LESSON 3: COUNTER MEASURES

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  It is being developed in real time.  Writer wants to express gratitude to Wikipedia for identifying the bulk of the research this blog has used in the development of this unit.[1]]

Development of this unit of study has brought this blog to the point of reporting what a third lesson might look like.  Hopefully, due to implementing the previously reported second lesson (see previous posting, “First Two Lessons in a Unit about Opioids”) the student has a well-rounded view of what the opioid epidemic is in terms of how it effects individuals in the US. 

Moving on, as a possible homework assignment leading to a third lesson can be for students reviewing a list of factoids and insights concerning counter measures available to help addicts.  The student can be handed a list of such counter measures for the various opioid drugs that have been developed.  Overall, counter measures take the form of prevention strategies, prescribing counter drugs such as methadone, behavioral therapies – such as 12-step programs – and individual and group therapies.

Here, in the form of counter measure factoids, are a sampling:

·        Among either doctor-prescribed or doctor-regulated treatment regimens there are both medical and behavioral components.  They count on various drugs – kratom, naloxone, methadone, or buprenorphine – and then combine it with behavioral treatments including individual and group therapies, residential treatments, and 12-step programs.[2]

·        Between the years 2003 and 2011, the use of buprenorphine has increased 40%.[3]  More recent figures are needed.

·        Buprenorphine comes in various forms including an implanted form called Probuphine.  The implanted form lasts six-months.[4]

Accompanying counter measure insights are:

·        Methadone, the most used counter drug, is itself a long-acting opioid.  As such it can function to replace heroin with just a single daily dosage by attaching chemically to the opioid brain and spinal cord receptors.  This leads to activating the brain and spinal cord in such a way as to diminish symptoms, reduce cravings, and suppressing highs that heroin and other opioids induce.  The aims, of this regimen, are to taper off the dependency the user has under a controlled environment and to increase the likelihood of avoiding a relapse.  Since, it is a controlled regimen, the patient needs to pick up daily dosages from a methadone clinic.  This is not feasible for all addicts or it adds to the possibility of patients being stigmatized since their treatment is subject to a level of public viewing.[5]

·        To meet the challenges of opioids, there has been two overall approaches:  medical and behavioral.  What is better?  It depends on the addicted person.[6]

·        Growing in popularity is a treatment that uses buprenorphine.  Administered like methadone, in terms of usage, but it’s under a much less controlled regimen.  Yes, there is the need for a prescription to attain this drug, but less regulated demands.  Patients receive month-long prescriptions, so there are no daily visits to clinics.  The claim by its advocates is that it is safer than methadone and its use aims at reducing or quitting the use of heroin or other opiates.  In addition, it is credited with eliminating cravings and withdrawal symptoms but not inducing a euphoric high among patients.  And lastly, since there are less clinic or doctor visits, costs are cut drastically.[7]

Again, this is a sampling of factoids and insights.  For a more complete list, the reader is encouraged to visit previous posting, “General Counter Measures among Related Groups,” August 18, 2018.  Also, soon there is going to be a special posting that will list all the factoids and insights this unit highlights.

If a list of factoids and insights is distributed before student arrive to class, the teacher can launch a discussion on the possible political forces at play when opioid policy is considered.  For example, representatives of the opioid industry worked to make that industry’s interest known within the federal government and worked to secure “friendly” policy positions.[8]  While not included in the above list, there are a couple of factoids regarding this factor in the referred to previous posting and in the posting to come. 

Students, in terms of this factor, should be able to identify these industry interests and pass judgement regarding their functionality in meeting the crisis and their morality regarding affected federalist values.  More specifically, the question students can address is:  is the general welfare of the commonwealth prominent among these corporate leaders’ thinking when considering the related activities, they undertake?

Another factor is the relative effectiveness of the reported counter measures.  This might lead to students speculating and being assisted in their unit assignment of investigating the local availability of counter resources.[9] During this class time, the teacher can request students to voice opinions and to back up their opinions with stated factual or insightful information they have been given.  This last effort advances student skills in building reasonable and effective arguments.

To round-off the instructional portion of this unit, is to suggest here that a two-day lesson be next.  This two-day effort could consist of students, who are arranged into groups, investigate one of three aspects.  The three are:  production and distribution, demographic factors, and governmental reactions.  The next posting will develop this two-day lesson.

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[1] The writer also wants to state that where possible, he has checked the sources and has at times added to the listed research.

[2] Ibid. AND Jennifer C. Veilleux, Peter J. Colvin, Jennifer Anderson, Catherine York, and Adrienne J. Heinz, “A Review of Opioid Dependence Treatment:  Pharmacological and Psychosocial Intervention to Treat Opioid Addiction,” Clinical Psychology Review, vol. 30, no. 2, March 2010, 155-166, abstract accessed August 23, 2018, https://www.sciencedirect.com/science/article/pii/S0272735809001421 .

[3] L. W. Turner, Stafan P. Drszewski, R. Mojtabai, Daniel Webster, S. Nesbit, R. S. Stafford, and G. Caleb Alexander, “Trends in Buprenorphine and Methadone Sales and Utilization in the United States, 1997-2012,” Value in Health, May 2013, abstract accessed August 23, 2018, https://www.valueinhealthjournal.com/article/S1098-3015(13)01627-6/fulltext?_returnURL=https%3A%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1098301513016276%3Fshowall%3Dtrue .

[4] “New Medication Formulations Could Quickly Make a Difference for Treating Opioid Addiction,” National Institute on Drug Abuse, August 22, 2017, accessed August 23, 2018, https://www.drugabuse.gov/about-nida/noras-blog/2017/08/new-medication-formulations-could-quickly-make-difference-treating-opioid-addiction .

[5] David W. Dixon and Ryan P. Peirson, “Opioid Abuse Treatment and Management,” updated June 21, 2018, accessed August 23, 2018, https://emedicine.medscape.com/article/287790-treatment .

[6] Ibid.

[7] Bryan Schwartz, “My View:  New Approach Needed for Opioid Epidemic,” Portland Tribune, July 25, 2017, accessed August 23, 2018, https://pamplinmedia.com/pt/10-opinion/367132-248727-my-view-new-approach-needed-for-opioid-epidemic- .

[8] This concern will be more fully addressed in a future posting that looks at governmental reactions.  The history already reported makes mention of industry policy as with the case of Purdue Pharma.

[9] It is also a good opportunity to check on students’ progress in accomplishing unit assignment.  Students can be told that the unit test will consist of them reporting their findings.  For that test, they will be able to use their notes.

FIRST TWO LESSONS IN A UNIT ABOUT OPIOIDS

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  It is being developed in real time.  Writer wants to express gratitude to Wikipedia for identifying the bulk of the research this blog has used in the development of this unit.[1]]

In terms of developing a unit of study that addresses the issue/problem area of opioid addiction, this blog has described several phases in that development.  At this point, it’s time to begin a new one, but first it is useful to quickly review the context for what follows.

So far, this blog shared a short history of the crisis and then divided the crisis into various aspects.  Those aspects are:  defining the problem in terms of its anti-federalist attributes, describing how the crisis has affected individuals, reporting existing counter measures, reviewing the demographic factor involved with the crisis, describing production and distribution of the drug, and reporting governmental reactions to the crisis. 

These aspects can now be used to organize the development of individual lessons.  Lessons usually take up one class period each, but this need not be the case – an individual lesson can stretch beyond a single class period.  In this posting, the first two lessons of this “opioid” unit are described and they do last one class period each.

These aspects were, in previous postings, mostly treated by conveying lists of relevant factoids and insights related research has discovered.  This process has been basically done and reported upon in previous postings, but – and one should remember this effort is being done in real time – the writer might add to these lists of factoids and insights as he becomes aware of added information.

In that light, a further insight can be added at this time.  It is one that advances the history of the epidemic.  Simply stated, it points out that the epidemic is more acutely felt in rural areas than in urban areas due to over-users in those more remote areas not having medical and therapeutic services readily available.[2]

Another bit of business is to suggest a unit long assignment.  That is, a useful activity for student to engage during this unit is for them to investigate local facilities – and what their structures and processes are – that are dedicated to meeting a local opioid challenge.  Of course, this assignment has more salience if opioids are having a significant effect on the welfare of the students’ community.  Here it is assumed the unit is being implemented in such a community. 

This concern also highlights an important shortcoming.  If one reviews textbooks in the civics field of study, one finds a lack of coverage dealing with local governance.  For example, reviewing the content – its index – of the best-selling American government textbook, William A. McClenaghan’s Magruder’s American Government,[3] shows no entries for community(ies), community development, neighborhood(s), or charity(ies).  “Localism” is ignored.

Therefore, an assignment in which students investigates such institutions that would be dedicated to addressing the local opioid problem is deemed here to be useful.  As will be described in a future posting, such an assignment can be the basis of the unit’s evaluation.

With those bits of related business taken care of, this posting proceeds to share lesson ideas for this unit.  In a potential lesson one, the first above aspect is addressed.  As a pre-lesson step, the student should be given a short history of the epidemic.  With that history, the student can acquire an acquaintance with the problem area and begin to formulate a definition of the epidemic. 

The objective is not for the student to recall the details of that history, but to have a conversational awareness of how the nation has arrived at the current condition and how extensive the problem is.  As a set of questions that, one, can be attached to the short history, and, two, serve as guiding any subsequent, discussion sessions within the unit, the following is offered:

·        How does an addiction on opioid drugs affect the ability of the individual to meet his/her communal responsibilities?  To what extent?

·        What are those responsibilities?

·        To what extent – magnitude – does the over-use of opioids manifest themselves in this community?

·        What are the local responses to this epidemic?  Are there private-non-profit organizations addressing it?  Are there local government – city and/or county – responses to the epidemic?  Are there state government resources made available to local responders to the epidemic?  Are there any federal government assets – funding or otherwise – attainable by local officials to meet the crisis?

·        How is this crisis affecting people locally in terms of income distribution, racial divisions, cultural divisions, and/or other prominent divisions among the local population?

·        What kinds of assets promise to be effective in meeting the crisis locally?

The assumption here is that both teachers and students, through the course of the unit, are willing to be so disposed as to talk about these and other concerns associated with the opioid crisis.

To convey the deleterious aspects of this crisis, the historical account – shared previously in this blog – contained cited death rates and they can be highlighted.  These can be augmented with the factoids and insights this blog has previously reported.  For example, in terms of drugs in general, a factoid is:  while the problem of cocaine deaths is a greater problem among black population, all types of opioids (including heroin) cause for more deaths among all races.[4]

Overall, the first lesson introduces the student to the problem area by having him/her define it (a la federalist values), give it historical context, and share some basic facts and insights.  In addition, by defining it, students should be able to communicate how the crisis has a civic significance. 

That is, the problem transcends the personal costs it has on individuals.  Questioning by the teacher in this final portion of the lesson should have students see this area of concern as one that challenges federalist values.  To be clear, the opioid crisis undermines the central federalist concerns that the US is a grand partnership among its citizens.

How?  As with any endeavor made up of partners seeking to achieve shared aims and goals, compromised partners – be it of a physical, emotional, or social origin – are in danger of not fulfilling their responsibilities as partners.  Of course, the various statistics reported in this blog is the evidence for this sort of dysfunctionality.

A second lesson can be aimed at looking at opioid abuse from the perspective of the individual.  Here, the emphasis is how difficult an opioid addiction can make a person’s life – the addiction, to those affected, takes on a high centrality of concern.  This leaves little room for other concerns such as being a family member, an employee, or a community member.  And those consequences do not even mention the possible medical problems over-use can very likely cause. 

As this blog reports elsewhere, medical consequences have both social and economic costs.  Among the economic costs are lost productivity, emergency costs, and related medical expenses that are often met by public funding since many affected addicts are not insured.

So, the basic question this second lesson addresses – and expects students to address – is:  what are the symptoms of an opioid addiction?  Supportive questions include:  how do individuals acquire opioids?  And, how have the medical establishment interacted with affected individuals?  One added concern, that probably gets more of an emotional response, is:  how does opioids interact with a person’s biology?

A creative exercise that students can do in this second lesson is for them to write a “day-in-the-life” of an opioid addict.  Here the resulting narratives can be evaluated by how well students include the factoids and the insights the blog have reported especially from the provided history.  The aim would be to engender in students an empathetic sense of what it means to be so victimized. 

With that focus, here is part of the biology involved:  opioid’s sedative qualities are caused by the effect on that part of the brain – the respiratory center in the medulla oblongata – that controls breathing.  If taken in high enough doses, they can function to depress respiratory processes, potentially resulting in respiratory failure and even death.[5]  This bit of information can be considered an insight into what has happened to many who consume these drugs.

If students know of such a cases, in their lives, they can include, in their narratives, the information they know to be true, but students should be instructed to respect the confidentiality of these peoples’ identities and other personal information.[6]

Hopefully, due to this second lesson, the student has a well-rounded view of what the opioid epidemic is in terms of how it effects individuals in the US.  It aims at making the material relevant by, one, being suggested to be especially implemented in communities where the epidemic is being experienced to heightened levels and, two, by whittling the problem down to how it affects the individual.

This lesson by lesson development will continue in the next posting by suggesting what could be presented in a third lesson.

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[1] The writer also wants to state that where possible, he has checked the sources and has at times added to the listed research.

[2] John Oliver, “Opioids,” Last Week Tonight (HBO TV cable production), May 21, 2018, available on YouTube, accessed August 27, 2018, https://www.youtube.com/watch?v=5pdPrQFjo2o .  A further word on this cite.  Oliver presents a very good review of the problem in terms of its present manifestation.  An educator, though, should be aware that despite its usefulness, it is riddled with satire and profanity including sexually referenced content.  Teachers should review cite before considering assigning its viewing.

[3] William A. McClenaghan, Magruder’s American Government (Florida Teacher’s Edition) (Boston, MA:  Prentice Hall/Pearson, 2013).

[4] Deborah Dowell, Rita K. Noonan, and Debra Houry, “Underlying Factors in Drug Overdose Deaths,” JAMA, vol. 318, no. 23, 2295-2296. 

[5] “Information Sheet on Opioid Overdose,” World Health Organization (UN), November 2014, accessed June 14, 2018, http://www.who.int/substance_abuse/information-sheet/en/.

[6] If helpful and students can do it, they can look up the cited sources this blog has shared in the form of footnotes.  This is a recurring possibility throughout any classroom instructional strategies reported in this blog.