Opioid dependence and opioid addiction are closely related, but two distinct conditions.
Opioids are powerful substances, whether they’re being used in a medically-sanctioned way or abused. Any opioid is likely to have an impact on your health and wellness, but how that plays out will vary greatly. Most people who use opioids regularly will experience some level of physical dependence, and others will develop opioid addiction.
Understanding the difference between physical dependence and opioid addiction can help you find the treatment that you need.
What is opioid dependence?
To understand physical dependence, you need to understand a bit about how opioids work in the body. Opioids attach to opioid receptors. Normally, these receptors can be used to send pain signals; having opioids bound to them prevents pain signals from being sent. That’s why opioids are commonly prescribed for pain.
However, over time your brain adjusts to the opioids that you’re taking — even if you’re following doctor’s orders. You might need more opioids to experience the same pain relief.
The brain changes that happen as a result of taking opioids can lead to opioid dependence. The Centers for Disease Control and Prevention defines dependence as experiencing withdrawal symptoms when you stop taking an opioid medication or using illicit opioids. Symptoms of opioid withdrawal can include anxiety, nausea, diarrhea and sweating.
Over time, if you continue to take opioids — whether prescribed or illicit — you’ll likely need more and more opioids to feel normal and avoid the symptoms of withdrawal. This is because your opioid tolerance has increased. That can lead to addictive behaviors.
What is opioid addiction?
Opioid dependence is a physical condition brought about by brain changes, whereas opioid addiction is a condition that can happen as your physical dependence becomes more acute, according to Waismann Method® Opioid Treatment Specialists.
Addiction to opioids is a pattern of physical and emotional responses that stem from your physical dependence on opioids. As you try to avoid withdrawal symptoms, your behaviors can change. This can have a devastating impact on your life and impact your career, friendships and family relationships.
People who are experiencing opioid addiction can display uncharacteristic behaviors, like:
Ignoring responsibilities to family or work because you are focused on obtaining opioids.
Having trouble controlling your emotions or behaviors.
Fixating on how and when you will next be able to obtain opioids.
With time, these symptoms of addiction can erode the bedrock of your life.
Treatment for opioid dependence and addiction
Whether you are struggling with opioid dependence or full-blown opioid addiction, the first step toward treatment is detoxing from opioids. Detox is the process of removing opioids from your body, so that you no longer need opioids to function at a normal level.
Detox can be painful, because it brings about the symptoms of withdrawal. However, there is a medical detox option that provides the highest level of comfort available. Rapid detox allows your body to be flushed of opioids while you are under anesthesia in a fully-accredited hospital. Because you’re sedated, you don’t feel the acute symptoms of withdrawal. Using a combination of medications, detox can happen much more quickly than it would under normal circumstances if you tried to detox on your own.
Addressing physical dependence is only one step toward recovering from opioid addiction. After you have detoxed from opioids, you can address the pain — whether physical or emotional — that drove you to use opioids in the first place.
At Waismann Method®, people who undergo detox receive continued care at Domus Retreat, where they can make a plan for an individualized approach to life in recovery. There are no set schedules or required meetings, but there is space to rejuvenate and recover, and guidance toward the next steps that are right for you.
A dignified approach to treating opioid dependence and addiction
Waismann Method® understands that opioid addiction is rooted in the physical brain changes that take place when opioids enter your body. Furthermore, addiction often results from using drugs to cope with underlying physical, emotional or mental health issues. There is no shame or blame in treating opioid addiction — just an understanding that no matter your past, you can have a new opioid-free beginning.
In Pennsylvania, one community health center is working with new and expectant moms to tackle opioid dependency.
New and expectant mothers face unique challenges when seeking treatment for an opioid use disorder. On top of preparing for motherhood, expectant mothers often face barriers to accessing treatment, which typically involves taking safer opioids to reduce dependency over time. The approach is called medication assisted therapy, or MAT, and is a key component in most opioid treatment programs.
But with pregnant women, providers can be hesitant to administer opiate-based drugs.
According to a study out of Vanderbilt University, pregnant women are 20% more likely to be denied medication assisted therapy than non-pregnant women.
“In the beginning, I was so scared as a new provider to write my first prescription for medication assisted therapy to pregnant women,” said Dr. Linda Thomas-Hemak of the Wright Center for Community Health in Scranton, Pennsylvania.
The health center serves low-income individuals who are underinsured or lack insurance altogether, many of whom struggle with opioid misuse.
“Pennsylvania was hit particularly hard by the opiate epidemic that really has plagued, terrified and challenged America,” said Hemak, who is a board certified addiction medication specialist.
On this episode of the podcast, we speak with Dr. Hemak about whether medication assisted therapy is safe for new and expectant mothers and how the Wright Center is helping women overcome opioid dependency during pregnancy.
Direct Relief granted $50,000 to The Wright Center for its extraordinary work to address the opioid crisis. The grant from Direct Relief is part of a larger initiative, funded by the AmerisourceBergen Foundation, to advance innovative approaches that address prevention, education, and treatment of opioid addiction in rural communities across the U.S.
In addition to grant funding, Direct Relief is providing naloxone and related supplies. Since 2017, Direct Relief has distributed more than 1 million doses of Pfizer-donated naloxone and BD-donated needles and syringes to health centers, free and charitable clinics, and other treatment organizations.
Transcript:
When it comes to getting treatment for an opioid use disorder, pregnant women have an uphill battle.
Most patients undergoing opioid treatment are prescribed safer opioids that reduce dependency while limiting the risk of overdose and withdrawal.
This kind of treatment is called medication assisted therapy, or MAT.
But with pregnant women, providers can be hesitant to administer opioids.
According to a study out of Vanderbilt University, pregnant women are 20% less likely than non-pregnant women to be accepted for medication assisted therapy.
“In the beginning, I was so scared as a new provider to write my first prescription for medication assisted therapy to pregnant women,” said Dr. Linda Thomas-Hemak.
Hemak is a board-certified addiction medication specialist and CEO of the Wright Center in Scranton, Pennsylvania.
“Pennsylvania was hit particularly hard by the opiate epidemic that really has plagued, terrified and challenged America,” said Hemak who has been practicing in the state for several years.
In 2016, the health center launched a comprehensive opioid treatment program to address the growing crisis in their community. They quickly realized a number of patients were pregnant—and had specific needs, from prenatal care to job support. And so, a new program was born.
“The Healthy MOMS program is based on assisting mothers who are expecting babies or have recently had a child, up until the age of two,” explained Maria Kolcharno — the Wright Center’s director of addiction services and founder of the Healthy MOMS program.
“We have 144 moms, through the end of August, that we have served in the Healthy MOMS program and actively, we have enrolled 72.”
The program provides new and expectant moms with behavioral health services, housing assistance, educational support; providers have even been delivering groceries to moms’ homes during the pandemic.
But the crux of the program is medication assisted therapy.
Moms in the program are prescribed an opioid called buprenorphine—unlike heroin or oxycodone, the drug has a ceiling effect. If someone takes too much, it won’t suppress their breathing and cause an overdose.
Nonetheless, it’s chemically similar to heroin, which may raise eyebrows. But while some substances, like alcohol have been shown to harm a developing fetus, buprenorphine isn’t one of them.
“Clearly there are medications, like alcohol, that are teratogenic. And there’s medications like benzodiazepines that have strong evidence that they are probably teratogenic. When you look at the opioids that are used and even heroin, there is no teratogenic impacts of opiates on the developing fetus,” Dr. Hemak explained.
So, opioids like buprenorphine can be safe for pregnant women. What’s not safe is withdrawal.
If someone is abusing heroin, overdose is likely. In order to revive them, a reversal drug called Naloxone is used, which immediately sends the person into withdrawal.
But when a woman is pregnant and goes into withdrawal, it can cause distress to her baby, lead to premature birth, and even cause a miscarriage.
Which is also why these women can’t just stop taking opioids.
“Stopping cold a longstanding use of an opiate because you’re pregnant is a very bad idea and it is much safer for the baby and the moms to be transitioned from active opiate use to buprenorphine when pregnant,” explained Hemak.
Because buprenorphine has a ceiling effect and is released over a longer period of time, women are less likely to overdose on the drug.
Regardless, there’s still a risk their baby goes through withdrawal once they’re born. For newborns, withdrawal is called neonatal abstinence syndrome or NAS.
Babies may experience seizures, tremors, and trouble breastfeeding. Symptoms usually subside within a few weeks after birth.
Fortunately, the syndrome has been shown to be less severe in babies born from moms taking buprenorphine versus those using heroin or oxycodone.
That’s according to Kolcharno who has been comparing outcomes between her patients and those dependent on opioids, but not using medication assisted therapy.
“Babies born in the Healthy MOMS program, we’re finding, that are released from the hospital, have a better Apgar and Finnegan score, which is the measurement tool for NAS and correlates all the withdrawal symptoms to identify where this baby’s at,” said Kolcharno.
But NAS is not the only concern women have post-partum.
During and after delivery, doctors often prescribe women pain killers. For those with an opioid dependency, these drugs can trigger a relapse.
Dr. Thomas-Hemak says preventing this kind of scenario requires communication.
The Wright Center works with their local hospital to ensure OBGYNs are aware of patient’s substance use history.
“We want the doctor to know that this may be somebody that you’re really sensitive to when you’re offering postpartum pain management,” said Hemak.
That way, doctors know to tailor patients’ post-partum medication regimens. Instead of prescribing an opiate-based pain killer they can offer alternatives, like Ibuprofen or Advil.
Maintaining an open line of communication between addiction services and hospital providers also helps to reduce stigma.
Women with substance use disorders have long been subject to discriminatory practices by both providers and policy makers.
From denying them treatment to encouraging sterilization post-delivery, women struggling with opioid dependency can be hard-pressed to find patient-centered health care.
But Dr. Thomas-Hemak says, she’s learned to set her opinions aside.
“I think one of the magical transformations that happens when you do addiction medicine really well is, it’s never about telling patients what to do.”
It’s about allowing them to make informed choices, she says, and understanding it’s not always the choice you think is best.
This transcript has been edited for clarity and concision.
Overdose survivors need more than a second (or third) chance: they need a parachute. When you’re in free fall, a little more time isn’t much help.
Perhaps everything that is terrible is, in the deepest sense, something that wants our love.
Rilke
The overdose epidemic in the U.S. has been called “the greatest public health crisis of our time.” It’s also our greatest opportunity.
The opioid crisis is an identity crisis: it’s a challenge to how we see ourselves. Do we truly believe that we are all in this together? One answer leads us deeper into despair. The other, into a hopeful future.
It’s been said that “doing more things faster is no substitute for doing the right things.” What are the “right things,” the measures that can resolve the crisis, not just postpone it? The right actions come from the right thoughts. Those thoughts come from feelings, and feelings are never right or wrong. But there are some feelings we are born with. They are our birthright. And one of them is love.
The Kindness of Strangers
Hatred never ceases by hatred, but by love alone is healed.
The Buddha
Behind the opioid epidemic is a prevailing lack of compassion, of caring about everyone equally. At the heart (or lack of it) of this societal disease is rampant inequality. The social determinants of health: stress, unemployment, lack of support, poor health care, etc. are major drivers of addiction. Many authors promote this view, including Gabor Mate, Bruce Alexander, Sam Quinones, Robert Putnam, and Harry Nelson.
Our increasing fragmentation affects everyone, poor or rich.
Drug overdose is the leading cause of death for Americans under the age of fifty…
Our material lives may be outwardly prosperous, but our psychological and spiritual lives are in freefall. What is driving us to self-destruction? There are many factors, all with one unifying theme: we are no longer living in community with one another and, consequently, we are lonely.
Francie Hart Broghammer
We all hunger for the same thing. The question is this: do we love our neighbor as ourselves? That’s not just a commandment; it’s a requirement. How do we rebuild community? First, by taking full responsibility for the fallout of not being one.
For Whom the Boom Tolls
Compassion is not a relationship between the healer and the wounded. It’s a relationship between equals. Compassion becomes real when we recognize our shared humanity.
Pema Chodron
I live in Asheville, a city that has recently, like the opioid crisis, exploded. Tourism is at an all-time high, and Asheville has appeared in dozens of destination top ten lists. It has also been ranked second in the country in gentrification.
Asheville sits in the heart of Appalachia, where the opioid crisis is at its worst. In 2017, North Carolina had the second highest increase in opioid deaths in the country. The Blue Ridge Parkway runs through town and I spend a lot of time there, mostly foraging. That’s where last summer, for the first time, I found not mushrooms, but needles.
Despite the crisis, the city just spent six months trying to shut down the local syringe exchange. The same thing is happening in other cities. In Asheville, the exchange had been operating without incident for over two years — until the houseless (a.k.a., homeless) in adjacent areas were kicked out to make way for new development.
Addiction depends on denial. What if development is the real addiction? Will we face up to the dark side of gentrification or just try to make it “go away?”
If a canary dies in a coal mine, you don’t blame the canary. Yet blaming the victim is exactly what we’ve been doing.
Blue Ridge Parkway, 8/20/18
License to Ill
A man came to the Rabbi and said, “Rebbe, my son has turned against me. What should I do?” The rabbi said, “love him even more.”
Hasidic story
Most people by now have heard that naloxone (Narcan) can prevent a deadly overdose. So many Americans are dying — often from a mix of drugs, but mainly due to opioids — that naloxone should be as ubiquitous as aspirin. Everyone using a drug that may contain opioids should carry it like an EPI pen. And with the increasing prevalence of fentanyl, a single dose may not be enough. Everyone should know how to tell how much naloxone to give someone in the midst of an overdose. This should be basic, universal knowledge.
But keeping someone alive is just the beginning. In fact, while naloxone may be physically safe, it does have one significant side effect: precipitated withdrawal. And not helping someone through it is like catching them from falling only to drop them from higher up.
A Devil’s Bargain
Be kind, for everyone you meet is fighting a hard battle.
Ian Maclaren
As one response coordinator describes it, precipitated withdrawal is like “the worst flu you’ve had… times 100.” For some, the feeling is so bad that they find themselves dying, so to speak, to use again.
To the uninformed, it is inconceivable that someone who nearly died from a drug would run out that very same day and buy more of it. Narcan works by binding to opioid receptors, blocking the effect of narcotics like heroin. In drug users with a physical dependency, it also has the effect of causing severe withdrawal symptoms. This all but guarantees that the first thing a user will think of after their overdose is reversed is getting another fix…
Christopher Moraff
Naloxone is not just a “bandaid on a bullet hole.” It can feel like ripping open a wound. For “withdrawal is the very situation that [users] are seeking to avoid in the first place.”
“A dose of naloxone,” according to the Chief Medical Officer for a Connecticut health agency, “is a chance. But if it’s not coupled with immediate offers of treatment, it may be a slim chance that leaves the revived individual running back to the same dealer who sold them their last lethal dose.”
Overdose survivors need more than a second (or third) chance: they need a parachute. When you’re in free fall, a little more time isn’t much help.
Back on the Chain Gang
Without forgiveness, our lives are chained, forced to carry the sufferings of the past and repeat them with no release.
Jack Kornfield
“They’re usually very angry when we bring them around,” says one responder. “One kid yelled at me, ‘You think this will make me stop doing drugs?’” Indeed, one substance abuse specialist in Ohio says that 67% of people revived with naloxone in her area use again within 24 hours. NPR reports that “about 30 percent of those revived with Narcan at Boston Medical Center have been revived there more than once… and about 10 percent of patients more than three times. Those statistics are in line with what’s seen in ERs elsewhere, public health officials say.”
According to a former agent for the DEA, one woman in Ohio, within 24 hours of being revived for the the sixth time, was using again. In the first half of 2017, one man in North Carolina was revived fourteen times.
To be clear, I am not saying naloxone provides a safety net that encourages people to take bigger chances. Studies have shown that naloxone does not increase drug use any more than free condoms increase sex. Nor am I saying we should place limits on the number of times we revive people.
What I am saying is that naloxone is no miracle drug. When you “come to,” the problem remains. Overdose survivors are 24 times more likely than the general population to die in the following year. One study found that for those revived with naloxone, nearly one in ten are dead within a year, the majority within the first month. Follow up is critical. But even that is not enough.
Not by Locks Alone
Few things can help an individual more than to place responsibility on him, and to let him know that you trust him.
Booker T. Washington
In June of 2019, New Jersey became the first state to allow paramedics to administer buprenorphine along with naloxone to ease the pain of withdrawal. Buprenorphine is the drug that, like methadone, is used in opioid replacement therapy. But this measure will, according to one expert, “make a meaningful difference only if rescued individuals are linked immediately to ongoing treatment and agree to participate in that treatment.”
“Immediate” is key. And at least one hospital in New Jersey has been making that link, through state-paid recovery coaches, since 2017. A coach might work with someone “for weeks or months.” And the cost to taxpayers of helping people in this way is surely far less than the cost of leaving them on their own.
Unfortunately, however, getting people into treatment is not enough. Not all treatment is good treatment. In fact, much of it is worse than doing nothing at all.
Under the Rug
Beware of all enterprises that require new clothes, and not rather a new wearer of clothes.
Thoreau
People usually go to rehab for 28 days, maybe a month and a half. In most cases, the treatment fails, if you regard failure as return to use. A study reported in the Irish Medical Journal found that 91% of people who go through rehab are using again within a year; 80% in the first month.
“Most honest program directors,” says veteran addiction expert Julia Ross, “will admit to 90% relapse rates, and I assume that if they admit to 90%, it’s probably worse.” Drug courts are no better. A national study of seventy-six drug courts found a reduction in the rate of rearrest of only 10 percent.
Moreover, when people come out of abstinence-based rehab, their tolerance has gone way down, so they are more likely to overdose. This is a common reason why fentanyl is killing people: it’s much stronger than they are expecting, especially in an opioid-naïve state. Making fentanyl test strips available can help prevent overdose, but that still doesn’t deal with the basic issue of why they’re using in the first place. What pain are they killing?
Zero Tolerance
Winning isn’t everything; it’s the only thing.
Henry “Red” Sanders
I watched my grandmother die a very slow death. At 90 years old, after three cancers, open heart surgery, and several strokes, she still fought tooth and nail. Christopher Ryan, author of Civilized to Death, compares our approach to death to the final minutes of an NBA basketball game. We drag it out. We go for quantity instead of quality. Is that also our approach to addiction? As long as they don’t die, we’re OK. This is similar to abstinence-based approaches to addiction treatment: As long as you don’t use, you’re OK. This amounts to saying, “it’s more important to look good than to feel good.”
To be clear: I’m not saying we should just let our neighbors die. I’m saying we need to do more than just keep people alive; not less. We need to treat the cause, not just the symptom.
Spare the Prod
If you want to be heard, whisper.
Author Unknown
The overdose crisis is part of a larger epidemic of despair. The facade of America as the “land of opportunity” is failing. Asheville today is “booming.” For whom? Are we saving lives or just saving face?
Fortunately, Asheville has begun to address its weak spots, and we now have three needle exchanges. We all need to look in the mirror and face where we — as a community, as a country — are really at. Because not doing so is killing us. Whether we die quickly from overdose or slowly from alcoholism, cancer, or depression, we are ALL canaries in a coal mine. And you can’t just rake the canary over the coals.
It’s one thing to save lives. But throwing someone into withdrawal without providing detox support or throwing them out of treatment because they’ve relapsed is like hitting a child to make them stop hitting other children. Such heavy-handed measures only perpetuate a cycle of abuse. Even a magic bullet leaves a wound.
Sticks and Phones
Can you love people and lead them without imposing your will?
…leading and not trying to control: this is the supreme virtue.
The Tao Te Ching
There’s a reason our greatest leaders practice nonviolence. If all we do is arm people with naloxone, if we fight firearms with firearms, the conflict will only escalate. Stronger opioids are already requiring stronger antidotes.
With this approach, we may win a few battles, but we will lose the war. You can’t win when you see this as a war to begin with. Because you can’t force someone out of addiction any more than you can force them to stay alive. Force is what causes addiction.
In 2015, Victoria Siegel, 18, died of a methadone overdose precipitated by cyberbullying. We worry about bullying in schools. What about parental bullying — or governmental? Some of us are aware of the alarming incidence of domestic violence. How many of us recognize how our culture is inherently abusive, our very way of life?
Sometimes we forget that we are treating people, not diseases. We are bio-psycho-social beings. We have feelings. If addiction comes from pain, and pain comes from hurt, then we need to reduce hurt, not just harm.
A Dying Shame
You cannot be lonely if you like the person you’re alone with.
Wayne Dyer
We will not end drug abuse until we end human abuse. We will not end human abuse until we end abusive thinking, because violence starts with what you think. A saying often attributed to Martin Luther King Jr. is that “you can have no influence over those for whom you have underlying contempt.” As long as I think, “you’re not good enough; this is all your fault,” or I say that to myself, addiction has a foothold.
The blame game has no winners. “We’ve lost what it means to just be ourselves and for that to be ok and for that to be enough. So we find ways to self-medicate,” says Rev. Shannon Spencer. People will use painkillers as long as the pain is killing them, for there are few emotions more agonizing than shame.
We Are Faminy
I don’t remember now how many days we stayed—long enough to hear David sing often and tease us about white people’s music, which, according to him, is only about “love.” He observed that the Hopi have many songs about water, which they consider the rarest and most precious of resources, and then asked, with feigned innocence, if white people sang so often about love because it was equally rare in our world.
Peter Coyote
To many, opioids feel like the opposite of shame. One user describes the feeling as “like being hugged by Jesus.” Indeed, “the very essence of the opiate high,” according to Gabor Mate, is that it feels “like a warm soft hug.” This is the feeling of unconditional acceptance and support, or love.
We live in a culture where love is the one thing we sorely lack. Millions of people are starving for just a few drops of it. If only for a few moments, we desperately need to feel like we’re OK, that someone wants us to be here, as we truly are. Like they say, it is rain that grows flowers, not thunder.
Inside, we know we’re not just here to feed The System. We know it should be feeding us. We should not be starving. We should not have to be forced, or force ourselves, to do anything. People need to be supported to decide for themselves what healing looks like for them and to approach it in their own time.
The Emperor in the Room
Opioids are like guns handed out in a suicide ward; they have certainly made the total epidemic much worse, but they are not the cause of the underlying depression.
Anne Case and Angus Deaton
To solve the drug problem, we need to focus on more than drugs. Otherwise, we are shooting the messenger. Drugs are like the emperor’s clothes; it’s time to look at who’s wearing them.
Like Dr. Jekyll and Mr. Hyde, opioids and their antagonists are two sides of the same coin. Focusing on either is like looking for your keys under the streetlamp when you know you dropped them further up the street. There is an “upstream” issue here. That issue is our domination-based, “have to” culture. If we stick to our guns, if we continue to be violent, inside and out, we will continue to die.
Whether we kill another person, the planet, or ourselves, we are a culture committing suicide. We are overdosing on “progress.” We are addicted to things far more insidious than opioids; you’re looking at one.
Progress isn’t progress when it’s in the wrong direction. The direction we’re going is apart. The direction we need to go is back together.
Only the Lonely
Humanity’s current crisis may not, at its root, be an economic crisis or an environmental crisis. It may well be a crisis of consciousness, a crisis in how see ourselves and the world around.
Peter Russell
If you’re in the right place at the right time, armed with enough naloxone, you can save a life. But what about an hour later, or the next day? You might get someone into treatment, but what about after that? A person that susceptible to overdose can scarcely be left alone. And that aloneness is the real problem. In fact, it’s how addiction starts.
The connection between social isolation and addiction shows up on many levels, from treatment to prevention. The most obvious is that you can get naloxone into the hands of every drug user, but it will do them no good if they overdose alone.
Human beings may be the most social animals on earth. Social isolation can drive us to despair, addiction, and even suicide. Loneliness is self-reinforcing and can lead to shame, for it can mean “I don’t deserve to be loved.” This can be the underlying emotional pain that comes back during withdrawal, whether from an opioid or from someone withholding their affection. And that lack of affection could be the primary cause of addiction.
Fatal Attraction
If one has a friend, what need has one of medicines?
Bhartrihari
There can be no healing without community. “This unique American moment asks not for a call to arms, but for a call to neighborliness.” (Francie Hart Broghammer)
No amount of “care” can substitute for the watchful eye of loving family, friends, or neighbors. No amount of “treatment” can make up for how we treat each other. It truly takes a village.
Ultimately, it’s not drugs that are killing us; they are just finishing us off. Whether or not we beat the horse, we’re already practically dead. Something has weakened us enough to succumb to drugs. It’s the same thing that allows dealers to intentionally make some of their merchandise deadly, or if it’s naloxone, to jack up their prices.
What our culture is most addicted to is exploitation. It’s what the system is set up for. It compels us not to care. As Ken Eisold says, “The loss of community is not a problem that can be dealt with through psychotherapy,” for what needs rehabilitation is our society. There’s something wrong “with the village.”
The greatest tool I know for rebuilding community is Nonviolent Communication (NVC). The best approach I’ve encountered for addressing the disconnection inherent in addiction is SeekHealing.
We are the Medicine
At the root of the opioid epidemic are deeper questions that we have to ask about society. What kind of society do we want to live in? Do we want to live in a society where we believe every life truly matters? Do we want to live in a society where we all chip in, recognizing that we are vulnerable in some way, whether it’s to addiction or loneliness or other conditions, and that we are stronger when we come together, when we recognize our interdependence, and when we help each other?
As tragic as the opioid epidemic is, if it can move us in a direction of shared understanding about our interdependence, if it can help us address these deeper social roots of disease, then I believe that we will have used it ultimately to improve ourselves to become stronger as a country.
Vivek Murthy
To make it out of this crisis, we need to look at the big picture. As writer David Dobbs puts it, “trying to understand mental illness without accounting for the power of social connection is like studying planetary motion without accounting for gravity.” If we only look at addiction on an individual level, we are missing the forest for the trees. If you don’t heal the forest, it gets harder and harder to heal each tree.
It’s especially hard to heal when you’re continually cut down. In this culture of mutual exploitation, we treat each other like truffula trees. We factory-farm humans and clear-cut them for fuel. We do it to each other and we do it to ourselves. All to feed the machine, the matrix. To race into space, we’re melting our wings.
Saving lives, then, is only the beginning. It’s the tip of the iceberg. Because it is we, not “they,” who have an addiction. This isn’t about how we use drugs; it’s about how we use each other. Because ultimately, there are no others. We are not just a bunch of individuals. We are one, interdependent whole. Our greatest public health crisis is that we’ve forgotten who we are.
The Opposite of Addiction
Sometimes out of really horrible things come really beautiful things.
Anthony Kiedis
This crisis is an opportunity, a wake-up call. If we take responsibility for it, there’s no limit to what we can do. It’s said that anything is possible if it doesn’t matter who gets credit for it. The same is true of blame.
We are all in this together. That’s the bottom line. There is but one answer to this crisis, and we each carry it at the bottom of our heart.
I write this today not to provide a listing of programs that my agency has funded nor an update on how we are doing in addressing the opioid crisis. I write this as a physician seeking the help of my fellow physicians and healthcare colleagues around the country.
Many of you are very familiar with the efforts that we, in the government, have put forward to stem the tide of the opioid crisis. States and communities have done the same across the country. Our commitment is real, but it is also potentially futile if we do not have providers out there, on the front lines, willing to take on treating the population of Americans living with opioid use disorder. I speak from experience when I say I recognize the difficulty that practitioners may have in doing this. I understand that it’s administratively burdensome, often more time-consuming than providing care for other conditions, and potentially anxiety provoking. I fully understand all of those things.
But, I also understand that people living with opioid use disorder deserve better from us as healthcare professionals. Individuals struggling with opioid addiction who have taken that leap of faith that there is treatment available to them, and sadly, that is not nearly enough people, deserve practitioners who are willing and able to provide needed evidence-based care and treatment. If we had the training to treat them, we, as healthcare professionals, would never turn away someone with diabetes because they were too difficult to treat. If we were equipped and certified to provide someone medication for chronic heart disease in our office setting, we would never send them away without treatment.
Why then do we do it to individuals with opioid use disorder? The data tell us that a lack of people trained to treat these disorders is not the issue; a lack of trained individuals willing to do so is what appears to be the problem. We have over 62,000 healthcare professionals that today can prescribe medications to individuals with opioid use disorder. There are also approximately 1,500 opioid treatment programs available to individuals with these disorders. We have a system in place to treat the 2.1 million people with this illness. We just need to mobilize to do so.
In no way am I blaming healthcare practitioners. I know this lack of enthusiasm to treat can be for many reasons. Perhaps it is because our training didn’t serve us well or serve this population well. Perhaps it is because when we went to medical school, addiction was a mere passing phrase, if even that. We did not learn about this disease in the way we learned about others in our clinical training.
Maybe it is also because we have heard the stories, the stories of doors being kicked in, offices being raided, practices being shut down because people leading our justice system may not understand the need to treat people with opioid use disorders in a certain manner. Maybe it is that we don’t want to take that risk. As a physician, I understand that and reached out to my colleagues at the DEA to find out more about the practices being used. And, I am here to tell you that the anecdotal information you may have heard is the exception and not the rule. The data tell us that there is nothing to fear for the very vast majority of practitioners. Of the over 1.68 million DEA-registered prescribers, only 77 total (or less than .004%) had any administrative action taken on them.
We can no longer turn our back on this population. Our family members, friends, coworkers, and neighbors are dying. We have the tools at our disposal. Unlike other conditions, for this one, we have a clear evidence-base which tells us what to do; we have the people trained and ready to do it so let us take collective action and do so.
Practitioners alone are not the only ones needed. We must do better in the government also. And, we are working on that. We are working to address administrative burden. We are working to mainstream substance use disorder training into our schools. We have expanded efforts to provide you additional training and technical assistance in your communities. This is available to you, at no cost, and I encourage you to take advantage of it through visiting getstrta.org.
Our citizens deserve more than we have been giving them. We need those who have signed up to help to do so. We believe that you are ready. We believe that this can be done. We need communities across the nation to count on us to deliver. And, deliver, we will.
We at SAMHSA stand ready to help. I am not here to deliver empty words of encouragement with nothing behind them. It is not my intention to leave practitioners on their own. We have tools for you, free of charge, and we want you to use them. I want you to hold us accountable for delivering for you and I want to do the same of you. We have to hold each other accountable because we came into the healing profession for a reason. And, we must demand that our fellow citizens also hold us collectively accountable for realizing that reason. We talk continuously about addressing the opioid crisis and creating access. Access is here. We have it; we do not need much. We just need action behind a system that is primed and ready. We need willingness of people who have already demonstrated interest. If even half of you with a waiver practice to your limit, there will be ready access for most in need. I recognize that this is ambitious, but it is not impossible. I know that you, too, can experience the reward I have as a physician willing to take the chance in treating this disease. The data tell us we can do this and I know that together we can.
For some patients who have been doing well on opioids long-term, it makes sense to “leave well enough alone,” the doctor said.
Today, much of the medical community is focused on reducing opioid prescriptions after decades of overprescribing, but one doctor is an outspoken critic of weaning patients who are doing well on long-term or high-dose opioid prescriptions.
Dr. Stefan Kertesz, a primary care physician who focuses on addiction medicine and works with the homeless population, told STAT News that he is challenging the idea that even people who are doing well on opioids need to have their medications reduced or replaced.
“I think I’m particularly provoked by situations where harm is done in the name of helping,” said Kertesz, who is also a professor at the University of Alabama at Birmingham School of Medicine. “What really gets me is when responsible parties say we will protect you, and then they call upon us to harm people.”
In particular, Kertesz takes issue with the CDC’s 2016 opioids prescription guidelines. The guidelines were interpreted very strictly, and have led to many pain patients—even those who have not abused their medications—seeing their care regimen change.
For some patients who have been doing well on opioids long-term, it makes sense to “leave well enough alone,” Kertesz said.
He believes that the general recommendation to be careful when prescribing opioids is sound advice. However, when the recommendations are taken as a mandate, problems can arise, he said in a written response to the guideline.
“This is a guideline like no other… its guidance will affect the immediate well-being of millions of Americans with chronic pain,” Kertesz wrote.
In another written response he said, “Most of us wish to see an evolution toward fewer opioid starts and fewer patients at high doses,” but doctors need to be able to leave some patients on opioids as clinically necessary without feeling like they are putting their careers at risk.
Kertesz encouraged the CDC to clarify that the guidelines were recommendations only, not policy proclamations.
“It is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation,” he wrote in one letter that he co-authored. “Patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”
Now, Kertesz is hoping to secure funding to study suicides caused by reduction in pain medications.
“You have three things that are potentially simultaneously associated with harm: Pain itself. Opioid dependence, the dependence itself. And the event, however we wish to interpret it clinically—as resurgent pain or untreated opioid dependence—in patients who are having opioids taken away,” he explained.
Despite his dedication to speaking out against uniform opioid reductions, Kertesz sometimes still feels nervous about standing against the mainstream medical community.
“Every single bit of it involves ambivalence and driving myself crazy,” he said. “Like, am I making a mistake? Am I going to blow up my career?”
