For heroin and other opioids, the only proven method is indefinite drug maintenance — not abstinence.
Addiction to heroin and prescription opioid painkillers recently has increased, leading to a rising number of overdose deaths. As an addiction psychiatrist who has treated opioid addiction for more than 30 years, I applaud recent efforts to restrict inappropriate access to pain medication and to make naloxone (a medication that reverses the effect of the drugs, thus saving people from overdosing) available. However, there is a major gap that is not getting the attention it deserves: treatment.
Most reports note the need to make treatment available. The problem is that the treatment most often available (so-called “abstinence-based” treatment, usually based on the 12 Steps of Alcoholics Anonymous), does not work for opioid addiction. The message to addicts that relapses are their fault for not “following the program” is not only stigmatizing and cruel, it is a lie.
There is only one treatment proven effective for established heroin or other opioid addiction: indefinite maintenance on another opioid medication, such as methadone or buprenorphine. Dozens of studies have shown that opioid maintenance reduces drug use, crime, sickness and death and that it restores people as functioning and productive members of society. It is regarded as the first-line treatment for opioid addiction by the World Health Organization, the U.S. Centers for Disease Control, and the U.S. departments of Veterans Affairs, Defense, and Health and Human Services.
On the other hand, there is not one high-quality clinical trial demonstrating the effectiveness of detox followed by abstinence. Even stabilization on opioid medication for weeks, combined with better counseling than is available in most communities, followed by opioid taper, does not work.
Does this mean that no one ever recovers using an abstinence program? Of course not. There are always exceptions. But they do not refute dozens of high-quality research studies.
Why is maintenance necessary for opioid addiction but not for, say, alcohol addiction? It is because opioid addiction directly affects the brain’s opioid system (i.e., endorphins) and suppresses natural brain opioid activity. The brain opioid system is our pleasure system. When the heroin is removed, the internal system does not return to normal; instead there is a “brain opioid deficiency.”
This means that abstinent addicts are unable to experience pleasure or a sense of well-being. Their brains are screaming for opioids, so they are constantly obsessed by craving. Medications like buprenorphine return the brain opioid system to normal function, relieving the misery and craving.
Former addicts do not have any sense of intoxication; they just feel normal. They are freed to pursue life’s normal pleasures (and miseries, of course).
Maintenance therapy is like giving insulin to diabetics. Abstinence-based rehab is like sending a diabetic to a spa for a month, teaching diet and exercise, and then sending them to support groups. And it works about as well as that would.
Given the overwhelming evidence supporting opioid maintenance treatment, a third initiative is essential if we wish to reduce deaths from opioid overdose: ensuring that 1) clients and families receive accurate information about the effectiveness of different forms of treatment, and 2) that buprenorphine or methadone maintenance is made accessible and affordable to anyone seeking it.
Currently, access is very difficult. Opioid maintenance treatment is only available in large cities, and especially with buprenorphine treatment, may only be available from cash-only clinics that charge $300 per month for five minutes with a doctor and a prescription. Since each physician can accept up to 100 patients, this lucrative-but-exploitative practice has attracted far too many unqualified physicians, some of whom have troubled paths (such as histories of addiction and licensure problems).
Unfortunately, legitimate agencies — such as state agencies and large health care provider organizations — have not stepped up to the plate. What is needed is the commitment of these organizations to offer affordable, accessible, high-quality opioid maintenance treatment, especially in rural areas.
Finally, addiction treatment programs and sober houses that “don’t believe in” opioid maintenance treatment need to be told by their licensing agencies that they have an ethical and legal obligation to provide accurate scientific information about treatment to potential clients and families. Withholding it or, worse, giving false information on the basis of ideology or personal preference are unprofessional and unethical, and can no longer be tolerated. People are dying out here.
Mark Willenbring is founder and CEO at Alltyr: Transforming Treatment for Addiction in St. Paul.
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