Fewer people are using painkillers these days for nonmedical reasons, and that’s good news.1 But many of those who have already gone down that road have developed serious dependency problems. Some are now abusing heroin and even dying from overdose, new studies show.1
The chronic nature of opioid relapse, and a reluctance of many addicts to seek help, means a new, comprehensive approach to treatment is needed. Researchers often say an opiate addict’s best chance at long-term recovery includes medication-assisted therapies, such as methadone or buprenorphine as well as psychological treatment.
But several obstacles can still stand in the way. Research published in October in the Journal of the American Medical Association (JAMA) examined data from 472,200 people ages 18 to 64 who participated in the 2003-2013 National Surveys on Drug Use and Health. The findings: Three-fourths of people who need help with nonmedical prescription opioid use aren’t getting it.1
Here are some reasons why, along with ideas being proposed to make treatment more accessible:
1. People dependent on opiates often don’t relate to the term “addict.” Many keep using just to avoid severe withdrawal symptoms, not to get a euphoric high. Along the way, some progress to heroin because it is cheap and easy to obtain. It used to be that people who used heroin did so to get high; many of today’s heroin injectors became dependent on opioids gradually.
Shaming techniques by friends, co-workers or even some treatment centers not only fails these addicts, but contributes to their relapse. In an opinion piece published last year in the Boston Globe, Dr. Steven Kassels, medical director of Community Substance Abuse Centers, calls for expanded treatment availability and a better understanding of our country’s heroin epidemic.2
“We read about the blame for the heroin epidemic, but rarely do we address a complex underlying issue — that we as Americans want instant results and we want total pain relief after an injury or procedure. Injudicious prescribing of pain medications undeniably contributes to the problem, and holding doctors accountable is essential; but this is not the only reason we have an unabated heroin epidemic. Other factors include: the war in Afghanistan, which directly led to a surge in heroin production; the reconstitution of Oxycontin so they could not as easily be used to ‘shoot up’ or ‘snort,’ resulting in more people turning to heroin as a drug of choice; the increased availability of opiates through the Internet; inadequate mental health treatment services resulting in some patients ‘self-medicating;’ and the lack of addiction treatment facilities due to a common community approach of NIMBY (Not In My Back Yard) along with the stigma associated with seeking treatment for the disease of addiction.”
2. Methadone has been proven to help people recover from opioid addiction, but the stigma surrounding it turns most people away.
“Methadone is perceived by many as ‘substituting’ one addiction for another,” according to PCSS-MAT (Providers’ Clinical Support System for Medication Assisted Treatment).3 “Methadone treatment is only provided in special addiction clinics, separated from the rest of healthcare, which may contribute to its stigma. This separation may also serve to distance methadone from the medical model of understanding addiction as an illness rather than as a moral failing.”
In step with a general need to eliminate the stigma associated with all addictions, information about the effectiveness of methadone and the promise of recovery it can offer an opioid addict needs to be discussed not only among addicts, but also among their families and their doctors.
3. Buprenorphine (Subutex® and Suboxone®) may be able to help ease some addicts’ cravings, but doctors aren’t comfortable with prescribing it, let alone going through the process of getting a waiver to prescribe it.4
Buprenorphine also has the potential for abuse, and usually people who try to obtain it illicitly do so to self-treat symptoms of their opioid use disorder, such as pain and depression. “Clinical concerns may be best directed toward increasing access to professional buprenorphine treatment, as a lack of easy access to legal buprenorphine may promote, rather than discourage, illicit buprenorphine use,” PCSS-MAT argues on its website. “Buprenorphine treatment plans may also benefit from recognizing the more complex needs of opioid-dependent patients with chronic pain and depression.”
Soon it may be easier for doctors to prescribe buprenorphine. The U.S. Department of Health and Human Services announced in September they are moving to revise buprenorphine prescriber guidelines. “Under current regulations, physicians that are certified to prescribe buprenorphine for MAT are allowed to prescribe up to 30 patients initially and then after one year can request authorization to prescribe up to a maximum of 100 patients,” HHS announced in a news release.5 “This cap on prescribing limits the ability of some physicians to prescribe to patients with opioid use disorder. The HHS revision to the regulation will be developed to provide a balance between expanding the supply of this important treatment, encouraging use of evidence-based MAT, and minimizing the risk of drug diversion.”
4. Most people who are unable to recover from heroin addiction suffer from psychological distress. With mental illness also being highly stigmatized, opiate addiction can be a double whammy. Effective treatment should include psychological help in an affirming environment.
In a 2007 research paper that followed 242 heroin addicts for more than 30 years, “non-recovered addicts were significantly more likely to use substances in coping with stressful conditions, to have spouses who also abused drugs and to lack non-drug-using social support. Stable recovery 10 years later was predicted only by ethnicity, self-efficacy and psychological distress,” according to the abstract.6 “These findings suggest that in addition to early intervention to curtail heroin addiction, increasing self-efficacy and addressing psychological problems are likely to enhance the odds of maintaining long-term stable recovery.”
5. Alternative recovery programs should be considered for those who make it clear they are not interested in a 12-Step program, especially if they give it an honest try and decide to drop out.
For example, 12-Step programs often frown upon medication-assisted therapies, such as methadone and buprenorphine, which could possibly help those addicted to opiates to get beyond painful withdrawal symptoms.3
Dr. Kassels sums it up this way: “One of the most effective interventions for opiate addictions is medication, including the opiate agonists and partial agonists methadone and Suboxone. These drugs have proved so effective that Steve Shoptaw, an addiction specialist, and psychologist in the department of family medicine at UCLA, says, ‘I won’t treat opiate addicts unless they take Suboxone.’ Most researchers agree that no single therapy is appropriate for every addict. Often they’re used in concert. An effective treatment regimen may include AA, but only for those patients who are open to it.”
- 1. Han, B. et al. (2015, Oct. 13) Journal of the American Medical Association (JAMA). Nonmedical Prescription Opioid Use and Use Disorders Among Adults Aged 18 Through 64 Years in the United States, 2003-2013. 314(14): 1468-1478. Retrieved Nov. 14, 2015, from https://jamanetwork.com/journals/jama/fullarticle/2456166
- 2. Kassels, S. (2014, April 1). The Boston Globe. The Scourge of Heroin Addiction. Retrieved Nov. 14, 2015, from http://www.bostonglobe.com/opinion/2014/04/01/podium-addiction/SFtRR381ZGKGbrfNEJxZuM/story.html
- 3. PCSS-MAT Training. Barriers to Treatment: Negative Stigma of Methadone. Retrieved Nov. 14, 2015, from http://pcssmat.org/opioid-resources/barriers-to-treatment/
- 4. Gordon, A.J. et al. Psychology of Addiction Behavior. (2011, June). Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration. 25(2): 215-24. Retrieved Nov. 14, 2015, from http://pcssmat.org/opioid-resources/barriers-to-treatment/
- 5. U.S. Department of Health and Human Services. (2015, Sept. 17). News Release. “HHS Hosts 50-state convening focused on preventing opioid overdose and opioid use disorder, takes important step to increase access to treatment.” Retrieved Nov. 14, 2015, from http://www.hhs.gov/about/news/2015/09/17/hhs-hosts-50-state-convening-focused-preventing-opioid-overdose-and-opioid-use-disorder.html
- 6. Hser, Y. (2007). Journal of Addiction Disorders. Predicting long-term stable recovery from heroin addiction: findings from a 33-year follow up study. 26(1): 51-60. Retrieved Nov. 14, 2015, from https://pubmed.ncbi.nlm.nih.gov/17439868/
Written By David Heitz