Too many overdoses

A 39-year old neighbor of mine recently died from an opioid overdose, leaving behind three young daughters.  The thing is, similar overdoses happen throughout the United States literally dozens of times a day (seriously– 20,000 Americans a year die from overdoses of heroin or opioids) and we’re doing all the wrong things to solve the problem.

At this point, the evidence is pretty close to overwhelming that the most successful treatment follows a medical model of addiction and treats opioid addicts with the very effective drug Suboxone (basically eliminates the cravings, but doesn’t get you high itself).  Meanwhile, most American jurisdictions, especially those where these overdose deaths are a full-blown epidemic, ignore medical science and insist on 12-step programs.  In addition to the fact that these programs are all distinctly religious (not exactly separation of church and state for court-mandated– or often strongly coerced– treatment) this approach just doesn’t work well at all.  For one, it was designed for alcohol, which affects the brain very differently than opioids.  Additionally, all the best evidence suggests that the failure rate from these programs is awful.  But that’s what we keep doing.

Anyway, an amazing story on this ran recently in HuffPo.  It’s really, really long (I wonder how many pages this would be in the real world), but really really good.  Here’s some of my favorite parts from the first two chapters (out of 8):

A heroin addict entering a rehab facility presents as severe a case as a would-be suicide entering a psych ward. The addiction involves genetic predisposition, corrupted brain chemistry, entrenched environmental factors and any number of potential mental-health disorders — it requires urgent medical intervention. According to the medical establishment, medication coupled with counseling is the most effective form of treatment for opioid addiction. Standard treatment in the United States, however, emphasizes willpower over chemistry.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls. Opiates, cocaine and alcohol each affect the brain in different ways, yet drug treatment facilities generally do not distinguish between the addictions. In their one-size-fits-all approach, heroin addicts are treated like any other addicts. And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids…

“The brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed,” Kreek explained. “The brain may get OK with time in some persons. But it’s hard to find a person who has completely normal brain function after a long cycle of opiate addiction, not without specific medication treatment.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreek said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

A 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University concluded that the U.S. treatment system is in need of a “significant overhaul” and questioned whether the country’s “low levels of care that addiction patients usually do receive constitutes a form of medical malpractice.”

Where buprenorphine has been adopted as part of public policy, it has dramatically lowered overdose death rates and improved heroin addicts’ chances of staying clean…

“If somebody has a heroin dependence and they did not have the possibility to be offered methadone or Suboxone, then I think it’s a fairly tall order to try and get any success,” said Dr. Bankole Johnson, professor and chair of the Department of Psychiatry at the University of Maryland School of Medicine. “There have been so many papers on this — the impact of methadone and Suboxone. It’s not even controversial. It’s just a fact that this is the best way to wean people off an opioid addiction. It’s the standard of care.”

But as the National Center on Addiction and Substance Abuse study pointed out, treatment as a whole hasn’t changed significantly. Dr. A. Thomas McLellan, the co-founder of the Treatment Research Institute, echoed that point. “Here’s the problem,” he said. Treatment methods were determined “before anybody really understood the a science of addiction. We started off with the wrong model.”…

There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer. Family doctors tend to see addicts as a nuisance or a liability and don’t want them crowding their waiting rooms. In American culture, self-help runs deep. Heroin addiction isn’t only a disease – it’s a crime. Addicts are lucky to get what they get.

Of course, it doesn’t have to be this way.  Other modern countries rely on a medical model and harm reduction principles and have way more success.  Of course, the ultimately failure is the literally thousands and thousands of lives lost every year that would not be if we actually took a rational, science-based approach to opioid addiction.

If you are more of a listener, there was also a terrific Fresh Air interview with the author.  And, Alec MacGillis provides a nice two-page summary.

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About Steve Greene
Professor of Political Science at NC State http://faculty.chass.ncsu.edu/shgreene

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