May 2018, Scott Gibbs ’89 emailed the Union College magazine. His oldest son had overdosed on a combination of fentanyl and morphine in November 2016. Marcus was 21 years old when he died.
His story inspired this article.
“I have so many fond memories of my four years at Union and the friendships that will last my lifetime,” Scott Gibbs said. “When Marcus passed away, I saw so many Union people — including my Sigma Chi brothers and basketball teammates — at the service.”
“I am committed to openly and honestly honoring Marcus and the blessing that he was for our family. We are hopeful that his passing will save lives.
Marcus grew up with his two younger brothers and parents in Hilton, N.Y., a suburb of Rochester. He was vivacious and effervescent. A big-hearted guy who loved the outdoors, sports and people. He ran cross-country in high school and volunteered at Open Door Mission to help men, women and children in need.
“Marcus was a hugger,” Scott Gibbs said in a video for Rochester General Hospital’s Donate Life campaign. “He was never bashful about hugging. I can still remember the last hug he gave me. We were in the kitchen. I can remember where we were standing. I can remember his whiskers on my face.”
“I go there a lot. I remember it a lot. I’ll be forever grateful for Marcus and the way he loved.”
Marcus also studied finance at Canisius College, but he struggled during his short time there (2013-14). He was arrested for having a large quantity of marijuana within two weeks of arriving, and didn’t like the mandated counseling and supervision he received after that.
In a piece Marcus wrote before he died, which he and his father intended to become a book about their experiences, Marcus recalled, “In college, after a calculus course…we would smoke fentanyl, snort Vicodin and pop percs until I hit the floor.”
After leaving Canisius, Marcus came home and enrolled in a local community college (2014-15). He was arrested once and avoided being arrested a second time, ending up in the ER instead. Both times, Marcus had drugs in his system. He dropped out of school in his second semester.
In June 2015, Marcus went to West Palm Beach, where he completed a week of detox, 30 days of in-patient treatment and approximately 90 days of out-patient treatment. He also lived 60 days in halfway houses and worked two jobs during that time.
When he returned to Hilton in October 2015, he became a car salesman. He thrived in his new profession but, unbeknownst to his parents, he had relapsed.
“Eventually, he realized he had to stop using heroin because he wanted to live,” his mother, Sue Gibbs said. “He knew people like him were dying.”
In late October 2016, after almost a year of heroin addiction, Marcus stopped hiding his dependence and bravely began detoxing at home with his family. The withdrawal was extremely difficult; he was taken to the emergency room twice. Both times, no detox beds were available.
Still, Marcus came through it and scheduled an intake appointment with an outpatient rehabilitation program Nov. 16. He was optimistic, but was worried (unnecessarily) that the clinic wouldn’t prescribe maintenance medication to prevent relapse — like methadone — if he didn’t have opioids in his system.
On the morning of his appointment, Marcus used again.
“He was found unresponsive in a convenience store parking lot,” Scott Gibbs said. “Even though the EMT team was able to resuscitate him, the brain damage was massive and irreversible. They estimate he had been without oxygen for 90 to 120 minutes.”
Three days later, on Nov. 19, 2016, he was taken off life support. It was at once the worst and proudest day of his parents’ lives. Their son died, but in doing so, gave life.
“I think Marcus chose to be an organ donor because it was significant, he was interested in serving others,” Scott Gibbs said. “Six of his organs were successfully transplanted to renew and sustain life for five recipients. We can only hope those lucky people will live on with some of his spirit in them.”
The irrecoverable loss experienced by the Gibbs family is not uncommon.
“There are so many parents losing their sons and daughters to opioid overdose and we feel devastated for each and every one,” Sue Gibbs said. “Their stories are often similar and sometimes longer or more turbulent, but their kids were beautiful and loved, just
like our Marcus.”
Also like Marcus, many of these men and women are first introduced to opioids by their doctors. Marcus was prescribed opioids three times — twice for oral surgery at 14 and once for knee surgery at 18. Each time, his parents only gave him a few days of the medication he was supposed to take, but they remember Marcus asking for more pills.
“When I asked him why, he said he liked the way they made him feel,” Sue Gibbs recalled. “Many people become addicted to pain medication after surgery. This was not the case with Marcus, but I believe those pills he took gave him a hunger for things he could consume to make himself feel ‘better.’”
“End-of-life situations are the right time for prescription pain meds,” Scott Gibbs added. “We do not have to manage most pain with these addictive medications.”
Dr. Patrick G. O’Connor ’78, chief of general internal medicine at Yale University School of Medicine, agrees that prescription practices need an overhaul. Overprescribing is one factor that’s led to this crisis.
How we got here
What we’ve seen since the early 2000s is a massive increase in the number of opioid prescriptions written by doctors,” said O’Connor, also the Dan Adams and Amanda Adams Professor of General Medicine at Yale. Data from the Centers for Disease Control illustrate this fact. In 2012, doctors wrote 259 million prescriptions for such drugs — enough for every American adult to have their own bottle of pills. Each day, 46 Americans overdose on prescription opioids. Between 1999 and 2016, more than 200,000 died as a result of a prescription opioid overdose.
CDC data indicate that the number of prescriptions written annually is declining after peaking in 2012 (there was a 19% reduction between 2006 and 2017), but it’s still too high. The amount of opioids prescribed per person is still about three times higher than it was in 1999.
So why have doctors been writing so many prescriptions? In the early 2000s, the focus on pain intensified sharply.
“Pain assessment became the ‘fifth vital sign.’ Doctors asked about pain the same way they checked blood pressure and weight,” O’Connor said. “Everyone was assessing pain, and if you weren’t, you were a ‘bad doctor.’ Simultaneously, there was a general increase in patients’ expectations that their pain would be treated — whatever it took.
And then there’s big pharma.
“The pharmaceutical industry took advantage of this focus on pain by creating new ways doctors could treat it,” O’Connor said. “Drug companies pitched their new opioid medications as highly effective for pain treatment, and as non-addictive or with lower addictive potential.”
But this has proved not to be the case. Opioids aren’t a one-size-fits-all answer to pain.
“Opioids are terrific for treating acute pain, such as from a fracture. They can be used very effectively at the proper dose and for proper duration, which in most cases is only a few days,” O’Connor said. “The chronic pain piece is where we lack data. Everyone — doctors, patients, pharmaceutical companies — made this extrapolation that if opioids are good for the management of acute pain, they must be good for treating chronic pain.”
“But the evidence doesn’t exist to support this approach to chronic pain,” he added. “It’s a hard lesson everyone is learning.”
So too is the lesson that prescription opioids are much more addictive than they were originally marketed to be.
“Opioids are very subject to tolerance. As a result, we’ve seen more and more patients getting these medications at higher and higher doses and as a consequence, they become dependent,” O’Connor explained. “Physicians are supposed to be trained to treat pain in an evidence-based manner that is effective and safe. Unfortunately, this does not happen as often as it should.”
“In many ways, our profession took the easy way and failed,” he added. “Doctors are not entirely to blame for the opioid crisis — this doesn’t capture the whole picture by any means — but they’ve certainly contributed to the problem.”
On the other hand, physicians are also a critical part of the solution.
According to the National Survey on Drug Use and Health, in 2016, 21 million Americans had a substance use disorder and needed treatment for addiction. Only 10% of them received it.
Why? It’s complicated.
Insurance often doesn’t cover addiction treatment. There’s a hugely negative stigma associated with addiction that prevents people from asking for help. And doctors and clinics specializing in addiction treatment are relatively and as a result, difficult for patients to access.
“In my view, the big gap with addiction is implementation science — getting effective treatments in the hands of healthcare providers and to the patients who need them,” O’Connor said in 2018 interview with the Yale Journal of Biology and Medicine. “How would we feel if only 10 percent of Americans with cancer or diabetes or hypertension received the necessary treatment? We need to do better.”
Primary care, with its widespread number of physicians in nearly every town, is one way to do that.
O’Connor led the team that first demonstrated that opioid-dependent patients treated in primary care clinics with buprenorphine (active ingredient in Suboxone) did just as well as those treated with buprenorphine in specialty addiction programs. Conducted in the mid-1990s, the study helped lead to the Drug Addiction Treatment Act of 2000. Signed by President Bill Clinton, it allowed properly trained primary care doctors to treat opioid dependence with buprenorphine (which O’Connor’s team proved to be safe and effective).
It was a step in the right direction, but primary care doctors still need to be trained. Enter Yale’s Program in Addiction Medicine.
Launched in 2017 and founded by O’Connor, the program is focused on developing new and innovative approaches to addiction treatment. It’s state-of-the-art training program in addiction medicine is also a model for other medical schools.
“We hope to prepare the next generation of physicians to provide patient-centered addiction prevention and treatment in a manner that gives addiction care the high priority it deserves in the healthcare system,” O’Connor said. “Our patients deserve no less.”
That’s why, when serving as president of the American Board of Addiction Medicine (ABAM), he led efforts to establish addiction medicine as a new medical subspecialty.
As co-chair of a 2015 White House symposium, “Medicine Responds to Addiction,” O’Connor helped bring together leaders in federal government, academic medicine and healthcare to more broadly make the case for this new subspecialty. The American Board of Medical Specialties (ABMS) approved it later that year.
“Addiction medicine is the only ABMS subspecialty in which physicians who are board certified in any of the 24 primary ABMS subspecialties — internal medicine, psychiatry, family medicine, etcetera — can sit for the certification examination,” O’Connor said in the 2018 journal interview. “Physicians from all medical specialties can be certified, greatly expanding the pool of addiction specialists nationwide.”
“Creating and certifying new addiction medicine specialists all over the country will really help bridge the gap in care,” he added. “Treatment should be available on demand. We know that when it is, treatment for opioid use disorder is very effective.”
Eric Dyer ’13 can speak to this. He’s been sober for seven years now.
Like a lot of people, Dyer has some things in common with his parents. His father, Rick, is a criminal defense lawyer. Dyer is also an attorney, though his practice focuses on healthcare law. Father and son were also both addicted to opioids. Rick, who has been sober 42 years, stopped using drugs before Eric was born, but was always open with Eric about his struggles. And that ended up being indispensable to his son.
“When I was addicted, it made it a lot easier to talk to him when I needed to get help. He had been through it,” said Dyer, who lives in Boston, Mass. “He understood and could totally relate.”
“We could connect on a lot of levels,” he added. “My dad always looked at his recovery as something to be proud of, and he used that in a positive way to help me.”
But recovery wasn’t easy for Dyer, who was addicted to prescription pills like oxycodone and was introduced to drugs in seventh grade. It was then he tried marijuana for the first time.
“The way I smoked was different from my peers, I wanted to use it every day,” Dyer said in an interview with MensHealth.com recently.
From there, he went to drinking, then cocaine, then he began snorting painkillers like Vicodin and Percocet. By the time his junior year at Union rolled around, he was physically dependent on opioids.
His grades were up and down, but if he had drugs on hand, he’d be up early, go to classes, get through the day. If not, he’d lay in bed and go through withdrawal — awful nausea, extreme leg cramps and back pain.
“It was the most uncomfortable feeling you could ever have, and the worst part was knowing the only thing that can fix it is more of what’s making you sick,” Dyer told MensHealth.com.
But he still couldn’t shake the drugs. He used a family member’s credit card to buy a laptop, then sold that computer to a drug dealer to get the pills his body needed.
On his 21st birthday, his girlfriend had had enough. She flushed his drugs down the toilet.
“I don’t know if I would have made it without her. She’s the person who made the jump for me,” Dyer said. “The person who believed in me long enough to give me a chance.”
“By the end, she had big things going on. It got to a point where she was like, I’m going to go do other things. That was a turning point — June 2011.”
That fall, Dyer checked into Gosnold Treatment Center in Cape Cod. In conjunction with his treatment program, he took Vivitrol, a form of naltrexone. It binds to the brain’s opioid receptors, blocking the effects of opioids.
He returned to Union in fall 2012, graduated in 2013, got his law degree and a master’s in business administration, and married the woman — Dr. Stacey Burns ’12 — who flushed his pills. He has a life full of promise now, but he knows how lucky he is to have had treatment and support.
“One thing alone is not going to do it. Vivitrol is great, it really helped me, but you have to have support. You have to have a safe place to live, people you can talk to and depend on. Sometimes even then it isn’t enough,” Dyer said. “If addiction was something you could beat on your own, you just would.”
At Union, a proactive approach
The College takes a proactive approach to educating students about substance use. Before first-year students arrive on campus, they complete an online requirement that increases awareness of alcohol and other drugs, and how to get help on national and campus levels. Orientation also includes ‘Party Smart’ floor meetings in all residence halls, which provide students with concrete action and intervention strategies they can use to make healthy decisions.
Educational efforts continue throughout the year with guest speakers, health and wellness fairs, and social norms and poster campaigns, said Marcus Hotaling, director of Union’s Eppler-Wolff Counseling Center. Additionally, counseling center staff are trained to address substance use.
The center also conducts the National College Health Assessment survey every two years, most recently in spring 2018. The data helps compare Union student drug use to 100,000 students around the country.
“Nationally, about 1.5% of the sample indicated that they had ever tried opiates,” Hotaling said. “In our sample, a total of three students (out of 384 who completed the survey) indicated that they had ever tried opiates.”
“We are fortunate that we have not had to work with many students presenting with opiate use disorder or addiction,” he added. “But we recognize we are not immune to this epidemic and continue to seek to educate ourselves on new initiatives and best practices in treatment.”
That includes making certain help is available. “We have an established referral network of substance use disorder treatment programs and clinicians in the Capital Region that we can, and have, referred to for students requiring a level of care beyond what we can provide,” Hotaling said. “Additionally, we work with all students who wish to seek treatment while away from campus to ensure their needs are addressed.”
Drugs and the brain
Addiction is a disease. It has a biology, much like any other disease.
“With cardiovascular disease, you can use imaging studies to see arteries that are blocked by abnormal plaques,” said Dr. Patrick G. O’Connor ’78, chief of general internal medicine at Yale University School of Medicine. “Similarly, you can look at the brain — through imaging — and see abnormalities in structure and function in people with substance use disorder.”
And it’s exactly these differences Dr. Marisa Silveri ’95 is studying.
Associate professor of psychiatry at Harvard Medical School, Silveri is director of McLean Hospital’s Neurodevelopmental Laboratory on Addictions and Mental Health in the Brain Imaging Center. There, she investigates the overlap between brain development, substance use and mental illness in adolescents.
The brains of participating teens are scanned (MRI) once annually for three consecutive years, starting at age 13 or 14. Their first scans are completed when they’re healthy and before they’ve experimented with cigarettes, alcohol, marijuana or any other drug.
“In general, we do not know enough about how the brain develops under healthy conditions,” Silveri said. “By studying teens recruited before they’ve used any substances or before they report any significant clinical symptoms of mental illness, such as anxiety or depression, we are characterizing a baseline profile of how the brain works. The goal is to identify neurobiological risk factors for substance use or psychiatric illness before they manifest.”
To pinpoint these risk factors, Silveri and her team look at patterns of brain activation (in specific parts of the brain necessary for performing various cognitive tasks), brain structure and neurochemistry over the course of the three years.
In the years following that initial, baseline scan, roughly “20 percent of our teen sample has begun using substances —alcohol, marijuana and nicotine,” Silveri said. “If baseline profiles in teens who go on to use substances differ from teens who do not initiate use, we call these neurobiological risk factors.”
One unique, potential risk marker she’s studying is gamma aminobutyric acid (GABA), an inhibitory neurotransmitter that regulates impulsivity, cognitive control and mood.
Silveri’s lab was the first to publish in vivo human evidence that healthy teens naturally have lower levels of GABA in the frontal lobes of their brains than adults — which was related to the greater impulsiveness in teens.
“Why would a brain be wired for impulsiveness, for taking dangerous risks? Evolutionarily, teens are biologically programmed to explore uncharted territory, to collect new information to aid in their transition to independence,” Silveri said. “Risky exploration in humans, however, is increasingly less related to survival-type activities, ranging anywhere from bungee-jumping to experimenting with drugs.”
But, she added, lower levels of GABA are also observed in psychiatric illnesses like depression and anxiety, and in individuals who misuse alcohol, marijuana and other drugs.
“GABA levels are altered by a number of substances. With alcohol, GABA levels increase, which is why we experience relaxation while drinking,” Silveri explained. “A person’s resting level of GABA, however, can influence how substances like alcohol feel. People with low levels of GABA tend to experience the effects of drugs less intensely, so they require more of the substance to feel the desired effect.”
GABA levels can change over time as well, which is what happens when someone develops a tolerance to drugs.
Opioids, for instance, inhibit the action of GABA, preventing it from regulating other neurotransmitters like dopamine, which produces significant feelings of pleasure. When dopamine floods the brain unregulated, people experience an intense high.
“When the brain is repeatedly exposed to substances that raise GABA levels, the brain adapts by decreasing production of GABA. This results in a lower resting GABA level, which is why a person might feel depressed or anxious when a drug leaves their system,” Silveri said.
It’s also why a person can get hooked on opioids.
“With repeat exposure over time, our brains adapt to the unregulated flow of dopamine and the amount released under the influence of opioids is no longer enough to feel the desired pleasure,” Silveri said. “So a person takes increasingly more opioids to regain that pleasurable high and their brain becomes physically dependent on the drugs. This is the cycle of addiction.”
“Addiction is much more complicated than this,” she added, “but GABA is part of it.”
She and her team have several ongoing initiatives to better understand GABA. One, related to the discussion above, studies GABA’s role in brain maturation and how it contributes to risky behavior. Behavior that, in turn, might interfere with healthy neurodevelopment and compromise safety and wellbeing. Another examines how low levels of GABA associated with binge drinking or with depression might be remedied by a month of sobriety or the practice of yoga.