BD was 12 years old when his father first talked him into shooting heroin. By 24, BD realized he could have a different life. He wanted to get his high school equivalency degree, even go to college. So BD entered treatment.
Now, he is experiencing the first heroin-free months of his adult life.
Once her high school’s star gymnast, JJ is still angry at the doctor who treated a sports injury with hydrocodone then continued to prescribe it for months. When he suddenly cut her off, she became sick – opioid withdrawal syndrome. When she was unable to afford pills from the streets, she bought and smoked what was cheap and available – black tar heroin.
At 18, she was old enough to enter a narcotic treatment program and begin the work of rebuilding her life.
These are two stories of addiction, of opioid use disorder. There are many such stories; stories of lives destroyed, lives temporarily or permanently lost. Sometimes we hear the story only because a loved one becomes the voice of the one who died. Some stories will never be heard.
Last year, an accidental opioid overdose forever silenced a human voice every 16 minutes. Every 16 minutes of every hour of every day.
It happens in the Northern San Joaquin Valley, throughout California and across America.
Many people are surprised to hear that for almost 50 years there has been a successful treatment. It’s called medication-assisted treatment and involves a combination of methadone and counseling.
Unfortunately, few people with opioid use disorder actually receive this treatment. Both the disorder and the treatment are highly, and unfairly, stigmatized – even by those who are addicted. The shame of addiction can be immense. But to remain untreated is to risk death. We can change this.
“Many of the barriers to effective (treatment) … stem from misperceptions and stigmas attached to opiate dependence,” the National Institutes of Health wrote in 1997. “Many people believe that dependence is self-induced or a failure of willpower and also believe that efforts to treat it will inevitably fail.”
It has been almost 20 years since this declaration, and opioid use disorder has increased dramatically. The best medical treatment (methadone or buprenorphine plus counseling) works but is underutilized. Lives depend on us reversing this course.
So what are the misperceptions and concerns?
If they loved (me / their family / their parents / their children / themselves) enough, they would stop.
Addictions reflect complex neurological processes and changes – which is particularly true of opioid use. The changes can be very difficult to reverse and cannot be reversed by willpower alone.
To understand this, look at how we learn. When we encounter something new, there are chemical changes in the brain that cause structural changes that help us remember. When something is very meaningful, more of the chemical is released and these changes happen quickly. Most of us didn’t need to eat vanilla ice cream more than once to recognize whether we liked it. When something is not very meaningful, these changes happen slowly, and we need repetition to establish memory. That’s how most of us learned our multiplication tables and important dates in American history.
Addictive substances cause the release of dramatically more chemical in our brains than is released by normal experiences. This large, “loud” signal results in the changes we see when we learn something is very good or necessary for survival.
But why don’t “they” just stop using?
When drugs change the brain, the brain’s drive to obtain the drug is similar to when we are dehydrated and crave water. In the lack of water, the brain is speaking truth; but the signal for drugs is not “honest.” That, unfortunately, does not keep this area of the brain from yelling, ever more loudly, that the drug is needed. The symptoms of withdrawal, sometimes quite severe, add more urgency to that dishonest signal.
But lots of people take narcotics and don’t get addicted. This means it’s a choice, right?
Nobody wants to become an addict. Over the last decade, scientists have identified genetic variations that predispose certain people to addiction. For opioids, genetics account for approximately 70 percent of the risk. The good news is that these genetic variations are found in less than 50 percent of the population. This is why the majority of people who take an opioid do not develop addiction. The bad news is that, if you carry unfortunate genetics, opiate exposure creates brain changes that are not under volitional control.
So how does substituting one drug for another help anything?
Methadone and buprenorphine are long-acting opioids used to treat opioid use disorder. Though they are both opioids, their effects on the brain are different from other opioids, which are shorter acting. Neither produces the euphoria felt with heroin or opioid pills. In addition, the longer action of these medications provides a very stable chemical environment, which helps quiet the brain areas involved in addiction. It is this stability that can help the brain shift back toward a more normal pattern. This shift toward “normal” can allow individuals to eventually taper off methadone or buprenorphine.
Think of a broken leg bone. If you walk on the leg without a cast, the constant irritation can delay healing. The extra stability of a cast facilitates healing, and eventually you can remove it.
But nobody ever gets off methadone.
Actually, people successfully graduate from medication-assisted treatment programs all the time. However, the stigma associated with both the problem and the treatment are often enough to keep people from sharing this experience. And because the changes in the brain are fairly slow to reverse, it is not unusual or unexpected for treatment to take several years.
Genetic variations lead to imbalances in the body’s natural opioid system. Some individuals might feel normal only if they continue with a long-acting opioid. Another medical disorder in which we see this variation is depression. Some depressed individuals only need an antidepressant for a few years; others might require medication for many years, or even a lifetime.
For almost 50 years, the federal government has advocated, monitored and controlled medication-assisted treatment for opioid use disorder, producing an overwhelming amount of data that shows such treatment saves lives, reduces crime and health care costs and improves communities.
In 2014, one person died every 20 minutes of accidental opioid overdose. In 2016, the CDC statistics showed one person died every 16 minutes in 2015 – an enormous spike. We have an effective treatment that will save these lives, but shame prevents many from seeking treatment.
BD and JJ found a way out. With education and understanding, so can many others.
Dr. Lyn Raible is chief medical officer for Aegis Treatment Centers in Modesto.
- National Institute on Drug Abuse: www.drugabuse.gov
- Substance Abuse and Mental Health Services Administration: www.samhsa.gov
- Health and Human Services: www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf
- Medication-assisted treatment: store.samhsa.gov/product/Cost-Offset-of-Treatment-Services-Fact-Sheet-/SMA09-4441
- Surgeon General’s report on addiction in America: https://addiction.surgeongeneral.gov/executive-summary