Pubdate: Wed, 09 Mar 2016
Source: Chicago Tribune (IL)
Copyright: 2016 Chicago Tribune Company
Author: Maia Szalavitz, Washington Post
Note: Maia Szalavitz is the author of the forthcoming "Unbroken 
Brain: A Revolutionary Way of Understanding Addictions."


America's epidemic of heroin and prescription-pain-reliever addiction 
has become a major issue in the 2016 election. The epidemic is worse 
than ever: Deaths from overdoses of opioids - the drug category that 
includes heroin and prescription analgesics such as Vicodin - reached 
an all-time high in 2014, rising 14 percent in a single year. But 
because drug policy has long been a political and cultural football, 
myths about opioid addiction abound. Here are some of the most 
dangerous - and how they do harm.

1. Most heroin addiction starts with a legitimate pain prescription, 
and most prescription opioid misuse leads to heroin addiction.

People who misuse prescription pain relievers are 40 times more 
likely to become addicted to heroin than those who don't, according 
to the Centers for Disease Control and Prevention. Recent research 
also shows that 75 percent of patients in heroin treatment started 
their opioid use with prescription medications, not heroin. That 
sounds like pain treatment is at the root of the problem, and the CDC 
is targeting doctors with new guidelines aimed at reining in prescriptions.

But overwhelmingly, prescription drug misusers are not pain patients. 
According to the National Survey on Drug Use and Health, more than 75 
percent of recreational opioid users in 2013-14 got pills from 
sources other than doctors, mainly friends and relatives. And even 
among this group, moving on to heroin is quite rare: Only 4 percent 
do so within five years; just 0.2 percent of U.S. adults are current 
heroin users.

The proportion of patients who become newly addicted to opioid 
medications during pain treatment is also low. A 2010 Cochrane review 
- - considered the gold standard for basing medical practice on 
evidence - found an addiction rate of less than 1 percent. A study of 
more than 135,000 emergency-room visits for opioid overdose found 
that just 13 percent of patients had a chronic pain diagnosis.

Further, a 2015 study showed that only 6 percent of those who 
received an initial prescription for opioids took the drugs for more 
than four months; the authors didn't determine how many of those 
ongoing prescriptions were medically appropriate and what proportion 
were linked to addiction.

The real risk factor for opioid addiction is youth, not pain care. 
Like 90 percent of all addictions, the vast majority of 
prescription-drug problems start with experimentation in adolescence 
or early adulthood, typically after or alongside binge drinking, 
marijuana smoking and often cocaine use. Having a prior or current 
addiction to another drug is the best predictor of developing 
problems with prescription drugs - not pain care.

2. The best treatment for heroin addiction is inpatient rehab.

When the media covers addiction in the rich and famous, an inpatient 
stay at a plush rehab center is almost always involved. Indeed, Dr. 
Drew Pinsky's "Celebrity Rehab" is typical of such programs. Pinsky, 
like many who run inpatient programs, rejects the ongoing use of 
anti-addiction medication (though Hazelden, the original model for 
the 28-day rehab center, began offering it to some patients in 2012 
after experiencing record high death rates). Similarly, most drug 
courts and many state Medicaid programs also deny continuing access 
to the two best-studied maintenance medications, methadone and 
buprenorphine (Suboxone).

The position that residential treatment centers and their 
abstinence-only philosophies are superior to medication ignores 
overwhelming data and keeps families from seeking the best care. 
Let's start with Dr. Drew's patients: Nearly 13 percent who appeared 
on "Celebrity Rehab" died not long afterward; most had been addicted 
to opioids. While that may be an especially poor showing, research on 
more than 150,000 patients receiving treatment for opioid addiction 
in Britain found that people in abstinence-only care had double the 
death rate of those who received ongoing maintenance treatment. And 
other studies find that maintenance medication cuts death rates by 70 
percent or more. Since untreated heroin addiction carries a mortality 
rate of 2 to 3 percent per year, the benefit is substantial.

This is why the World Health Organization, the National Institute on 
Drug Abuse, the Institute of Medicine and even the White House drug 
czar's office all agree that maintenance treatment - indefinite, 
possibly lifelong medication use - is superior to abstinence rehab 
for opioid addiction. While some argue that total abstinence is a 
moral imperative, dead people can't recover. Sadly, only a small 
proportion of people with opioid addiction are currently in 
medication-assisted treatment - largely because of limits placed on 
it by misguided ideology, government policies and insurers.

3. Recovery from heroin addiction is rare.

The prognosis for heroin addiction seems grim because of the high 
mortality rate and because rehabs typically report relapse rates of 
60 percent or greater. However, the odds of recovery are better than 
they appear.

Early evidence for this idea came from studies of Vietnam veterans, 
who should have had particularly high addiction and relapse risk 
because young men are the group most at risk for addiction in 
general. Heroin and opium were cheap and easily available to American 
servicemen overseas; nearly half tried these drugs, and half of these 
soldiers became addicted. But upon returning home, just 12 percent of 
those who had been addicted relapsed within three years, and only 2 
percent were still addicted at the end of the study - nowhere near 60 
percent. Fewer than half got any treatment, and it didn't make a 
difference in terms of who recovered.

This phenomenon, known as "natural recovery" or "maturing out" of 
addiction, is common with other drugs, too. Large population surveys 
show that most people who are addicted to alcohol or cocaine quit 
without treatment. The same type of study shows that around 60 
percent of people who met the criteria for prescription opioid 
addiction at one time no longer do so - and one third of them never 
received any treatment. This research also finds that the average 
prescription opioid addiction lasts eight years; for heroin, the 
average is a decade. For alcohol, the average addiction lasts 15 years.

So why do heroin addicts appear so hopeless in the public 
imagination? Because people who quit on their own don't show up for 
treatment - and so, while they are included in large epidemiological 
studies, they aren't included in treatment research. This means that 
rehabs see only the worst cases, leading to an unduly pessimistic 
picture of recovery. Although opioid addiction certainly can be 
deadly, it doesn't have to be - and those who struggle with it should 
absolutely seek help. Still, more research is needed to understand 
what people who recover without help can teach those who need it.

4. Tough love is the only thing that works. Programs that distribute 
clean needles and overdose-reversal drugs prolong addiction.

The idea that people with addiction must "hit bottom" - or experience 
the worst possible consequences - before they can get better is 
prevalent among parents and policy-makers. One drug court official 
told a researcher that "force is the best medicine" for treating 
addiction, and the 12-step program Al-Anon warns against "enabling" 
addiction by doing things like helping people avoid jail.

But research shows that the opposite is true. Like any other human 
beings, people with addiction respond best to being treated with 
dignity, care and respect. Programs that nonjudgmentally distribute 
clean needles, provide overdose-reversal drugs or offer safe spaces 
for injection do not prolong addiction; in fact, a Canadian study 
found that 57 percent of people who came to a safe injection facility 
to shoot up ultimately entered treatment. An approach for helping 
addicted family members that uses kindness, rather than confrontation 
or detachment, was found in another study to be twice as effective as 
a traditional confrontational "intervention" - and no studies show 
that harsh treatment or incarceration is superior to empathetic care.

Similarly, there is no evidence that naloxone programs, which provide 
users and their families with the overdose-reversal drug, prolong 
addiction. But they do prolong life: The overdose death rate was cut 
by nearly 50 percent in communities that fully implemented these programs.

5. Whites have recently become the majority of people with heroin addiction.

In an article headlined "In Heroin Crisis, White Families Seek 
Gentler War on Drugs," The New York Times recently claimed that 
"today's heroin crisis is different," because it is not "based in 
poor, predominantly black urban areas" and because use "has 
skyrocketed among whites." NPR, The Atlantic and other major media 
outlets have run similar stories, often citing a study, published in 
JAMA Psychiatry, which found that 90 percent of new heroin users in 
the past decade were white.

What most of them omit, however, is that the same study showed that 
whites have made up more than half of all people with heroin 
addiction since the early 1970s and hit 80 percent before 2000. In 
1981, Newsweek panicked about a new wave of "middle-class junkies," 
and in 2003, a Times headline read "Heroin's New Generation: Young, 
White and Middle Class." White people using heroin is nothing new.

The reason for the misperception is political: Politicians from the 
first "drug czar," Harry Anslinger, in the 1930s to Ronald Reagan in 
the 1980s have portrayed heroin and other illegal drugs as a black or 
"foreign" problem in order to justify tough policies. In the early 
1900s, when heroin was sold over the counter without warning labels, 
the typical user was a white middle-class woman, and she was seen as 
a victim of unscrupulous manufacturers, not a criminal. After heroin 
became illegal and was framed as a problem of the poor and 
minorities, law enforcement began to predominate. Only now are 
policymakers beginning to recognize the failure of criminalization.
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MAP posted-by: Jay Bergstrom