloxone, but other states allow pharmacies to sell naloxone without a personal prescription.
Our brain has receptors that receive signals from other parts of our body. Opioids attach to receptors on nerve cells in the brain, spinal cord, and other organs. This allows them to block pain messages sent from the body to the brain.
When the opioids attach to the receptors, they also cause a large amount of dopamine to be released in the pleasure centers of the brain. Dopamine is the chemical responsible for making us feel reward and motivates our actions. The dopamine release caused by the opioids sends a rush of extreme pleasure and well-being throughout the body. Over time, prolonged use of opioids causes harmful effects, like extreme sleepiness or insomnia, confusion, nausea, vomiting, muscle pain, constipation, heart infections, pneumonia, and addiction.
Prescription pain relievers and heroin are chemically similar and can produce similar effects. Heroin is sometimes cheaper and easier to get than prescription opioids. As a result, people who are addicted to prescription opioids sometimes switch to using heroin. Four out of five new heroin users report misusing prescription opioids before trying heroin.8 You can overdose on both heroin and prescription opioids. Less than 4 percent of people who had misused prescription pain medicines started using heroin within 5 years.
Opioids can show up on a drug test within hours of being taken. Opioids, including heroin, can show up on a drug test for days, and in some cases weeks, after being taken. How long they stay in your system depends on how long a person has been taking the drug, the amount of drug they use, or the person’s metabolism.
The most commonly used prescription opioids are oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, and morphine. Opioids also go by different names: oxy, percs, and vikes are slang terms for opioid pills. Common names for heroin include Big H, Horse, Hell Dust, and Smack.
The brain gets so used to the opioids that when someone stops taking them, they can go into withdrawal. Withdrawal symptoms include sweating, shaking, vomiting, sleep problems, and diarrhea. The symptoms can be so severe that it can be hard for someone to stop using opioids, even if they want to. Quitting opioids can be hard, but it is possible.
There are three Food and Drug Administration approved medicines to treat opioid addiction. Medicines like buprenorphine and methadone bind to the same receptors in the brain as prescription opioids to reduce cravings. Naltrexone is another medication that treats opioid addiction by preventing opioids from having an effect on the brain. Additionally, an old medicine called clonidine, and a newer medicine called lofexidine, help lessen withdrawal symptoms for people who are trying to stop. A combination of behavioral therapy and medication has proven to be the most effective in treating opioid addiction.
Comments
Summary of the LINCS Discussion on the Impact of the Opioid Epidemic on Adult Education
Julie Neff-Encinas shared the challenges of counseling students to talk with their medical providers about the impact of their treatment on their ability to function in classroom, and the hesitation for undisclosed reasons. Similarly, Katherine Cavanaugh shared her work with reentry adults who are in class because it is part of their probation requirements, or their recovery under the state’s vocational rehabilitation system. She also wondered how to promote open-ended discussions among adult learners and still protect their privacy rights? She asked, “What should be the role of the educator to avoid 'preaching' and practice 'teaching to reach and help' reentry adults learn more effectively?”
Jeffrey Abramowitz shared that the realities of drug and alcohol treatment following prison is the fear that asking for help or support will lead to additional supervision, retribution or additional monitoring. It is important for returning citizens to understand that they can and will receive confidential and unconditional support, if they comply with their program, participate and stay dedicated to overcoming the challenges that they will be facing. Jeff also highlighted the impact that shame plays in the re-entry process of formerly incarcerated adults. He noted that having successfully completed the sentence imposed by the courts, they next face a sentence imposed by society through barriers and challenges of finding employment, housing, and accessing addiction treatment. He connected this need to implement holistic wrap around support services that provide contextualized learning as a way to bring students into career sectors that they are passionate about in building new futures. Jeff commented that having peer mentoring with men and women that have traveled down a similar path is very helpful in keeping students engaged.
Julie Neff-Encinas also commented that peer mentoring is key to creating highly successful treatment programs, but noted that probation often restricts persons from forming tight relationships with others with a criminal history, unless in controlled settings. She noted that this is an obstacle to creating mentoring relationships for learners. Susan White Ahl wondered if a recovery community may have individuals interested in sharing their stories.
Kathy Tracey shared the PBS resource Understanding the Opioid Epidemic for Educator as a resource to consider in answering the questions raised. Jeffrey Abramowitz shared Guidelines for Successful Transition of People with Mental or Substance Use Disorder from Jail and Prison: Implementation Guide.
Paul Jurmo commented on the need to develop relationships with agencies to:
Andrew Pleasant commented that the prevention of opioid abuse should receive as much attention and funding as response and treatment. Michael Cruse shared the U.S. Health and Human Services's resource library, aimed at prevention-related services, and general advice on disclosure with adult learners from the Learning to Achieve resource, a research-based collection of professional development materials focused on increasing the achievement of adults with learning disabilities.
Jamie Harris asked about preventative methods to avoid addiction and also ways to identify when a person is in the beginning stages of addiction. . Michael Cruse shared Operation Prevention's classroom resources, which introduces learners to the science behind opioids, their impact on the brain and body, and is available in English and Spanish. He also highlighted the LINCS Resource Collection's links to Operation Care, which has relevant materials on addiction, alcoholism, and depression that connect with many of the same issues experienced by individuals with opioid dependence and addiction.
Richard Bruno shared the analogy of Upstream-Midstream-Downstream Preventions. Upstream is primary prevention, which works to prevent people from falling into the river of addiction in the first place. Midstream is putting up a net to catch people before they fall over the waterfall and overdose, and includes harm reduction strategies for active users, like clean needle exchanges, safe consumption spaces, fentanyl testing strips, Medication Assisted Treatment to, and substance use counseling. Downstream is administering the antidote naloxone (Narcan) to someone who has overdosed and may drown at the bottom of the waterfall.
Richard noted that drug dependence is characterized by chronic use and withdrawal symptoms upon rapid cessation, which is different from addiction, which is characterized by compulsive use despite harm and cravings. Opioid use disorder is characterized by DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) criteria for substance use disorder. Richard suggested that providing resources – to include medical evaluation - may be helpful. He also noted the importance of using person-first language, such as PWID (People Who Inject Drugs) to refer to people struggling with addiction, and avoiding inflammatory language like ‘addict’ or ‘abuser’.
Michael Cruse connected the conversation to the U.S. Department of Labor, Employment and Training Administration’s National Health Emergency Dislocated Worker Demonstration Grant Pilot Program to Help Communities Fight the Opioid Crisis. This $21million fund is enabling six states to retrain workers in communities impacted by the widespread opioid use, addiction, and overdose. These states are: Alaska, Maryland, New Hampshire, Pennsylvania, Rhode Island, and Washington. The $21 million dollars from the grant funding to these six states will likely be used to create resources and programs that will be replicated across the U.S. to address the long-term impact on communities. Using Maryland as an example, he highlighted recently released guidance on the implementation of workforce solutions to address Maryland’s opioid crisis. This is supported by other efforts in the state aimed at the prevention of opioid use as early as K-12, through the Maryland State Department of Education's Heroin and Opioid Awareness and Prevention Toolkit. Kathy Tracey also highlighted the Ohio Bureau of Workers’ Compensation’s Opioid Workplace Safety Program, which will provide up to $5 million over two years to help employers hire, manage and retain workers in recovery from an opioid addiction.
Richard Bruno cited research that the return on investment has been shown to be $1,538 for every employee undergoing over 60 days of treatment, noting that this leads to reduced absenteeism, tardiness, conflicts with managers and coworkers, and productivity lost. He highlighted the therapeutic workplace program at Johns Hopkins Bayview Medical Center as a novel employment-based intervention that uses, "access to employment and wages to reinforce therapeutic behavior change”, and concludes that this type of intervention could be applied across many industries.