While Minnesota deals with the deadly opioid epidemic in some parts of the state, policymakers need to keep in mind that substance abuse in general is widespread, and every person who develops an addiction has a distinct set of circumstances that needs to be addressed to achieve recovery.

By Thad Shunkwiler, Department of Health Science, Minnesota State University, Mankato

Each year millions of Minnesotans and their communities are impacted by drug use, and rural Minnesota communities face unique challenges as it pertains to substance use and substance use treatment. It is my hope that this letter will provide some context to these challenges while offering possible solutions.

When examining the issue of drug abuse, one can’t help but notice the media coverage of the “Opioid Epidemic.” Opioid abuse has taken center stage in the conversation about drugs, and rightfully so. Opioid abuse has killed thousands of Minnesotans over the past ten years. However, what often gets lost in the opioid conversation are the other drugs that are being abused. As highlighted in the article “It’s an Addiction Crisis” by Marnie Werner from the Center for Rural Policy and Development, rural Minnesota hasn’t felt the impact of the opioid crisis nearly as much as the metro area. What rural Minnesota is experiencing more so than opioid addiction is methamphetamine addiction.

While both are considered drugs of abuse, meth and opioids are very different in their impact on the user. Opioids are a group of drugs whose primary purpose is to provide pain relief. In fact, opioids are the most effective drugs on the planet at relieving pain. They do so by blocking the receptors and neurotransmitters within the brain that interpret pain from our bodies, and thus they play a very prominent role within the medical field and for therapeutic purposes.

When the user abuses these drugs beyond therapeutic levels, the drug can have a reinforcing effect in the brain. In short, the user experiences a pleasurable high by abusing opioids. Many abusers of opioids will report that the feeling of pleasure is like experiencing a “full body orgasm.” This intense feeling of pleasure quickly teaches the user that they can feel much better under the influence of the drug then they ever could without it. This is how the psychological dependence on this drug forms so rapidly—the user “wants” the drug in order to feel better.

In addition to forming a strong psychological dependence, though, opioids quickly create a physical dependence. Due to the chemical nature of the substance, our body makes adaptations to the presence of the opioids. These adaptations lead to a phenomenon known as tolerance—the user needs more of the substance to achieve the same effects. If the user continues to use long enough, the body develops a dependence on the substance where it “needs” the drug in order to function. When the user takes the drug away, the body enters a period of withdrawal. For many, opioid withdrawal feels like the worst case of the flu they’ve ever experienced, and avoiding withdrawal is often the reason people continue to use the drug. Once physical dependence sets in, the user “needs” the drug, not to get high, but to simply feel normal. This combination of psychological and physical dependence is what makes opioids so difficult to treat and recover from.

When comparing opioids to meth, however, there are some stark differences in the experience of using the drug and also in recovering from the drug. Meth belongs to a group of drugs known as psychostimulants. Stimulant drugs as a group increase brain activity. Meth works by mimicking the pleasure neurotransmitter dopamine. Dopamine is responsible for us feeling pleasure. We naturally produce dopamine when we perform various tasks to keep us alive. For example, when we eat, our body rewards us with dopamine. When we engage in sexual behavior, our body produces dopamine to reward us while encouraging us to procreate.

Meth hijacks this natural process. It tricks the brain into producing excess dopamine, causing the user to feel a level of pleasure not possible without the drug and leading to some of the strongest psychological dependence among drugs of abuse. This intense pleasure is not without consequence, however. Neurotransmission is like gravity in that what goes up must come down. The meth user will feel immense pleasure for a period of time, but when the drug effects stop, the user has a crash that brings about a period where they feel miserable. In order to cope with these feelings, the user takes more of the drug regardless of health consequences, constantly chasing those feelings of euphoria at the expense of everything around them—their jobs, their family, and their health.

When examining how to best treat abuse, either for opioids or methamphetamines, we must first look at answering the etiology or origin of addiction. Why people turn to drugs is a complex and multifaceted issue. For some, it’s to cover up the symptoms of underlying mental health issues, a sort of self-medicating approach. For others, it’s to take away the emotional or physical pain that life brings. For many others, it starts with the intention of having fun, but then they succumb to the physical hooks certain chemicals provide. Regardless of the reasons that bring people to perceived chemical solutions for their problems, drug abuse can be and should be treated.

Treatment for drug abuse is not a “one-size-fits-all” affair. Each person who develops an addiction brings with them their own unique set of circumstances that need to be addressed if recovery is to be achieved. What complicates treatment even more is that each drug requires a different combination of treatments to be most effective. In other words, how we treat opioid dependence is not likely to be the same formula for treating methamphetamine addiction. Some components are similar—counseling to treat psychological conditions, for instance—but others vary depending on the chemical nature of the drug being abused. For drugs like opioids, research indicates that a combination of counseling and medication-assistance therapies (MAT) produce the best results. MATs work by controlling the physical dependence the user develops while taking the drug. By relieving the user of the physical withdrawal that occurs after discontinuing use, the user can focus on the psychological dependence and learn about life without the drug. Access to MAT programs is limited, and even more so for rural Minnesota.

When dealing with meth, the emphasis should be placed on psychological dependence, as physical dependence doesn’t exist in the same way it does for opioid drugs. Meth users need in-depth psychological counseling to address the reasons for using as well as coping skills for living a life without the drug. Often, when a drug user becomes sober, mental health symptoms that have been buried by substance abuse resurface. If these underlying concerns are not addressed, relapse is a near certainty.

Treatment provider shortage

While we can use science to understand the best ways to help people recover from addiction, however, science cannot help us fix the growing concern of a shortage of treatment providers in rural Minnesota. The Minnesota Department of Health authors the “Mental and Behavioral Health Workforce Reports.” Their issue on the licensed counselor workforce (October 2016) concluded that there is a “relative inaccessibility of care in sparsely populated areas in rural Minnesota.” This lack of local treatment providers places great strain on the user seeking treatment and stakeholders looking to provide adequate high-quality care in outstate Minnesota.

In addition to the geographical concerns of providers, the same report indicated that the “median age of current treatment providers were in the mid to late 40’s.” As treatment professionals are retiring from the field, we will not be in a place to sustain the number of providers needed to address the issues in our state. The combination of a current provider shortage in rural Minnesota and an impending shortage fieldwide should be sounding alarm bells for those concerned about Minnesota’s ability to treat addiction. 

“An ounce of prevention is worth a pound of cure.” —Benjamin Franklin  

Treating addiction once it has set in is only half of the battle in helping Minnesotans. The best form of treatment comes before the issue requires any medical intervention at all. It comes in the form of prevention. Treatments as outlined above are undoubtedly expensive. Furthermore, even when funds are available we must have trained providers to provide the care. Prevention is a cost effective and empirically validated way in which to curb future substance use problems.

In many conversations with rural Minnesota school districts, however, one glaring gap in their curriculum is meaningful substance use prevention. This is not meant to point fingers at schools, whom I believe to be doing everything they can to set kids up for success, but rather an opportunity to intervene and inform education leaders that substance use prevention works. One of the very basic premises in substance abuse is that the earlier people start using substances, the greater the likelihood that they develop a substance use problem. This means, if we are successful in preventing students from delaying their substance use even a few years, we will have saved some of them from ever needing treatment services in the future. A refocus on prioritizing prevention would help offset future treatment provider shortages.

My recommendations for the state of Minnesota are threefold:

  • To be careful not to focus exclusively on opioids, thus losing sight of the current drug problems that face our rural communities. The opioid crisis deserves all the attention and funding it is receiving, but we will be failing thousands of people by only addressing opioids. We must also acknowledge and act on treating all forms of addiction.
  • To address the current rural provider shortage, the state could look at incentivizing providers to work in outstate communities. This is something already occurring with other healthcare providers, so let’s look at adding addiction professionals to this program. In regard to future shortages, I would recommend working with institutions of higher education to develop a workforce development plan to ensure programs that train treatment providers have what they need to fill the ongoing demand for professionals.
  • Lastly, we need to prioritize an increased focus on substance use prevention in Minnesota schools. Minnesota needs to invest in prevention opportunities to help offset future treatment needs. Setting up grants for schools to fund these programs either internally or by bringing in external prevention professionals would help all Minnesotans impacted by addiction.

I want to thank you for taking the time to learn about some of the problems that rural Minnesota is facing in regard to substance abuse. Whether struggling with mental illness, or dealing with addiction to a drug, all Minnesotans deserve an opportunity to receive treatment and make the most of their lives.

Thad Shunkwiler, LMFT, LPCC, ACS, CCMHC, is an assistant professor in the Department of Health Science, College of Allied Health and Nursing, at Minnesota State University, Mankato, where he trains the next generation of licensed alcohol and drug counselors.

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