We Know How to Treat Opioid Addiction

When I was 22 years old, I was treated for an addiction to opioids. In the five years since, I wake up each morning and scan my news filters to read about some of the 78 people who die each day from overdose. Which depressed Rust Belt city was hit today?

The opioid crisis is one of few in public health that, despite all efforts, continues to worsen. Nearly 2 million people in the United States are addicted to painkillers and an additional 450,000 are addicted to heroin. Fortunately, we have a proven way of lowering the death rate and easing the ills of addiction: medication-assisted treatments like methadone and buprenorphine. Unfortunately, thanks to a moral and policy-driven opposition to these treatment techniques, we’re not using it.

The first hurdle comes from misunderstanding how medication-assisted treatment works. Here’s the science behind it: Our brain produces natural opioids. But with the continued flooding of external opioids like heroin, the brain gradually stops producing its own. An internally depleted opioid system leaves us constantly sore, sensitive to pain, depressed, fatigued but unable to sleep. When I was still addicted but not using, I always felt a pang of doom impossible to relieve. These medications—which are synthetic and semi-synthetic opioids—help stabilize users and stanch these side effects while giving the brain a chance to heal.

Once maintained on the right dose, the receptor sites are activated just enough to keep the opioid system sated without producing the intense highs and lows (the hallmark of addiction) of opioids like heroin. This gives the brain, and most importantly, one’s connection with the world, a chance to rebuild. Simply put, these medications hydrate a thirsty system. On these drugs we can work, drive, and behave virtually indistinguishably from ordinary Janes and Joes.

Research also consistently shows that methadone and buprenorphine save lives. A 2015 study in the U.K. compared 151,983 opioid dependent patients who received different kinds of treatment: It found that over four years those who received only counseling were twice as likely to die from a fatal overdose than those treated with medication. A 2014 study in New South Wales, Australia, found a similar result in opioid-dependent patients leaving prison: In this high-risk population, being on either methadone or buprenorphine meant the risk of dying was reduced by a staggering 75 percent.

The World Health Organization calls these medications “essential” because expanding access to them reduces crime, infectious disease, and death. In blocking access, these all rise.

Given all of this, it should come as a shock that only a quarter of patients who sought treatment for opioid-use disorders in the U.S. received these medications. This is particularly problematic because drug treatment programs have a notoriously high dropout rate. Those that are given these medications stay engaged in the process for longer than those who don’t use them.

Outside of the lab, certain areas provide a real-world testament to the medications’ effectiveness: In 1995, during an HIV outbreak in France, the government instituted what’s called a “low threshold model” that let doctors prescribe methadone and buprenorphine on demand. Since, 2004, France has seen a remarkable 80 percent reduction in overdose deaths. Baltimore did something similar in 1995 and by 2008, the city saw a 66 percent reduction in overdose deaths. In contrast, the rest of America makes it extremely hard for doctors to prescribe these essential drugs: Methadone can only be used to treat addiction at highly regulated clinics; and to prescribe buprenorphine, doctors must take an eight-hour course and apply for a special license from the Drug Enforcement Administration. They also have patient limits (which were recently bumped from 100 to 275).

America needs to implement this model. But there is rampant misinformation, rigid ideological resistance, and outdated policy that keeps it from happening. To prescribe opioids to a person addicted to them simply does not compute within America’s deeply carved grooves of a medication-adverse, 12-step self-help culture that dominates our version of addiction treatment. Close to 80 percent of our residential treatment centers are steeped in the 12 steps of Alcoholics Anonymous, many of which operate on unscientific beliefs about which medications are appropriate.

It’s an odd stance for a country that so often throws pills at our problems. But in rehab, if you have anxiety that means no Xanax. If you have ADHD that means no Adderall. Some rehabs are so chemophobic that they once debated whether or not coffee should be allowed. At Hazelden in Minnesota, where I went, their largesse came in the form of half-caffeinated coffee. (If you made nice with the cafeteria workers, they’d hook you up with the real stuff.) So it’s no shocker that giving opioid users opioids is rejected, almost on principle.

I often hear medication-assisted treatment called “trading one addiction for another.” This stems from a fundamental misunderstanding of what addiction is. Addiction, as defined by psychiatry, is the agonizing, compulsive pursuit of a behavior despite the negative consequences said behavior reaps. The perturbed opioid system that users experience—the thing that makes it so hard for them to actively live in the world—is a medical problem. Why wouldn’t we use a medication to treat it?

My friend Hal kindly volunteered his experience to illustrate why he’s not addicted to buprenorphine, which he has taken for a couple years. He’s 26 and had a brutal habit that occupied his formative years. After a near-death overdose, a detox facility gave him the drug and referred him to a doctor to prescribe it. Now, he takes this maintenance drug, lives with his sister in Chicago, works as a barber, and contributes to his community.

So where is the addiction? He’s no longer stealing his grandmother’s jewelry to buy drugs. Hal left his addiction behind when he rejoined the world with the help of buprenorphine. Hal would go into withdrawal without the drug, but that is not addiction. That is what’s called physical dependence, and it happens to anybody and everybody who takes opioids. His vocation, his relationships, that he thinks life is worth living, is excited about what the future holds—this is what recovery looks like. It doesn’t matter what molecules are in his bloodstream.

Nonetheless, a collective miasma emanating from a treatment industry deems Hal as not being truly in recovery because he’s still taking some form of opioid. Frustratingly, it took Hal three different treatment attempts that cost his family tens of thousands of dollars before he finally found the doctor who gave him buprenorphine. And that doctor was not affiliated with any residential treatment facility (an industry that rakes in an estimated $35 billion per year).

Because I write openly about addiction and my experience of it, I get all kinds of messages. Not long ago a business developer at a South Florida treatment center called Banyan wrote to me: “Doing my best to stop the spread of medically assisted treatment that exists throughout the Midwest … I’d love to get you involved in some way.”

Of course, I’d like to do the exact opposite. In 2011, after I finished five days of detox, much like Hal, I was given a bottle of buprenorphine and a doctor to keep my refills flowing. I was then enrolled at Hazelden, a treatment center in Chicago close to where I grew up, to begin intensive outpatient treatment. This entailed a few hours a day of group therapy and educational lectures.

Before enrolling, I was told by several different staff that I had to get on a plan to taper off the buprenorphine. “We don’t do that here,” they said. I even heard from the clinical director that these drugs stunt spiritual development. Being young, unfamiliar with the scientific literature, I thought I should listen. They seemed to know what they were doing.

But when I tapered off the buprenorphine, I was back in hell. The drug not only relieved cravings, but it curbed my Kierkegaardian-sized dread. Being alive day after day in that way is unbearable. Eventually, heroin seems like a sensible solution, and sure enough I found myself back to the needle within a couple months of getting off it.

It wasn’t before long until I wound up in Hazelden’s residential facility. The doctor gave me buprenorphine for only a few days—called a rapid taper. This approach is unscientific and is not supported by the literature. As a result, I suffered through months of withdrawal. What kept me there wasn’t the treatment, certainly wasn’t the coffee, but rather my parents’ commitment to me—something that ended up costing a college’s tuition. I’m lucky—most who wind up in my situation have nowhere near the resources to stay long enough to fully go through withdrawal. And doing so was terrible, but eventually it worked for me. I’m 27 now and haven’t touched the stuff.

Just after my discharge in 2012, Hazelden instituted a buprenorphine maintenance policy. Too many of their clients were dying weeks, sometimes days after they left the facility.

The stigma against these medications also comes in the form of policy barriers. For no other drug does a doctor need to take an eight-hour course, get licensed by the DEA, and adhere to strict patient limits, but these strict standards reduce the number of doctors even able to prescribe methadone and buprenorphine. A friend of mine in Akron, Ohio, was trying to kick her habit but told me her community health center is turning patients away because they’ve hit an arbitrary limit of patients they’re allowed to treat. The limit was supposedly put in place to prevent the doctors authorized to prescribe from becoming “licensed drug dealers,” as many who fear the medication assume. But France saw no such problem—neither did Baltimore. A low-threshold model would make these medications easier to get for those who need them.

There seems to be light at the end of the tunnel. Cigna, one of America’s biggest health care providers, recently announced that they dropped a longstanding “preauthorization” policy that made doctors fill out time-consuming forms about any opioid-dependent patient they planned on treating with medication. Others providers plan to follow suit. And a recent report from the surgeon general called “Facing Addiction” fully embraced these medications, stating that they are “surrounded by misconceptions and prejudices that have hindered their delivery.” Of course, the Trump administration, which is already off to a rocky start when it comes to accepting evidence-based anything, may hinder the continued acceptance of such treatments.

Either way, the recovery community and treatment staff at treatment centers have a long way to go, both in terms of use and perception. Someone with diabetes who takes insulin and receives nutritional counseling is simply receiving “treatment.” Not insulin-assisted treatment or counseling-assisted treatment. So why do we still refer to methadone or buprenorphine use as medication-assisted treatment? It’s time to drop the “assisted” modifier here—medication for opioid users is simply treatment. Perhaps if we can do that, more widespread acceptance of a treatment method that can save lives will follow.

Zachary Siegel is a master’s degree candidate at the University of Southern California’s Annenberg School for Communication and Journalism. Follow him on Twitter.

Rural landscape

Dying To Be Free

There’s A Treatment For Heroin Addiction That Actually Works. 
Why Aren’t We Using It?

That day, in August 2013, Patrick got in the car and put the duffel bag on a seat. Inside was a talisman he’d been given by the treatment facility: a hardcover fourth edition of the Alcoholics Anonymous bible known as “The Big Book.” Patrick had tagged some variation of his name or initials on the book’s surfaces with a ballpoint pen, and its pages were full of highlighting and bristling with Post-its.

Back in the wood-paneled living room of their Lexington, Kentucky, home that afternoon, Patrick and his parents began an impromptu family meeting about what to do next. Patrick’s father, Jim, took his usual seat in the big red chair, and Patrick’s mother, Anne Roberts, sat on the couch. Patrick took the footrest between them, sitting with his hands on his knees. Was he ready to be home? Did he have a plan to get a sponsor? Maybe he should start looking for a job or apply to graduate school?  Read the entire article

The Opioid Epidemic: A Complex Monster

As an addiction treatment professional, people often ask me two questions: First, how do I think the current opioid epidemic is different from previous periods of increased drug abuse? And, more important, when is it going to get better? My response to both is always cautious, and usually delivered after a long pause: “It’s completely different; it’s much worse,” and “I don’t know.”

It always troubles me to deliver such a somber declaration, but the reality and statistics of the situation support my viewpoint. The current prescription drug abuse and opioid epidemic is responsible for considerably more deaths than previous epidemics, with mortality rates currently four to five times higher than rates during the “black tar” heroin epidemic in the mid-1970s, and more than three times what they were during the peak years of the crack cocaine epidemic of the 1990s.

I have yet to see significant improvement in any of the metrics attached to this plague, be it death rates or any other important statistic. It is not that there is an absence of people working hard to turn the tide; I can tell you firsthand that a lot of efforts are in progress by a lot of intelligent, dedicated individuals. The answer to the difficulty in combating this epidemic lies in the complexity of the monster itself.

What Caused the Opioid Epidemic?

There are three basic components that have gotten us into this quagmire. Each is substantial and complicated it its own right. The medical, social and economic drivers of this epidemic are as fascinating as they are terrifying. I am going to briefly summarize each one, but if you want a more detailed storyline, check out Dreamland: The True Tale of America’s Opiate Epidemic, by Sam Quinones. Each of these issues — medical, social and economic — could be its own blog or book chapter, but by nature this blog post is a practice in brevity.

First, the medical establishment has drastically changed its view of pain and the treatment of pain with powerful medications. For decades, the medical profession considered only the suffering of cancer and post-operative patients severe enough to be dosed with heavy-duty opioids. But in the 1980s, doctors began arguing in medical journals that all forms of chronic pain should be treated more aggressively. Congress declared the first decade of the new century to be the “decade of pain control and research.” Makers of narcotic painkillers, like Purdue Pharma, downplayed the risk of addiction and devised slick promotional campaigns for the drugs. The pain medication OxyContin, an oxycodone opioid, was one of the most dramatic examples of this, as demonstrated by the fact that in 2002, doctors were prescribing 10 times more OxyContin than they had in 1997.

Seeing Pain Differently

The Opioid Epidemic: A Complex MonsterThere has also been a fundamental change in the way pain is perceived in our society, by both doctors and patients. Pain is no longer understood as something that had to be endured; it could be easily and quickly treated with pills. “By the 1990s, it became unacceptable for patients to be in pain,” says Carl Sullivan, MD, an addiction specialist.

In addition there was the “Pain is the 5th vital sign” campaign seen in new pain management standards put forth by many healthcare entities. These positions were based on flawed science and blatant misinformation and accompanied by dangerous assumptions that opioids are highly effective and safe and devoid of adverse events when prescribed by physicians.

Furthermore, many hospital doctors’ pay and promotions are now tied to patient satisfaction scores. These can be sunk by bitter patients who feel their providers don’t dispense painkillers readily enough. The result is that unreasonable pressure is placed on conscientious physicians who can have a hard time differentiating between a desperate patient who is genuinely suffering and a manipulative one who’s seeking out drugs to fuel their dependence or addiction.

Lastly, there is the economics of it all. Shortly after Purdue Pharma introduced OxyContin in 1996, the company spent large amounts of money directly marketing to patients, physicians and pharmacists. Purdue bolstered its sales force and compiled databases of doctors who were likely to prescribe the drug. Its sales representatives received millions in bonuses for persuading doctors to write scripts. Just as the medical establishment and government entities were recognizing the inundation of both appropriate and inappropriate opioids to the public, the drug cartels in Mexico recognized the growing opiate abuse issue in the U.S. and took advantage of this by mowing down fields of marijuana in 2000 and planting poppy extensively.

As more “pill mills” were shut down and the supply of prescription opioids declined, the cartels and dealers made significant changes in their own marketing and distribution of heroin. They targeted suburban populations where prescription opiates were already a problem, used extensive untraceable cell phone networks and delivery services and employed chemists to make heroin both cheaper and more addictive (e.g., adding fentanyl).

But there is hope. Through the utilization of comprehensive, evidence-based medical care and in conjunction with psychosocial support, people are getting treatment that can save their lives and rebuild our communities. Check out my next blog for an uplifting discussion about combating this scourge on our society.

Addiction.com Expert Blogger

About the author

Shawn A. Ryan, MD, MBA, is an assistant professor, department of emergency medicine, at the University of Cincinnati, and chair of quality and patient safety at Jewish Hospital-Mercy Health Partners. Dr. Ryan graduated from the University of Kentucky College of Medicine and obtained his MBA at the University of Cincinnati College of Business while simultaneously completing his emergency medicine residency there. His dual degrees provided background for Dr. Ryan to lead the quality department at Jewish Hospital as well as many other initiatives for Mercy Health, including the prescription drug abuse epidemic and post-acute care collaboration. Dr. Ryan is currently practicing addiction medicine at Brightview Treatment Center in Cincinnati, is published on this issue and has spoken nationally at conferences in regards to opiate abuse.  He also serves on many regional, state and national committees addressing this complicated subject.

EXCLUSIVE: Mercy Health strikes deal with new medical center

Mercy Health-Cincinnati has formed an affiliation with BrightView, a medical center that recently opened in Norwood to provide treatment for patients battling drug or alcohol addictions.

Heroin and opiate abuse have reached epidemic levels in Greater Cincinnati, according to medical experts.

“There is a very strong demand in Greater Cincinnati for quality chemical dependency services provided with compassion,” said John Starcher, CEO of Mercy Health-Cincinnati. “In BrightView, we’ve found an affiliation partner that shares our desire to help improve the health of our community and will help us expand patient access to these much-needed services on an outpatient basis.”

Long-Term Follow-Up of Medication-Assisted Treatment for Addiction to Pain Relievers Yields “Cause for Optimism”

In the first long-term follow-up of patients treated with buprenorphine/naloxone (Bp/Nx) for addiction to opioid pain relievers, half reported that they were abstinent from the drugs 18 months after starting the therapy. After 3.5 years, the portion who reported being abstinent had risen further, to 61 percent, and fewer than 10 percent met diagnostic criteria for dependence on the drugs.