Although people get addicted to opiates in all countries, nowhere has the problem reached the disastrous level of an epidemic as it has here in America. The United States accounts for nearly 25 percent of drug-related deaths every year. For the first six months of 2017 alone, there were 610 opioid-related deaths in Massachusetts, most of them from an overdose.
In other states, the problem is worse. In Colorado, Ohio, and West Virginia, 20-30 overdoses a week in one town is not uncommon. Opioid overdose is the leading cause of death for people aged 25-35. This number is higher than reported deaths from motor vehicle accidents. The numbers of opioid-related deaths has not increased dramatically for the black, Latino and other populations, but it has skyrocketed for the suburban white population.
For several decades now, the life expectancy of Americans has improved steadily. This has been credited to various factors, including an improved diet and better healthcare. However, for the first time since 1993, the life expectancy of the average American went down, mainly due to opioid-related overdose fatalities. There have been about 200,000 deaths from opioid overdoses over the last decade. Whether or not this administration takes action to correct the issue, this is indeed a national emergency.
We need to get on top of this. Of course, public policy decisions at the level of government are crucial. Drug companies, as well as powerful lobbyists of lawmakers (protected by obfuscation and greased palms), have much to answer and pay for in this bleak scenario. Government must stop wasting time on useless admonishment in the ‘just say no’ mode or the criminalization reflex that crushed a generation of predominantly black cocaine users. Instead, education, prevention strategies and easy access to affordable and effective treatment must be implemented as a massive public health initiative matching this emergency.
I want to lay out a little about how opiates work in the human body and how they can lead to addiction before considering how various mindsets work against effective treatment options. Then we can begin to explore the opiate addiction treatments that are available today.
What are opioids?
Opioids are drugs that modulate the perception of the outside world as noxious – things may be felt, but we are less stressed out by them, pay less attention to them and so stop registering them as ‘painful.’ They have been used as pain relief for millennia. It was the Sumerians who first discovered the euphoric and soothing effects of the opium poppy plant, from which all opiates are derived – heroin, codeine, Dilaudid, hydrocodone, and others. “Opioids” refer to synthetic versions, like methadone, fentanyl, oxycodone, and others. These days, most professionals use the words opiate and opioid interchangeably.
Opiates (we’ll just call them all this from here) are terrific. They mitigate appalling pain and soothe anxiety. They should be used for severe pain, especially in palliative conditions like cancer. But they’ve been used for way too many things in the past few decades, including benign and chronic conditions, like back pain. Given for a long time our body adapts, grows accustomed to them and then starts to need them just to feel normal. This has led to the disaster: there are more prescriptions written for opiates than there are people alive in the USA. Ninety-five percent of the world’s opiates are prescribed in the USA. The correlation between rampant prescribing and the epidemic is irrefutable.
It’s important to note that the body produces natural opioids, principally beta-endorphin. This can block pain and generate a calming, anti-depressant and anti-anxiety effect by directly soothing our stress systems. They tell us not to pay so much attention to the issue, not to feel something as painful. This is a carefully balanced system. Chronic unremitting bad things need to be responded to, moved away from or altered, or we need to learn to manage them, with the help of our community, while we continue to function.
When we take big doses of opiate pills, they can bind to the body’s endorphin receptors and this careful balance is thrown out. Our stress system is inappropriately silenced. This can feel so good, but is tragically temporary. Not only does this relief wear off, but afterward our stress system is on fire. It bounces back even more fiercely, and unbalanced, so that the pain and distress is now felt as even worse. With continued use, the body’s stress system ramps up and the brain is tuned to obtaining the only thing that relieves it – opiates. Without them, people feel miserable, distressed and craving – they are addicted.
What is Opiate Addiction?
Doctors prescribe pain killers because they genuinely want to help their patients enjoy a productive and pain-free life. Under proper doctor supervision, prescription opiates can dramatically improve and even enhance a person’s quality of life.
However, after taking opiates for an extended period of time, tolerance for the drug is inevitable. This means the person needs a higher dose of the drug to experience the same level of relief. Prolonged use can also cause drug dependency. This is when the body becomes so used to having the drug in its system, that it can no longer function normally without it. Withdrawal from the opiate results in symptoms that can include chills, depression, and fatigue – a state of anxious misery quenchable by one thing – opiate.
If patients share this increasing tolerance and dependence with their doctors – and if doctors ask – alternate means of pain relief can be sought. People want relief from the pain as well as the euphoric feeling generated by being pain-free. People in this situation may resort to getting multiple prescriptions (from different doctors) to experience the relief and the high that comes with taking opiates.
Without timely intervention, the day will come when prescription drugs will no longer provide adequate relief. Opiate use merely gets people back to feeling normal. People soon start seeking stronger forms of the drug – like heroin or fentanyl – to get the high they experienced in the beginning. When even this is not enough, addicted individuals start looking for ways to get the opiates to the brain more quickly. This is when smoking and injecting replace oral use.
Drug tolerance and dependence are normal possible outcomes of taking any type of opiate for an extended period of time. Drug addiction, however, is a state where the whole being is completely turned towards obtaining the drug. Addiction steers thinking and behavior away from attachments and moral commitments. This makes people seem antisocial and impulsive. All the things they held dear and worked for can crumble and feel unattainable and a lonely hopelessness sets in.
Mindsets Preventing Effective Opiate Addiction Treatment
Treating opiate addiction is a long and complex process. There is no one-size-fits-all template and certainly no quick fixes. Before any treatment can begin, however, society in general and doctors in particular need to overcome restrictive mindsets that hamper even the most tried and tested opiate addiction treatment.
Reward versus Punishment
All brains respond to reward more than to punishment. Positive reinforcement elicits the desired behavior more quickly and more robustly. People are pretty insensitive to punishment. This is especially true for adolescents and those with a more impulsive nature than others. These are the people most susceptible to finding drugs quickly and losing control of them. Once addiction sets in, the brain is super-sensitive to one reward especially: the drug it’s been trained to want.
To be simplistic (and without any wish to demean) think of any basic training paradigm, such as teaching a puppy to sit. How effective is screaming or hitting the puppy when he gets it wrong? You get a scared, confused, ‘disobedient’ dog. Instead, you display a calm, engaged, and kind demeanor and reward any movement towards the desired behavior. You shape the behavior by giving praise and food whenever the dog does as he is commanded, in this case, when he sits down. Any behavior can be shaped and it’s fun. The only complexity is the time spent and the consistency of the trainer.
We tend to forget this basic tenet when it comes to the treatment of opiate addiction. Instead of employing a compassionate treatment approach, or ones utilizing rewards for wanted behavior (housing, money, love for progress, etc.), society chooses incarceration, confrontation, shaming, and limit-setting. America is putting more and more people in jail for drug addiction (up from 24,640 in 1980 to more than 188,000 to date) and yet the number of people dying from drug overdose continues to rise.
These approaches fail. They’ve failed for decades.
Depriving opiate addicts of the drug to which they have become addicted or punishing them for being addicted, does not break the chain of addiction. Neither does it empower or encourage them to seek more positive alternative solutions from their families or supportive communities. All it does is drive them to seek satisfaction from another source.
Powerful reinforcement paradigms, such as ‘contingency management,’ have repeatedly been demonstrated to be the most effective of the behavioral interventions. But while Psych Garden utilizes them, few other places do. There is warmth and community, in addition to a genuine welcome and continuous encouragement. Unfortunately, there can also be shame and criticism, and many people feel discouraged by the idea of starting at day one again.
Blaming the Person Addicted to Opiates
Another mindset that works against effective opiate addiction treatment is one that blames the person for their addiction. This does not mean they cannot be held responsible for his or her decision to take drugs. But blaming them for their addiction implies getting addicted was something they could have prevented entirely. This is simply not true.
Addiction is more complex than poor self-control or lack of willpower or even the absence of a moral compass. A propensity to addiction depends on a combination of factors. This could include genetics (impulsivity and muted arousal that constitute family history), developmental trauma (neglect, adverse childhood events) and availability of the drug.
Additionally, people with a family history of drug use are more likely to be introduced to and find drugs early and find them more compelling. They also have higher tolerance and so are able to expose themselves to higher amounts of the drug, incurring more withdrawal and habituation. No one gets into drugs thinking they will become addicted. It is always an unwelcome process.
An addicted person may, in the beginning, enjoy the high or the pain-free existence their preferred opiate provides. But as the brain becomes dependent on the drug, it becomes less about liking or enjoying the experience. Instead, it becomes an automatic neurobiological response to any stimulus that triggers the need for the opiate. A stimulus could stem from learned associations like people, places and things, as well as emotional cues like sadness, boredom and loneliness. Opiate addiction treatment options that do not understand and address the problem as a compulsion are doomed to fail in the long run.
Blame and shame, an emphasis on just saying ‘No,’ or constant admonitions to be ‘strong’ – these ideas are so erosive and alienating and ultimately destructive. Of course people need to make a commitment and feel responsible for the consequences of their actions. But maintaining compassion and an appreciation of the ambivalence within – the pull of the drug versus the draw of valued goals – is the core of effective treatment.
Alternative Pain Treatment Options
In their desire to help their patients, doctors have been too quick to prescribe painkillers in egregious doses. Big pharmaceutical companies, of course, encourage this practice with outrageous and dishonest marketing and lobbying machineries. When relief comes by simply taking two capsules a day, other treatment options quickly fall by the wayside.
As a result, underlying issues that could potentially diffuse the pain or reduce the stress are not sufficiently explored. There are a number of effective pain and stress remedies that do not involve opiates. Acupuncture, biofeedback, mindfulness and massages are just a few examples of non-medication interventions that have proven to be helpful. Non-steroidal drugs (such as Tylenol) have also been shown to be as effective as opiates in trials. These options may not offer the immediate and intense experience of relief that opiates do, but they do not carry a risk of addiction or death either.
To be certain, there will be times when prescribing painkillers becomes necessary. Ideally however, an opiate prescription is only one aspect of a comprehensive treatment plan that takes a long-term view of the patient’s recovery.
Abstinence versus Harm Reduction
When all the issues of the person coming to treatment are simplified and stripped down, treatment providers sometimes display a mindset prevalent in society. They focus on the drug alone and believe that stopping drug use will make everything OK. They also maintain that no significant change can occur until drug use stops. But like any over-simplification, much is lost.
People are not automatons. The complexity that brought them to the point of treatment has to be grasped in full, not ignored. People may have been traumatized, cheated, and alienated. Their maturation may have been stunted to the extent that their identities are undifferentiated, their values unclear and their potential obscured. The drug use is wrapped up into ways of relating to others, having sex, tolerating feelings, even sleeping and eating.
To tell someone that they simply need to stop is so simplistic that you risk misunderstanding the most important aspects of the person to whom you are talking. They are likely to feel misunderstood, and such misalignment will get in the way of effective therapy. Sensitivity to this complexity and to the experience of the person coming for treatment is the core of harm reduction. An insistence and focus on abstinence as the goal of treatment shuts out many people who are curious and concerned, but not yet committed or ready to leave their drug habit behind. It shuts down collaborative exploration and purposeful problem solving.
Harm reduction also acknowledges that other goals, not just the pursuit of abstinence, are valid and worthwhile. Improved health, connection, functioning and pursuit of valued goals should be the direction of treatment, rather than the dogged fixation on abstinence. Doctors and society tend to see this ‘purist’ goal as desirable, even achievable. A dramatic 180 degree turn would indeed be quite a triumph – for the person, the doctor and society as a whole.
The reality however, falls far short of this ideal. Simply reducing the harm that opiate addiction wreaks on an individual’s life is a significant accomplishment. Giving someone who’s using the ability to once again relate meaningfully to his or her family, friends and co-workers is huge. These goals are worth pursuing in and of themselves.
Safer and more controlled opiate use is possible. This can be especially challenging in America where drug use is illegal and so obtaining and using drugs becomes a dangerous undertaking. But this is not impossible. People can shift to safer modes of using, decrease their use, and at the same time be engaged in a therapy that helps them reorient themselves towards valued goals.
This has been accomplished in other countries, such as Canada and Portugal. Following decriminalization policies and utilizing safe injection sites, these countries offer individuals who are using far greater odds of living productive lives despite their drug habit. Actually, many people continue using safely for years if they have a safe source.
One famous example of such an individual is Margaret Thatcher’s physician. A revered and senior doctor, he nevertheless injected morphine for decades. Obviously, this is not the desirable or final goal. I am sure this doctor was miserable, tortured and could have benefitted greatly from outreach and relief. But I’m just making the point that drug abuse treatment need not be an all or nothing proposition.
Though I’m loathe to lump these drugs in with other opiates, opiate replacement therapy drugs, like buprenorphine or methadone, are profoundly effective in alleviating cravings, withdrawal symptoms, and blocking the ability to get ‘high.’ These drugs satiate the wanting and permits the normalization of the body’s stress systems and behaviors. An obsession with abstinence has kept many thousands of people from these effective, life-saving and life-changing medicines. Put another way, the abstinence fixation has left many to die.
Opiate addiction treatment options that aim for harm reduction rather than complete abstinence is not a cop-out. It requires doctors to engage their patients wherever they may be in their personal struggle with drugs. To help them reach goals they feel ready to work towards, rather than goals that have been imposed on them by society. Viewed from this prism, opiate addiction treatments need to be tailor-made for each individual and the personal journey that they have chosen to undertake.
Opiate addiction costs America more than $180 billion dollars each year. This amount covers combined expenditures for healthcare, lost productivity, law enforcement costs, and prison facilities for drug offenders. Treatment options vary, but none will be truly effective if the whole person, rather than just the ‘opiate addict,’ is not respectfully engaged throughout the process. This process must include the understanding and application of well-researched interventions, such as the use of buprenorphine and naltrexone.
Doctors, as well as society in general, need to be careful not to let restrictive mindsets hinder treatment. The harm reduction approach is essential for compassionate engagement appropriate to the person’s stage of change. For meaningful and lasting change, the person who is using must be convinced that a dramatic and difficult shift, such as giving up opiates, is bearable, achievable and worth the effort.. Treatment professionals, using available tools from science and experience, must remain present to their patients’ pain and suffering wherever they may be on their journey to wellness and recovery.