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Kevin Pedersen's wrestling days were 15 years behind him, and yet he still couldn't let the sport go. Miami was full of change in the early '90s, not much of it any good, but these high school wrestling meets were locked in time, their rituals the same as Kevin remembered. Kids in headgear, sizing each other up. Always some dad in the stands letting loose. A hush as a match began, and ultimately a ref raising a winner's hand. At every meet, a wrestler crying at the outcome. There's no purer contest, Kevin thought. One guy against another, no teammate to draft off of or accuse: This is how you know if you measure up. Little Kevin Pedersen, 5-foot-4, buck-oh-five, smallest guy in the room. There had always been a champion inside of him. Without wrestling, he would have been the only one to know it. And now here he was: a decorated agent for the Drug Enforcement Agency, with a gun on his hip and another tucked in his boot. Out there in South Florida, always on call, he saw the worst in people, the price paid for an undisciplined life. Back in these gyms, wrestling's ceremony reassured him, relaxed his mind enough to let him dip into his past. But Kevin's past wasn't his alone. At the meets, someone would inevitably recognize Kevin and remind him of his curious bond with a teammate. What about Alex? Kevin would grin and gosh-dang along with them, reminiscing, although he could never understand the appeal of the outlaw. Before Alex DeCubas and Kevin Pedersen landed on opposite sides of the drug war, wrestling brought them together. Alex worked his bullish chest and shoulders into a brown leather coat as he scanned for his driver among the desperate faces of a country shattered by the cocaine wars. The car left the capital, driving to the rural town of Cota, Cundinamarca, and to a compound set atop an imposing cliff. A high wall encircled the property, tipped with shards of glass, keeping thieves out, and others in. This was Jorge Gnecco's place. Alex had gone into business with Gnecco, running a 2,kilogram load of pure Colombian cocaine through St. Lucia and into Fort Lauderdale. Gnecco summoned Alex, who hadn't heard about the theft. Alex stepped out of the car and moved to the compound's study, where Gnecco waited. The drug lord lit into Alex. You were in on it, he yelled at him, slamming a fist on his desk. You got a debt. Twenty-five million. You're not leaving until I get paid. Hundreds of millions of dollars in drug sales had passed through Alex's hands, but he wouldn't part with any of it for something he hadn't done. In friendlier times, Gnecco had shown Alex his favorite photos, leafing through them like they were baseball cards: pictures of men Gnecco had kidnapped, in sets of two. In the first picture, a brutalized face looked startled by the camera flash, the man maybe expecting a bullet along with it. In the second picture -- a lifeless form, splayed out on the ground. Gnecco had always laughed at those shots. And so Gnecco wouldn't allow him to leave. A rotating crew of his soldiers kept watch on Alex. For weeks, he'd spend his days pacing the patio, up and back on the Mexican clay tiles of his open-air prison, the high wall hemming him in. Most evenings, the guards turned on their favorite telenovela, and before they went to bed, they locked up Alex in a steel cage at the edge of the enclosed patio. The days passed, 45 of them, Alex dropping weight like back in his wrestling days from the table scraps they fed him. How much longer until that sadistic prick pulls out the camera? If I'm gonna survive, I gotta escape. One night, when the guards gathered around the TV for the series finale of their soap opera, Alex saw an opening. They had yet to put Alex in his cage, and now their eyes were getting heavy. Alex crouched at one end of the patio and gripped his leather coat. Still the athlete, he burst from his stance and raced 90 feet to the wall. He leaped, grabbing the top of it, his coat protecting his hands from the shards of glass. Pulling himself up, he tossed a leg over. Alex fell straight down the steep slope, landing in the hillside's rain-softened orange clay. He tumbled and slid to the edge of the road below. When he stopped, he was orange from tip to tail but uninjured. A car approached, the sign on its roof legible in the dusk: taxi. Alexander Wells. They met at a Little League game in Miami in , Alex glaring down from the mound, a hulking year-old, as Kevin walked his slight frame into the batter's box and whipped through a few meager practice swings. Alex was known for striking out the side, but now he served up a walk, feeling sorry for the little guy. It just didn't feel right striking him out. Their families lived in Miami's Palmetto neighborhood, and a couple of years later, the boys would attend Palmetto Junior High School together. They decided to join wrestling for different reasons. The Air Force lieutenant colonel, now stationed at the Miami airport and plagued with memories of the Pacific theater, had fallen into alcoholism. Alex's father, Luis, had fled Castro's revolutionary Cuba and had opened an upscale men's boutique in Coral Gables. He wore a different suit every day, projecting an image of success as he made his entrance to Alex's wrestling meets. El tigre! When Alex and Kevin joined the high school team as sophomores, Alex had grown into a , pound bruiser, legs and torso thickly arranged. Kevin admired his power -- how Alex latched on to bigger guys and slung them around like it was their first go on the mat -- and the ease with which he walked the halls and talked to girls. Alex respected Kevin's technique and discipline, the pounder who lifted year-round, jogging laps in the Miami bake. The two ran in different circles, but in the wrestling room, they connected. Alex looked after his undersized teammate; other kids knew that if they provoked Kevin, Alex would be there to answer. In , both wrestlers went undefeated in the regular season, Alex as the varsity heavyweight and Kevin as a lightweight relegated to JV. At the final of the state championship meet, Alex scored a last-second pin on his opponent, an unbeaten senior, to earn Palmetto High its first state team title. Before every practice, the two would square off, no matter that pounds separated them. Alex would flip Kevin and grind his face into the mat. And Kevin would get tougher. That spring, Kevin won the Florida state pound championship, closing out an undefeated season. Alex won his second state title. They were both named All-American. Weeks later, the pair appeared in Sports Illustrated 's 'Faces in the Crowd,' side by side, their bond for all the world to see. Kevin Pedersen was a disciplined technician on the mat. Courtesy Kevin Pedersen. Alex picked up and began speaking Spanish. The next day, the two men drove south down Palmetto Expressway. Baptist Hospital appeared up ahead -- but Uncle Pedro just kept on driving. Your dad's not sick. Silence as the car kept going. Your father's dead. He shot himself. Luis DeCubas' clothing boutique was practically bankrupt, and in the store's back office, he had taken out his Walther PPK, aimed the pistol at his chest and fired. After Alex received the details, he and his brother, Luis Jr. The blood had curled up on the concrete floor. Towels in hand, the brothers scrubbed away the final indication of their father. Luis left letters for his family. To Alex he wrote: You've made me so proud, my tiger. Now go be a success. Go out and grab life with gusto. In his grief, Alex struggled with how to apply his father's final words, the plea for his second-born son to be daring, to never settle for a pedestrian existence. Consumed with sorrow and hobbled by knee injuries, Alex left wrestling and Georgia. He returned to Miami, took a job at a tool store. The drug trade was sweeping through the city, and the adventure and easy money lured in Alex. He started selling small bags of weed and coke. One afternoon, two guys walked into the tool store, their gold Rolex Presidentials catching the warehouse fluorescents. They were in the jewelry business, among other interests. As they looked over Alex, the pair decided to discuss their real work. He did. When Alex found what they were looking for, J. He went on to explain that he and Sam specialized in ripping: stealing drugs from dealers. Alex liked the sound of the money, and he missed the adrenaline he once found in wrestling. And he figured nobody would call the cops. Posing as DEA agents, they busted in and ordered everyone facedown on the tile floor. Kid , Sam said, go check the back bedroom. Gun drawn, Alex cracked the bedroom door. A woman sat on the bed, stock still. Two pit bulls suddenly rushed into his peripheral vision. Alex unloaded. A couple of shots dropped the dogs; another bullet skipped off the tile floor and clipped the woman in the leg. They continued ripping: pot, quaaludes, coke, cash. Whatever they could find, whatever they could steal, wherever it had to go down -- in a home, in a warehouse, on the shoulder of the highway. Alex had found his own path to success. Pedersen, wearing an Airborne T-shirt and his hair high and tight, sat alone at the end of the bar. Kevin had heard the whispers from the Palmetto wrestling crowd, about how Alex had gone into the drug trade, and now they would come to life. Alex, with gold chains and a shaved head, was bigger than Kevin remembered, his frame filled out to pounds. He smoked a cigar, surrounded by people who had the appearance of sycophants. He looks like a drug dealer, Kevin thought. Alex walked over, gripping Kevin in a hug. They shared a drink, went over old times, and then Alex brought Kevin current. I know you're an officer in the Army, but I'm gonna do things my way, and I'm gonna be on top of the world. You just wait and see. Alex took a last pull on the cigar. Then he stubbed it out on his own forehead. It was constant, easy money. Getting married hadn't been in the plans, but Linda Lieberher's pregnancy changed things, and Alex wanted to do right by her. Alex laid out for the yacht, the food, the booze and the band playing Buffett covers. There'd be a honeymoon in Hawaii. After three years, Alex had moved up in the trade, from ripping straight into smuggling. His crew would wait for a twin-engine Beech 18 from Colombia to drop bales into the water off the Bahamas. His men would gaff them onto a boat and run them to South Florida. At most, it was a few days at sea. At 3 the next afternoon, he would slide into Joe's Stone Crab, and everyone would already be there, the guys in the trade giving one another knowing nods over the beers that kept coming. Nobody kept a 9-to Nobody went to an office. Everyone totaled out to zero for the IRS. They didn't discuss the trade in front of civilians, but anyone would be blind to miss Alex's Mercedeses, Corvettes and Cigarette boats. He had stash houses sprinkled along the coast. What kind of guy owns a Cessna when he can't even fly? Alex drove I, speaking his Spanish into parking lot pay phones from Boca to Homestead. Some nights he wouldn't come home, and when he finally showed, he'd never explain. He tried to keep Linda in the dark. But in the mornings, when he walked in, the weight of a score now swept off his shoulders, she began to understand whom she was marrying. On the yacht, Linda looked vulnerable in her wedding dress, spun around the deck by a man who half the crowd knew was moving Colombian flake by the ton. At one point, one of Alex's partners beckoned him to the bar. They talked in the low tones of business. A load is coming in, steaming toward the Bahamas. Time to get saddled. The yacht docked, and Alex's crew detached from their wives and girlfriends, gathering at the gangplank. Alex whispered to his bride, Gotta go, honey baby. Alex DeCubas eventually found ways to extend his smuggling operation to other parts of the globe, from Western Europe to the Mediterranean. In , word reached Julio Cesar Nasser David, the head of the North Coast cartel, one of the country's four major trafficking organizations. Everyone called Nasser the Old Man; he'd been in the game since running cigarettes was the big score. Based in Barranquilla, along the Caribbean, Nasser was the freighter man, moving mass quantities by sea. Nasser heard of an outfit that was bringing kilo loads ashore through the Bahamas without losing any powder. Alex flew to Venezuela, careful to avoid the Colombia stamp on his passport, a curious marker to any Fed who was paying attention. Nasser's men drove Alex along the coast road over the border, farther into Barranquilla. Past midnight, the car pulled up to Byblos, a Lebanese restaurant. Several dozen soldiers of the North Coast cartel ringed the property, heavily armed. Inside, Alex saw a long table, loaded with plates of fattoush. A belly dancer surged around the floor. A door opened, and in came the Old Man: Here was Alex's entry to the direct supply of the cartels. I don't take a load unless we move it in hidden compartments. I'm not gonna throw the package on the deck and cruise in at 2 in the afternoon with all these other bozos, just praying to make it. Nasser smiled. He liked how the kid operated. From now on, you're not gonna need to work with anybody else. The Old Man wanted to run the biggest loads of any cartel, and he had the boat to do it. The Nerma was feet from stem to stern. Registered in Panama, it carried a Danish captain and crew. It had established a legitimate route too, hauling goods from Colombia to Jacksonville, Florida. Alex and his outfit handled their first Nerma load on June 18, With the moonlight painting the swells, the Nerma slowed to 5 knots around the Berry Islands in the Bahamas. Alex's boats bobbed in the nearby darkness. One at a time, they tied up to the Nerma. The Danes operated the ship's crane, depositing portions of the load onto each boat. Her husband was in prison for selling cocaine, and Betty had her own history with the drug, a conviction for possession. Kevin was still in love with the Betty he knew at Palmetto. The couple married in , with Kevin adopting Betty's son, Danny. When Kevin found pot and coke in their home, he sat down his new wife. I'm an Army officer, he said. I can't have this around my family. As an officer's wife, Betty made her pledge: I'm clean. Kevin left the Army in and took a job with his father-in-law in the tire business. Betty started using again, or maybe she'd never stopped. Her party drug had hardened into an addiction thanks to the endless supply that guys like Alex were bringing to the street. By the time Kevin was 30, he sat his wife down one last time: Betty, I'm filing for divorce. Betty took Danny with her. Kevin lost the house in Homestead. His father-in-law handed him walking papers. Kevin was a West Point grad, a state champion, but that was all just more paper to tack onto the wall of the studio he was renting by the month. The line of Kevin's life was so thin. A wire is all it ever was, cinched tight between two tall ideas: success and failure. With the wire holding in the breeze, Kevin had to walk it. When that wire snapped, Kevin, free-falling, grabbed for air. One night in , Kevin picked up his Colt Commander 9 mm. He put it to his temple. He dropped to his knees in that lonely place. How had it all come to this? But instead of pulling the trigger, he experienced a sudden understanding, one he believed to be divine. He flung the gun to the far side of the room. His situation became clear -- the addiction of his ex-wife, the unraveling of his marriage and the role that outfits like Alex's played in it all. Kevin got to his feet with a resolution: I want to fight the war on drugs. Kevin Pedersen and DEA agents like him led lives as adventurous as those of the traffickers they pursued. President Reagan handed the drug problem to his vice president, George H. Bush, and Congress made the money flow in his direction. Coast Guard, Customs, U. Marshals staffed up, and the courts stiffened, began routinely handing down to-life stretches in place of the previous five or Traffickers began flipping, making whatever deals they could with prosecutors, because 30 years was just too hard to do. Alex didn't notice the tide turning against him. He had too much work off-loading bricks of coke, tossing them like footballs into a stash house, 2, kilos stacked in the garage, another Coupe de Ville pulling up the drive for a run to Chicago. Alex didn't realize that the Feds had busted a guy who knew about a freighter slowing round Great Stirrup Cay in the Bahamas. This was all routine, Alex's crew well-acquainted with the Nerma by now. But tonight a Coast Guard helicopter hovered high in the darkness, an infrared camera trained on the Nerma. Alex's crew was hustling to stash the load when they heard a chopper above. That's weird, a crew member thought. I know we're not in any flight path. From the Old Man to Alex DeCubas and on down, a federal grand jury would indict more than suspects in the Nerma operation. But by the time of the broadcast, Alex was gone, having disappeared on the highways of the American West. Assassinations, mass killings, bombings -- Escobar's tactics plunged Colombia into chaos. By the time Alex arrived, Escobar faced new government pressure. There, he continued to conduct his affairs, now from behind a monsignor's desk. But no matter how much cocaine anyone processed, it was worthless if you couldn't get it to market. Alex was worth 1, hands plucking coca leaves on the Andean slopes. Ultimately, Escobar's network noticed the work of his new soldiers. To remain on Escobar's good side, Chitiva arranged a visit to La Catedral, sneaking past the government guards in a supply truck until he was face-to-face with the greatest trafficker of them all. He'd return to La Catedral time and again, always with a cut of the action. But in the end, Escobar grew restless and fled his prison, and Colombia's many traffickers didn't see the point of paying extortion fees to a man on the run. Alex and Felix aligned with an equally dangerous outfit called Los Pepes. Instead of paying Escobar, Alex now funneled proceeds to this new group, renegades bent on destroying Escobar. Now Escobar was the hunted. Firing from many angles, they took his life on an orange-tile rooftop on Dec. Escobar's bloated corpse signaled the end of an age. The agents carrying the DeCubas case knew all about Kevin and his ties to the kingpin: the state championship at Palmetto, the page out of Sports Illustrated. And Kevin's DEA superiors believed his energies should be directed elsewhere. They started him on local stings. He cruised with cops, making busts in counties across South Florida, which led to cash seizures in the millions, his name inching up the monthly bust rankings back at the DEA compound in Doral. Kevin infiltrated a ring that was moving product to Italy: He packed 30 kilos of coke in his bag to Rome, where he bartered for 10 kilos of heroin in return. At trial, the target, Giovanni Tummolillo, threatened Kevin and his new family -- his wife, two daughters and Danny, whose custody he'd won from Betty. Kevin was learning that a DEA agent lived and died by the quality of his confidential informants. This was all preamble to a first-of-its-kind DEA operation that would soon be his to lead. But now he was on their turf. The cartel's soldiers eyed Alex suspiciously when his vehicle emerged out of the Andean fog and came to a stop at the compound. Some of these men knew Alex as Juan. Some knew him as the transporter. Now they would put him to the test. They tossed Alex a soccer uniform, and he followed them over to a groomed field along a plateau, lights punching through the night. They placed Alex in goal. His knees were shot from wrestling injuries, but his instincts and reflexes were still there. The Cali boys found that they couldn't get a ball by the big man from Miami. They played games until 2 a. Alex DeCubas, shutout goalie of narco soccer -- the lieutenants of the Cali cartel took him in. Over the next five years, Alex, working with various partners under various aliases, would expand their reach into Western Europe, then deep into the Mediterranean. Alex went to their weddings. He went to their funerals. And it was standing over a coffin, looking into the face of a murdered friend, when Alex wondered, Will this ever happen to me? Is he still alive? He would have to wait to find answers; his bosses had set him to work under an alias on Operation Cali-Man. This was new ground for the DEA, a covert money-laundering operation. In the process, Kevin would compile reams of banking data that enabled the DEA to identify and target high-ranking members of Colombia's drug underworld. The traffickers would often ask Kevin to buy goods and then send them down to Colombia by container ship. This was another way of laundering. Sometimes it was refrigerators, but usually they wanted cars. Sometimes those vehicles made it through to Santa Marta, Colombia. Other times Kevin had to inform a contact that the assets had been 'lost. Kevin then persuaded a contact of his to plant a story in a Florida paper, reporting a tropical storm that had never reached land. Those Land Cruisers, fancifully washed into the sea by a phantom storm, were then put to use by the DEA. Kevin accompanied the snitch to the city's main shopping mall. He sat a good distance away from the target, inside the food court, biding time until the exchange. And as the people bustled all about, speaking a Spanish that Kevin struggled to understand, his mind turned to the familiar. He asked himself, Does Alex ever come to the food court? Six years in Colombia and Alex wanted more control, a bigger cut. At a stoplight, a truck pulled up alongside Alex's Toyota pickup. It was a tanker, hauling a load of fuel in its cylindrical trailer. Alex looked at the fuel tanker and thought If he could build one, and pack it with coke, he would be the greatest trafficker of all. Through his contacts at the port in Cartagena, Alex imported steel from Belgium. Outside Cali, a factory rolled the steel into three cylindrical sections, more than feet long. Alex took on an engineer who had served in the Russian navy. Aluminum had to come out; it'd kill the batteries. The fluid transference must be reworked to maintain proper ballast. But the hull was sound and the motor looked good. The work carried on. Alex's submarine took three years to build. By , the sub was 60 percent complete. It was designed to hold 10, kilos of cocaine. But keeping a secret about a submarine designed to hold 10, kilos was nearly as impossible as building the sub itself. On Sept. Alex was nowhere to be found. In , in a rural farm area of Colombia, authorities discovered a submarine that Alex DeCubas was building to smuggle cocaine. He was running low on cash when a call came in from an old associate. He told Alex about a group from Cali that wanted to run an operation to Europe. Sounds good, Alex said. He was 45 now, puffed out and balding. Life as a fugitive was showing. They went over the particulars of the Cali operation. It all sounded routine to a man who had run dozens of these maneuvers. Alex's contact slipped him an envelope with the loan inside it. On his way home, Alex drove down the tree-lined Avenida Bolivariana. A man was waving his arms up ahead. There were flashing lights, a few motorcycles. As Alex drew closer, he could see cops in riot gear. They directed Alex's Jeep to the side of the road. No big deal: Colombia was full of roadblocks, and most every cop was for sale. But now the cops led him to the local police station. They popped the hood of the Jeep, looking in and around it. Standing apart from the group, a man kept an eye trained on Alex, who reached for his wallet and ID, the one that referred to him as Francisco Cruz. The photo on this fake was Alex in a wrestling singlet, Don't bother, said the senior cop. There's no need to do that, Alex. And then Alex knew; he hadn't heard his real name in many years. His contact had traded him in for a better fate of his own. A heavy metal door cranked opened, and in walked a DEA agent and a U. They explained how extradition would go. The DEA agent had another message: Kevin says hello. Kevin Pedersen spent more than two decades honing his craft within the DEA. He and his new wife, Michele, owned two tire franchises of their own, with a boat out back and a Mercedes in the driveway. His younger daughter, Lauren, was in middle school, and his older, Krista, was in college. He'd received a Purple Heart and a Bronze Star. Two heroes in the family. In December , Kevin had attended Alex's sentencing hearing in federal court in Miami. Alex entered the courtroom shackled. When the old wrestling pals locked eyes for the first time since that night at the Crown Lounge in , they exchanged smiles and a subtle wave. The judge hit him with 30 years in federal prison. It was done; Alex was locked up. And there, for the first time, he reflected on his life. He'd be 76 years old when he got out of this place, so Alex decided to cooperate with the government and tell the authorities whatever they wanted to know. The Feds pared his 30 years to nine. With time served, Alex walked free in , the same year Kevin retired. Check out our episode podcast. With time on his hands, Kevin found himself back at the wrestling meets. He didn't know the kids, but that didn't matter. And soon he got an idea. He took a volunteer job at Westminster Christian School in Palmetto Bay as an assistant wrestling coach. One night he got a call from his old coach at Palmetto, Barry Zimbler. He invited Kevin to a dinner party at his house, a reunion of his wrestlers. This would be a welcome-home party for Alex, who Zimbler felt needed support as he set out on his new life. At first, Kevin didn't want to go. Coach Zimbler had never thrown a party for any of the wrestlers who had lived within the rules. A wrestling teammate of theirs, Dom Gorie, had flown on the space shuttle, four times, and there had been no gathering for him when he returned to Earth. Alex was a hardened ex-con who showed little remorse for his actions. I had a good run, Alex would say of his decades in the underworld. The former DEA agent loathed his disregard. But Kevin also knew the story of the prodigal son and its lessons of forgiveness. So he went to Zimbler's dinner and was surrounded by his old teammates. Kevin found Alex in the kitchen and was quickly wrapped in one of his old bear hugs, each man now barrel-chested. Alex and Kevin chatted, avoiding the heavier subjects of re-entering a society that had changed so much since Alex had skipped town 20 years ago. After the crowd had thinned, the old teammates talked about old times, and Kevin said, Hey, let me show you something. He pulled out his DEA badge, and they held it up for a picture, the laughs beginning to soften years of hard feelings. Kevin wouldn't be able to shake the camaraderie that he felt at the dinner. He reached out to Alex and started rebuilding a lost relationship, occasionally calling on the phone or meeting for a beer. When he became Westminster's head coach in , Kevin passed along the rote lessons of sports to his team, about forging lifelong bonds, not placing limits on yourself, the rewards of discipline. He preached that a scrawny JV wrestler can become an All-American. And that even if a kid finds himself on the wrong path, it's never too late to turn around. On March 19, , the doors to the wrestling room at Westminster Christian School opened to the heat of a Miami afternoon. Kevin was beginning another practice when he saw a blue Jeep Grand Cherokee park outside the entrance to the room. The driver stepped out gingerly, and from the brightness of the day he walked into the dankness of the wrestling room. Kevin gathered his wrestlers. Kevin Pedersen and Alex DeCubas reunited after 40 years apart, because of what first drew them together: wrestling. FIFA The exclusive account of how a small band of federal agents and an outsized corrupt official brought down the sports world's biggest governing body. The death of his father set a battle raging inside the world's greatest golfer. Baker Mayfield is used to defying critics. In fact, he's not sure how to play without them. ESPN 0 0 0. The astonishing story of how two wrestling teammates from Miami came to oppose each other in the cocaine wars -- one as a drug smuggler, the other as a DEA agent. By Brett Forrest. Editor's note: This story was originally published on Aug. Pin Kings: DeCubas' cocaine trail went beyond the U. Pin Kings: 'It's a big one' In , in a rural farm area of Colombia, authorities discovered a submarine that Alex DeCubas was building to smuggle cocaine. Podcast Check out our episode podcast. All rights reserved.

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Byblos buy cocaine

Official websites use. Share sensitive information only on official, secure websites. Other tools evaluated chronotype and sleep and mood disturbances. This study included participants. Higher ORT-OUD scores were associated with a family and personal history of alcohol and substance consumption and higher insomnia and anxiety scores. The opioid crisis is considered a global health issue \[ 1 \]. It originated in the s with the surge in opioid analgesics prescribing, particularly oxycodone, resulting in overdoses and fatalities attributed to their use; these have steadily increased ever since \[ 2 \]. A second wave of deaths due to heroin occurred in Finally, a third wave of deaths emerged in , primarily attributed to synthetic opioids, notably fentanyl and its analogs \[ 4 \]. The opioid crisis was declared a national public health emergency on October 27, As of today, over , overdose deaths occurred during the month period ending in April , according to data from the Centers for Disease Control and Prevention CDC \[ 6 \]. In the United States alone, more than million opioid prescriptions are recorded annually, with an exponential increase in prescriptions over the past fifteen years, accompanied by a rise in the number of hospitalizations and deaths caused by opioid overdose \[ 7 \]. Moreover, the increased accessibility of opioids has led to massive medication hoarding and diverted consumption for nonmedical purposes \[ 8 \], contributing to persistent issues such as Opioid Use Disorder OUD. In Lebanon, data on opioid consumption are scarce. However, there has been longstanding evidence of nonmedical use of prescription drugs, and recent years have witnessed a significant surge in opioid and psychoactive substance use \[ 9 , 10 \]. The Lebanese Ministry of Public Health \[ 11 \] reported a six-fold increase in opioid prescriptions from to Prescription opioids seem to be readily available, as almost two-thirds Moreover, Lebanon has experienced numerous conflicts, political turmoil, and monetary instability since , further aggravated by the recent economic collapse and the COVID pandemic \[ 14 \]. Since October , the country has been grappling with overlapping crises, political unrest, sporadic violence, uncertainty about the future, and a lingering sense of insecurity. The massive blast at the port of Beirut on August 4, , further weakened the Lebanese population, making it vulnerable to mental disorders, including anxiety, sleep disorders, and post-traumatic stress disorder \[ 15 \]. This climate has likely increased stress and distress levels among the Lebanese population, precipitating mental health and sleep problems that may contribute to medication abuse and use disorders, both in prescription and illegal drugs \[ 16 \]. More importantly, a study revealed variability in the frequency of follow-up by Lebanese practitioners regarding opioid prescriptions, with a substantial proportion of these practitioners not assessing additional risk factors before prescribing opioids to patients, which may further contribute to increasing OUD cases \[ 17 \]. OUD stands as the most lethal consequence of opioid use and is at the core of the opioid crisis. It can lead to several social and economic harmful repercussions \[ 18 \], affecting various aspects of the quality of life, including physical health, psychological health, social relationships, and environment \[ 19 \]. Consequently, prioritizing primary prevention strategies becomes crucial, focusing on identifying risks through scalable prevention services and techniques. Identifying patients at risk of OUD before initiating chronic opioid therapy is crucial in preventing abuse and implementing sustainable prescription drug monitoring programs. Rating scales play a considerable role in this process by helping identify individuals at higher risk of developing OUD. Hence, several scales have been developed to detect substance use-related health risks and substance use disorders \[ 21 — 25 \]. Some of these scales are designed to screen for multiple substances, including opioids, in adults already taking opioid medications for pain management. However, most of these tools comprise 17 to 24 items, thus requiring a considerable amount of time to complete and calculate the total risk score during evaluation, except for the revised version of ORT ORT-OUD. While ORT-OUD has been validated in various languages, it has not been validated in Arabic \[ 21 , 29 \], and no study in Lebanon has yet evaluated the risk of developing an OUD after opioid treatment or its correlation with other disorders. The secondary objective was to assess the correlates of the risk scores with sociodemographic and clinical factors, including sleep disorders, chronotype, anxiety, and depression. Snowball sampling was applied to recruit the sample. The survey was shared on social media platforms because of pandemic-related restrictive measures and to ensure better access to all the Lebanese regions to enhance the representativeness of the sample. All Lebanese adults over 18 with access to the Internet were eligible to participate no incentive was offered in return for their participation. A total of respondents from the general population filled out the questionnaire, which required around 20 min to complete. To assess test-retest reliability, the ORT-OUD scale was administered twice to a subsample of the general population who agreed to be contacted by phone. At least a one-month interval with a maximum of three months separated each call. The recruitment took place at the Skoun addiction center, which offers a free-of-charge program in Beirut, Lebanon. All patients 46 patients in total who were present at Skoun during the inclusion period between May and July were invited to join the study and fill out the questionnaire. Patients had to meet inclusion criteria, i. Patients were asked to fill out a paper version of the questionnaire to enhance the completion of the survey and were supported by a research assistant who ensured that all questions were addressed; of note, the research assistant did not interfere during the process, except for providing guidance to participants in completing the questionnaire. Comrey and Lee suggested a minimum of ten observations per variable to perform an exploratory factor analysis \[ 30 \] when assessing construct validity. Since the revised ORT is a 9-item questionnaire, a minimum of 90 patients was required for this study. For the epidemiological study, the minimum sample size was calculated using the Epi-info software. The online questionnaire was available in English and Arabic, the native language in Lebanon Appendix 1 , and consisted of four parts. The first assessed the sociodemographic characteristics of the participants, including age, gender, weight, height, marital status, nationality, highest educational level, employment status and occupation, religion, current household monthly income, socioeconomic status, and medical history of chronic and mental illness. The socioeconomic status was assessed using the crowding index calculated by dividing the number of individuals living in the house by the number of rooms , which was then categorized into quartiles. Other questions were related to medical coverage, smoking and alcohol consumption, and self-perception of the financial situation. The second part of the questionnaire consisted of two validated scales for the evaluation of substance use disorders, i. The chronotype of the participants was also evaluated using the Composite Scale CS \[ 34 \]. Permission from copyright holders was obtained to use the validated scales. Only three subscales were used in this study: opioids, sedatives or sleeping pills, and alcoholic beverages. This selection was based on existing literature that has shown a correlation between OUD mainly and sedatives and alcohol use disorders \[ 37 , 38 \]. Each item was weighted differently, and higher total subscores predicted higher risks of developing related substance use disorder. According to the total score, participants are classified into potential high, moderate, or low-risk level. It was created by unweighting all items and reducing their number to nine by removing one item related to preadolescent sexual abuse. A cut-off point of 2. The selected cut-off score of 2. The PSQI is a self-report questionnaire designed to assess sleep quality and sleep disorders over a one-month period. It consists of 19 items that generate seven component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping pills, and daytime dysfunction. The total score is calculated by summing the scores of these seven components. The higher the score, the worse the sleep quality \[ 31 \]. The ISI is a self-report instrument used to measure patient perceived insomnia. It targets the subjective symptoms and consequences of insomnia and the level of worry or distress caused by these difficulties. The total score enables to determine the presence and severity of insomnia. Values between 0 and 7 indicate the absence of insomnia, 8—14 sub-threshold insomnia, 15—21 moderate insomnia, and 22—28 severe insomnia \[ 32 \]. The ESS is a subjective measure of sleepiness widely used in sleep medicines. It consists of a list of eight situations where individuals rate their tendency to doze on a scale from 0 no chance of dozing to 3 high chance of dozing. According to scores, sleepiness is categorized as normal 0—10 , mild 11—14 , moderate 15—17 , and severe 18—24 \[ 33 \]. The CS is a question tool used to evaluate the chronotype, which refers to the general preferences regarding the timing of waking up, falling asleep, and peak performance \[ 34 \]. The scores range from 1 to 4 or 5, depending on the question. Scores can indicate an evening circadian typology 22 or less , morning circadian typology higher than 44 , or intermediate circadian typology between 22 and 44 \[ 39 \]. The total score for each subscale is the sum of the seven items ranging from 0 to A score between 0 and 7 indicates no anxiety or depression, while scores of 8 to 10 suggest mild anxiety or depression, 11 to 14 moderate anxiety or depression, and 15 to 21 severe anxiety or depression \[ 35 \]. The translation procedure started after getting the approval from Professor Martin Cheatle, the author of the scale. Independent professional translators conducted both the translation and back-translation. The research team and translators compared the original English version with the back-translated version to ensure that the questions had the same meaning, making the necessary corrections as needed. Cultural adaptation of the items was not performed during this process. The scale was then piloted following the finalization of the translation. It was administered to 56 bilingual participants in both languages. Its reliability was found to be excellent, with a single measures intraclass correlation coefficient of 0. The final version of the questionnaire was deemed easy to understand and complete. A pilot test was conducted among ten individuals who were not part of the study to ensure the clarity of the questions. Based on their feedback, one question in the sociodemographic section was reformulated for better comprehension. The responses from the pilot study were not included in the final database. Descriptive statistics were calculated for all variables in the study. The Kolmogorov-Smirnov test was used to verify the normality of the continuous variables. Means and standard deviations were shown for normally distributed variables, and medians and interquartile ranges for non-normally distributed variables. Frequencies and percentages were displayed for dichotomous and multinomial variables. This analysis was performed on the nine items of the ORT-OUD scale, and a Varimax rotation was applied since the extracted factors were not found to be significantly correlated. The number of factors corresponding to Eigenvalues greater than one were retained. The test-retest reliability was evaluated by the intraclass correlation coefficient ICC, mean measurement for the scores of participants with repeated measures. ICC values less than 0. Bivariate and multivariable analyses were performed for sample 1 general population , taking the opioid use risk scores as dependent variables. The Mann-Whitney test was used for comparing two groups, and the Kruskal-Wallis test was used for comparing three or more groups when the continuous variable did not follow a normal distribution. Finally, multivariable analyses were conducted to account for potential confounding factors. Sample 1 consisted of participants from different regions of Lebanon, with The mean age was Of the total participants, Sample 2 comprised 46 patients with a previous diagnosis of OUD. Table 1 summarizes the sociodemographic characteristics of the included population. None of the scale items was removed; the items converged to a solution of four factors with an Eigenvalue over 1, explaining a total of The four factors were: History of substance abuse 3 items , history of alcohol abuse 2 items , history of illegal drug abuse 2 items , and psychological factors 2 items. A Kaiser-Meyer-Olkin measure of sampling adequacy of 0. Results are summarized in supplementary data. Details are presented in Tables 4 , 5 and 6. In this study, the ORT-OUD was translated into Arabic and validated in the general population sample 1 , and its criterion validity was confirmed in a clinical sample of participants with OUD sample 2. Construct validity analysis resulted in the distribution of items on four factors, i. These factors demonstrated rational explanations, appropriate sampling adequacy, anti-image correlations, and communalities. It is worth noting that the initial validation of the ORT-OUD scale in the original paper determined the discriminant predictive validity and the receiver operating characteristic ROC curve in two samples of chronic nonmalignant pain patients taking long-term opioid therapy; the first sample of patients developed OUD after starting opioid therapy, while the other one displayed no evidence of OUD. Furthermore, to the best of our knowledge, no previous research has conducted the translation and validation of the ORT-OUD scale. Nevertheless, the average ICC between the test and retest indicated good reliability \[ 42 \]. OUD patients who use nonmedical sedatives and tranquilizers often exhibit higher rates of polysubstance use and other substance use disorders \[ 44 , 45 \]. This correlation highlights the potential risk of drug-drug interactions and fatal opioid overdoses associated with the simultaneous consumption of opioids and sedatives such as benzodiazepines \[ 46 \]. Moreover, several studies among OUD patients have found correlations between the use of nonmedical sedatives and tranquilizers and sociodemographic characteristics, such as female gender, younger age, and indicators of opioid use severity \[ 47 — 49 \]. These characteristics have been associated with a higher likelihood of using nonmedical sedatives and tranquilizers, making them essential to understanding the patterns of substance use and polysubstance use among individuals with OUD. Another study among OUD patients revealed that This finding indicates good convergent validity of the Arabic version of the ORT-OUD, affirming its usefulness in assessing opioid use risk and its relationship with other substance use disorders. The difference in prevalence rates between the two scales can be attributed to their different approaches to assessing OUD risk. Indeed, ORT-OUD evaluates the risk of developing OUD by considering various well-known risk factors such as age, family, personal history of substance abuse, and mental health conditions, while the ASSIST-opioid subscale focuses more on current substance use habits, thus leading to lower estimated prevalence \[ 21 , 24 \]. Interestingly, one of these studies evaluated the association between hurricane exposure and the risk of opioid-abusive behavior. Our study was conducted in the context of multiple crises, including the COVID pandemic, an economic collapse described as one of the worst crises of the past century \[ 15 , 54 \], and the devastating Beirut port explosion in August considered one of the largest non-nuclear blasts ever recorded in history, with more than deaths, injured, and , displaced Lebanese citizens \[ 14 , 15 , 55 \]. Nevertheless, as data on OUD before these crises are lacking, no conclusions can be drawn as to whether these crises might have potentially affected the high prevalence values reported in this paper; more robust, larger-size epidemiological studies would provide a better understanding of prevalence trends over time. Another valuable factor is the lack of comprehensive evaluation and follow-up by healthcare practitioners when prescribing opioids. It has been reported that a significant number of healthcare practitioners do not thoroughly assess patients for potential risk factors before prescribing opioids in Lebanon. Additionally, inadequate follow-up and insufficient communication about possible adverse effects are common among healthcare practitioners in Lebanon. This lack of proper evaluation and follow-up can contribute to the emergence of an opioid epidemic by increasing the likelihood of people developing OUD \[ 17 \]. This study also aimed to explore the association between sociodemographic and clinical data and the risk of OUD in the Lebanese population. It is well-established that a family history of substance use disorder is a risk factor for OUD in patients with chronic nonmalignant pain \[ 56 — 60 \]. Furthermore, research has demonstrated that teenagers with a family history of alcohol or drug abuse and a lack of pro-social skills are more prone to transition quickly from occasional use to severe patterns of abuse or dependence \[ 61 \]. Thus, understanding these factors helps elucidate the etiopathology and trajectory of addictive behaviors. Finally, social risk factors, such as connection with deviant peers, popularity, bullying, and gang affiliation, can help in shaping positive beliefs and attitudes toward drug use. Therefore, friends and family provide immediate access to substances and also serve as role models for behavior and drug use \[ 62 , 63 \]. When exploring sleep patterns, a positive and significant correlation was observed between the risk of developing OUD and sleep disorders, as evaluated by the ISI. The association between illegal psychoactive substance use and sleep problems appears to be bidirectional \[ 64 \]. Sleep problems have been found to increase the risk of developing substance use disorders \[ 65 — 67 \], which, in turn, might lead to sleep problems \[ 67 — 70 \]. Evidence suggests that chronic use of some illicit substances results in chronic sleep alterations, distinct from the acute effects of these substances \[ 71 \]. Another study has even shown that suvorexant, an orexin-blocking sleep medication approved for the treatment of insomnia, can also decrease opioid-induced cravings \[ 73 \]. Our study is the first to assess the relationship between chronotype and the risk of OUD in the Lebanese population. While it yielded inconclusive results with the Composite Scale used to evaluate chronotype, other studies found a connection between circadian preferences, such as eveningness, and substance use disorder in young adults and adolescents \[ 74 , 75 \]. Regarding mood and other psychiatric disorders, our results revealed that individuals with high anxiety scores as evaluated by the HADS-A and those with psychiatric illnesses were more likely to develop OUD. A strong association exists between opioid- and anxiety-related symptoms and disorders \[ 76 \], which are more common and more strongly associated with the use of prescribed opioids than other substances \[ 76 — 78 \]. Furthermore, individuals with a genetic predisposition for OUD are at increased risk of developing anxiety, stress-related disorders, and major depressive disorder \[ 79 \]. Common mental health disorders and problematic drug use have been found to be associated with the initiation and use of prescribed opioids in the general population \[ 80 \]. Therefore, it is essential to accurately evaluate and identify psychiatric disorders before starting an opioid treatment for pain management \[ 81 \]. Finally, our study revealed that higher waterpipe use was linked to a lower risk of developing OUD, probably because the high nicotine content of waterpipe smoke helps reduce anxiety \[ 82 \], thereby decreasing the need to seek drugs, including opioids. Additionally, anxious individuals may have difficulty self-regulating during stressful situations and may turn to external methods, such as tobacco use, to cope with stress \[ 83 \]. This study has several limitations. However, it was selected because it is the only scale with complete validity and reliability data in Arabic \[ 85 \]. Thus, our results may not be generalized to the entire population. Finally, due to the presence of multiple crises, including the COVID pandemic and the massive Beirut port explosion, the prevalence values reported should be interpreted with caution, as these external factors may have influenced the results. Additionally, the lack of data related to OUD before these crises limits our ability to draw definitive conclusions about the specific influence of these factors. Despite all these limitations, this study is the first to validate an OUD questionnaire in the Lebanese population. This validated tool can now be used in any Arabic-speaking country to assess the risk of OUD before initiating opioid therapy. Moreover, our study is the first nationwide and regional investigation of OUD and potential risk factors, such as sleep disorders, chronotype, and mood disorders. By taking into account modifiable risk factors such as insomnia and anxiety, this scale can help identify people at risk of developing OUD, allowing for targeted interventions to reduce the risk of OUD and improve patient outcomes. Additional file 1 - Supplementary Table 1. Supplementary Table 2. Dolla Karam Sarkis, whose profound influence, enduring wisdom, and unwavering support have left an indelible mark on this work. She is remembered with the utmost reverence. We dedicate this article to her memory, acknowledging her lasting impact on our scholarly endeavors. The authors would like to thank all the participants who agreed to participate in this study. LRK and BM contributed to the design. PS undertook the statistical analysis. HS edited the whole article for English language and intellectual content. BM and LRK supervised the whole process and critically reviewed the article. All authors contributed to and have approved the final manuscript. Our study was conducted in accordance to the Declaration of Helsinki. The topic was explained to all participants in the introductory section of the survey, which also included the consent to participate mandatory to have access to the questionnaire. Participants from the general population group could either maintain their anonymity guaranteed throughout the process of data collection and analysis or allow the principal investigator to contact them again for the re-test part of the scale validation. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. BMC Psychiatry. Find articles by Karam Chamoun. Find articles by Joseph Mouawad. Find articles by Pascale Salameh. Find articles by Hala Sacre. Find articles by Ramzi Haddad. Find articles by Lydia Rabbaa Khabbaz. Find articles by Bruno Megarbane. Find articles by Aline Hajj. Received Mar 5; Accepted Oct 24; Collection date Open in a new tab. Components Factor 1: History of substance abuse Factor 2: History of alcohol abuse Factor 3: History of illegal drug abuse Factor 4: Psychological factors Personal history of substance abuse prescription drugs 0. Multivariate analysis considering the opioid use disorder score as the dependent variable. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Personal history of substance abuse age between 16—45 years. Variables entered in the model: gender, occupation, family income, governate, education, marital status, religion, socioeconomical quartiles, family history of substance abuse, family history of substance abuse illegal drugs , family history of substance abuse prescription drugs , personal history of substance abuse alcohol , personal history of substance abuse illegal drugs , personal history of substance abuse prescription drugs , age between 16—45 years, Psychological disease Attention deficit disorder ADD , obsessive-compulsive disorder OCD , bipolar disorder, schizophrenia , age, weight, height, number of cigarettes per day, number of waterpipes per week, number of alcohol glasses per occasion, HADS-A score, HADS-D score, PSQI score, ISI score, CS score, ESS score.

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