Treating Opioid Addiction: 1990s v. 2010s
She had dark curly hair and dark eyes, a casually dressed 18-year-old college student not quite making eye contact with me. Coming into my consulting office from the waiting room, she had appeared hesitant and a little shy. I asked her what had brought her to the office, and I was shocked at what she had to say.
It was the mid-1990s, the exact year I can't be certain of now. I had been practicing addiction medicine for over 20 years. I had spent 10 years in southern Wisconsin and another 10+ years in the metro Atlanta area. My practice was a mostly suburban practice and inner-city patients rarely came to my office. So I had never seen a heroin addict in my practice, at least not to my knowledge.
Sitting across from me in my office was a young Jewish woman, a freshman at the University of Georgia in Athens. She was from the Atlanta area where her parents still lived. She had a boyfriend in Atlanta, and she would come to town and they would inject heroin together. She said she wanted to quit and needed help. Opioid addiction was something that I had plenty of experience with, but it was always prescription opioids: oxycodone, hydrocodone, codeine, and morphine. We used to put these patients through a 30-day residential program where we worked on detoxification, breaking down denial, identifying other mental health issues and treating them, working on family issues, teaching people non-chemical coping skills, and exposing people to 12-step recovery programs.
We did pretty well with the alcoholics for whom such a program was designed, and a lot less well with patients addicted to other drugs. In particular, opioid addicts had a very high relapse rate, over 90%. I still remember the gentleman who was addicted to hydrocodone that I treated several times in our 30-day program. He was a retired engineer from a major manufacturing establishment in the Atlanta area. He had a wife, a grown son and daughter, and grandchildren. After several rounds of unsuccessful treatment, his wife finally divorced him and he went to live with his son, daughter-in-law and grandchildren. One day his daughter-in-law told his nine-year-old grandson to go tell grandpa that dinner was ready. But earlier in the day, grandpa had gone into the closet in his bedroom, put a shotgun in his mouth, and pulled the trigger. I don't suppose his grandson has ever gotten over the sight. No, what I had offered the patient and his family had not worked, and I was crushed when I heard about what happened.
The alternative treatment to what we had to offer was methadone. Patients had to go to a federally licensed clinic that would provide a daily dose of methadone designed to take away cravings for heroin and allow them to function in their daily lives. It was an option, but the problems associated with methadone were considerable. The daily visits to the clinic were a burden and methadone itself is a heavy duty drug although the right choice for some people.
The young lady, like most people, was unwilling to attempt either option, so I offered her outpatient detoxification and counseling. She came back once or twice more, and then I didn’t see her again. I have no idea what happened to her, but I hope she eventually got lasting help. I no longer remember her name.
Since then, I have seen over a thousand people like her. Recently, I saw a young couple who had become addicted to oxycodone that they were buying on the street. Like the young lady from the University of Georgia, this was their first attempt at seeking help. They said their lives were too busy to go into a structured out-patient rehab program because they had to work. They wanted medication assisted treatment, specifically, Suboxone. This is an immensely useful, life-saving medication that was not available to me in the mid-90s. As a physician, I have to meet people where they are and work with what willingness they have, so I did prescribe Suboxone for them. When I saw them again this week they both admitted that even though they had started taking the medication, they had not completely stopped using either. They had not followed up on any counseling or support group recommendations that I had made. I told them that recovery was not going to happen to them because they're nice people. They would have to work for it. There is a certain minimum amount of effort that they were going to have to put into this in addition to taking medication, and that they had to make recovery a priority. Still, I have a lot more hope for them than I did back in the 90s because of great advances in what we refer to as medication-assisted treatment.
Addiction is a chronic progressive brain disease in which the afflicted individual has lost control of a substance or behavior that produces a high, a powerful sense of well-being and euphoria. The addicted person, to whatever substance or behavior it might be, becomes obsessed with whatever it is that they are doing or using to experience this euphoria, and sooner or later enters a stage of compulsive use. Once they have gotten to this point there is no return to sociable drinking, drug use, gambling, or whatever it is that they have become addicted to. Without treatment, periods of abstinence are inevitably followed by relapse into the addictive behavior. And because this is a chronic disease, treatment needs to be ongoing. And because it is a serious illness, treatment needs to be intensive.
Opioid addiction, in particular, has an extraordinary relapse rate without such an effort. As most people know, opiates cause physical dependency, and the withdrawal syndrome is greatly feared by the addict. Nevertheless, with treatment, the addict can be successfully detoxified over a period of about a week. The problem, however, is that after this period of detoxification they still don't feel right. They enter into a period that is called “postacute withdrawal syndrome,” which can last for weeks to months. During this period of time, the addict is frequently depressed, lacks energy, feels unmotivated, has a limited capacity to experience pleasure, and sleeps poorly. They have persistent urges to use drugs. These feelings persist because of chemical changes that have taken place in the brain, caused by the repetitive use of heroin or other opioid drugs. Addicts in this situation are obsessed with the thought that all they have to do is get one dose of heroin or oxycodone or whatever it is that they normally use, and that they will feel normal again. This is half true. The true half is that they will feel much better. The false half is the part about using just one dose. As soon as that dose is used, the compulsion to repeat kicks in with full force, and the addict will not be able to stop using.
Early in the natural history of opiate addiction, the addict is no longer looking to get high, but rather, just to get by. It is a terrible, life-destroying trap. And all too often, the life ends prematurely and suddenly in an accidental overdose. Everyone knows that we are in the midst of a terrible opioid epidemic. Just to quote one statistic, the incidence of overdose deaths in the United States has exceeded the incidence of motor vehicle deaths ever since 2009. We have desperately needed more options to treat these patients successfully.
In 2000, President George W. Bush signed a law referred to as DATA 2000. This law authorized the use of Schedule 3 or higher opioid drugs to treat opioid addiction. Ever since the Harrison Act was passed in 1914, it has been illegal for a physician to prescribe an opioid drug to a drug addict for the purpose of treating the addiction. So we needed an act of Congress to usher in a new era of medication-assisted treatment. Buprenorphine is an opium-derived drug that was synthesized in the laboratory in the 1960s. It had been used as an injectable drug for the treatment of moderate to moderately severe acute pain with good success. However, it was recognized that buprenorphine had great potential as a drug for the treatment of opioid addiction for several reasons.
First, it has what is referred to as a ceiling effect. This means that when used as directed by the normal sublingual (dissolved under the tongue) route, there is a limit to how much drug effect can be achieved. Overdoses in this situation simply do not occur, unless it is taken along with alcohol or other drugs of abuse. Secondly, because it does not fully activate the opioid receptor, it does not produce a high. So there is no incentive to take more than the prescribed dose. Thirdly, it has a long duration of action, so it only needs to be taken once per day to prevent drug cravings. Fourthly, it blocks the high caused by other opiate drugs. Lastly, because it is so safe it can be prescribed by a physician, filled at a pharmacy, and taken at home rather than having to go for a daily dose at a clinic. Since buprenorphine came to market in 2003 branded as Subutex and Suboxone, over 3 million patients have been treated with this medication. It has been life-saving and life-changing for a great many of these patients. Over the past 16 years, many other buprenorphine based products have become available for the treatment of addiction as well as for chronic pain.
Another drug used in the treatment of opioid addiction is naltrexone. Unlike buprenorphine, naltrexone does not activate the opioid receptor at all. Rather, as a full antagonist, it blocks it completely. Patients taking naltrexone are unable to experience any effect if they take an opioid drug. Naltrexone is available as an oral tablet for daily administration, or as a monthly injection, called Vivitrol. Like buprenorphine, naltrexone is only successful if used as part of a comprehensive plan of counseling and support group attendance. It can be used after opiate detox, and is also useful for the first 6 to 12 months after the buprenorphine has been discontinued.
One of the great obstacles to success in coming to grips with our opioid epidemic and treating patients successfully is the ignorance that is prevalent in our society about this disease. Some people continue to moralize about addiction, thinking that addicts should just "say no" and act right. There has also been resistance to medication-assisted treatment both from the traditional abstinence-based recovering community and from people surrounding the medical field who view it as simply replacing one drug with another.
The fact is that opioid addiction is a chronic brain disease. The addict's brain is unable to function normally when drug use is stopped. These patients need all the help that they can get. Fortunately, we now have evidence based, safe medication-assisted approaches to helping these patients transition from being actively addicted to becoming re-integrated as functioning members of society. Over a million people have been successfully treated and had their lives potentially saved by the measures taken to address the opioid epidemic.
Now, I am relieved that when a patient tells me that they have become addicted to an opioid, I don't have to tell them that I'm sorry and can’t do anything. I can offer solutions that work. It’s just a matter of figuring out what works for them.