Pubdate: Sat, 14 Jan 2017
Source: Wall Street Journal (US)
Copyright: 2017 Dow Jones & Company, Inc.
Author: Sally Satel


Addiction isn't an illness like any other. Patients need not just the
right medicines but therapy, support and, in some cases, tough supervision

The grim faces of the nation's opioid epidemic -- an overdosing parent
slumped in the front seat of a car, mouth agape, with a neglected child in
the rear seat -- have become too familiar in recent years. More babies are
now being born with narcotics in their systems, foster care is strained,
and growing numbers of grandparents are raising the children of their own
addicted children.

With an estimated 2.6 million people addicted to opioids -- including
heroin, fentanyl and oxycodone -- the toll is daunting. Fatal opioid
overdoses have risen from around 8,200 in 1999 to 33,000 in 2015,
according to the Centers for Disease Control and Prevention, making them a
leading cause of accidental death. Last year, deaths from heroin slightly
edged out gun homicides for the first time since the government began
keeping such data.

Politicians and health agencies are deeply concerned. They overwhelmingly
call for a "public-health approach" to the epidemic, emphasizing treatment
with anti-addiction medications. As the U.S. surgeon general recently
implored, it's time for us to view addiction "not as a moral failing but
as a chronic illness."

As a psychiatrist who has treated people addicted to heroin for more than
25 years, I endorse treatment over punishment. But the medicalized
rhetoric of the public-health establishment -- namely, that addiction is a
brain disease in which neural circuits are "hijacked" by drugs --
oversimplifies the problem.

Consider an addict's typical course of treatment under this approach. A
young woman -- let's call her Kristy -- is found curled up on the floor of
a supermarket restroom, passed out with a needle still in her arm.
Emergency personnel rush to the scene and quickly administer Narcan, a
nasal spray containing a fast-acting opiate antidote called naloxone. A
few minutes later, Kristy sits up, coughs and looks around hazily.

When taken to the emergency room after being revived, Kristy may simply
bolt before any referral to treatment can be made. The siren call of the
next fix is strong.

Let's hope, instead, that Kristy, frightened by her near-death experience,
does want treatment. The emergency-room clinician would refer her to a
local physician or an outpatient clinic, where she is likely to be offered
a popular anti-addiction medication called buprenorphine, or "bupe."

As an opioid drug itself, bupe is a pharmacological replacement therapy,
like methadone, the classic anti-addiction opioid medication. It prevents
withdrawal symptoms and suppresses drug craving, and usually comes as a
filmstrip that dissolves under the tongue.

Bupe has some clear advantages over methadone. Its chemical properties
make it less risky if taken in excess. And unlike methadone, which must be
dispensed in clinics tightly regulated by the DEA, bupe can be prescribed
by any qualified physician, who can refill a month's worth of the drug
from his or her office.

Some patients do very well with bupe, but there are problems. Too many
patients continue to use illicit opioids while using the drug. Federal
guidelines recommend that those taking bupe receive routine urine
toxicology screening (for illicit drugs) and behavioral counseling, but
overseeing such a program is a lot to ask of busy primary care doctors,
who are the usual prescribers.

Another challenge to recovery is dropout. Despite the heartache that
addicts cause themselves and others, ambivalence surrounding quitting is
great, and premature termination of treatment is common. Attrition rates
of 40% to 60% within a few months of admission are typical in treatment
programs. Less time in treatment means that addicts have less time to
learn recovery strategies, like identifying the specific circumstances in
which they are most vulnerable to craving the drug.

Rushed treatment in the office of a primary-care doctor also means less
attention to fixing the often broken lives of addicts. Healing family
rifts, reintegrating into the workforce, creating healthy social networks,
finding new modes of fulfillment -- all are imperative, but they take time
and focused therapeutic care.

The unstructured setting of a doctor's office can lead to the abuse of
bupe itself. Sometimes patients cut off pieces of their bupe strips and
sell them to other addicts, who use the drug to detox themselves or to get
through times when heroin isn't available or is too costly. Bupe is now
the third most diverted prescription opioid after those containing
oxycodone (e.g., Percocet) and hydrocodone (e.g., Vicodin).

My own work in treating addiction takes place in a traditional methadone
clinic. Our nurses watch patients swallow the cherry-flavored liquid daily
for at least the first few months. If a patient starts using heroin again,
we can provide more frequent counseling, do more regular toxicology
screening and suspend any take-home doses of methadone to spur better
self-control. This careful monitoring is why there is a very low rate of
diversion of methadone from clinics.

A similar system could be developed for the early stages of treatment with
bupe. Patients would only be referred to local physicians once they are
stabilized, a process taking anywhere from a few weeks to a year.
Community doctors, who are now often reluctant to accept addiction cases,
would be more amenable to treating patients who are securely into their

I speak from long experience when I say that few heavy users can simply
take a medication and embark on a path to recovery. It often requires a
healthy dose of benign paternalism and, in some cases, involuntary care
through civil commitment.

Many families see such legal action as the only way to interrupt the
self-destructive cycle in which their loved ones are caught. Users
sometimes want it, too. "If I don't do this, I'm going to lose my freedom
eventually anyway," a 33-year old heroin user told NPR as he prepared to
ask a judge in Springfield, Mass., to commit him to care.

Drug courts are a way to leverage supervision from the criminal-justice
system. If participants fail drug tests or violate other rules of the
program, the judge tries to sway behavior by imposing consequences ranging
from community service to more intrusive supervision to "flash
incarceration" (jail stays of a few days).

Many drug courts expunge the records of those who complete treatment, and
other variants of criminal-justice supervision can shape behavior using
such carrots and sticks alone. The addition of bupe or an opioid blocker
(naltrexone) can be offered as an adjunct to these programs.

With public attention and resources now closely trained on the opioid
epidemic, there is a real opportunity for enlightened systems of care.
Never before in the history of addiction management have there been so
many different therapeutic elements to apply in combination to promote
recovery. But we can't afford to focus on just one set of these tools
under the false idea that addiction is a disease like any other.

 -- Dr. Satel is a resident scholar at the American Enterprise Institute
and a part-time psychiatrist at Partners in Drug Abuse Rehabilitation and
Counseling in Washington, D.C.
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