Medication-assisted treatment is often called the gold standard of addiction care. But much of the country has resisted it.<\/p>\n
If you ask Jordan Hansen why he changed his mind on medication-assisted\u00a0treatment for opioid addiction, this is the bottom line.<\/p>\n
Several years ago, Hansen was against the form of treatment. If you asked him back then what he thought about it, he would have told you that it\u2019s ineffective \u2014 and even harmful \u2014 for drug users. Like other critics, to Hansen, medication-assisted treatment was nothing more than substituting one drug (say, heroin) with another (methadone).<\/p>\n
Today, not only does Hansen think this form of treatment is effective, but he readily argues \u2014 as the scientific evidence overwhelmingly shows \u2014 that it\u2019s the best form of treatment for opioid addiction. He believes this so strongly, in fact, that he now often leads training sessions for medication-assisted treatment across the country.<\/p>\n
\u201cIt almost hurts to say it out loud now, but it\u2019s the truth,\u201d Hansen told me, describing his previous beliefs. \u201cI was kind of absorbing the collective fear and ignorance from the culture at large within the recovery community.\u201d Hansen is far from alone. Over the past few years, America\u2019s harrowing opioid epidemic \u2014 now the deadliest drug overdose crisis in the country\u2019s history \u2014 has led to a lot of rethinking about how to deal with addiction. For addiction treatment providers, that\u2019s led to new debates about the merits of the abstinence-only model \u2014 many of which essentially consider addiction a failure of willpower \u2014 so long supported in the US.<\/p>\n
The case for prescription heroin<\/strong><\/p>\n The Hazelden Betty Ford Foundation, which Hansen works for, exemplifies the debate. As one of the top drug treatment providers in the country, it used to subscribe almost exclusively to the abstinence-only model, based on an interpretation of the 12 steps of Alcoholics Anonymous and Narcotics Anonymous popularized in American addiction treatment in the past several decades. But in 2012, Hazelden announced a big switch: It would provide medication-assisted treatment.<\/p>\n \u201cThis is a huge shift for our culture and organization,\u201d Marvin Seppala, chief medical officer of Hazelden, said at the time. \u201cWe believe it\u2019s the responsible thing to do.\u201d<\/p>\n From the outside, this might seem like a bizarre debate: Okay, so addiction treatment providers are supporting a form of treatment that has a lot of evidence behind it. So what?<\/p>\n But the growing embrace of medication-assisted treatment is demonstrative of how the opioid epidemic is forcing the country to take another look at its inadequate drug treatment system. With so many people dying from drug overdoses \u2014 tens of thousands a year \u2014 and hundreds of thousands more expected to die in the next decade, America is finally considering how its response to addiction can be better rooted in science instead of the moralistic stigmatization that\u2019s existed for so long.<\/p>\n The problem is that the moralistic stigmatization is still fairly entrenched in how the US thinks about addiction. But the embrace of medication-assisted treatment shows that may be finally changing \u2014 and America may be finally looking at addiction as a medical condition instead of a moral failure.<\/p>\n The research is clear: Medication-assisted treatment works<\/strong><\/p>\n One of the reasons opioid addiction is so powerful is that users feel like they must keep using the drugs in order to stave off withdrawal. Once a person\u2019s body grows used to opioids but doesn\u2019t get enough of the drugs to satisfy what it\u2019s used to, withdrawal can pop up, causing, among other symptoms, severe nausea and full-body aches. So to avoid suffering through it, drug users often seek out drugs like heroin and opioid painkillers \u2014 not necessarily to get a euphoric high, but to feel normal and avoid withdrawal. (In the heroin world, this is often referred to as \u201cgetting straight.\u201d)<\/p>\n Medications like methadone and buprenorphine (also known as Suboxone) can stop this cycle. Since they are opioids themselves, they can fulfil a person\u2019s cravings and stop withdrawal symptoms. The key is that they do this in a safe medical setting, and when taken as prescribed do not produce the euphoric high that opioids do when they are misused. By doing this, an opioid user significantly reduces the risk of relapse, since he doesn\u2019t have to worry about avoiding withdrawal anymore. Users can take this for the rest of their lives, or in some cases, doses may be reduced; it varies from patient to patient.<\/p>\n The research backs this up: Various studies, including systemic reviews of the research, have found that medication-assisted treatment can cut the all-cause mortality rate among addiction patients by half or more. Just imagine if a medication came out for any other disease \u2014 and, yes, health experts consider addiction a disease \u2014 that cuts mortality by half; it would be a momentous discovery.<\/p>\n \u201cThat is shown repeatedly,\u201d Maia Szalavitz, a long time addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, told me. \u201cThere\u2019s so much data from so many different places that if you add methadone or Suboxone in, deaths go down, and if you take it away, deaths go up.\u201d That\u2019s why the biggest public health organizations \u2014 including the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, and the World Health Organization \u2014 all acknowledge medication-assisted treatment\u2019s medical value. And experts often describe it to me as \u201cthe gold standard\u201d for opioid addiction care.<\/p>\n The data is what drove Hansen\u2019s change in perspective. \u201cIf I wanted to view myself as an ethical practitioner and doing the best that I could for the people I served, I needed to make this change based on the overwhelming evidence,\u201d he said. \u201cAnd I needed to separate that from my personal recovery experience.\u201d<\/p>\n Medication-assisted treatment is different from traditional forms of dealing with addiction in America, which tend to demand abstinence. The standards in this field are 12-step programs, which combine spiritual and moralistic ideals into a support group for people suffering from addiction. While some 12-step programs allow medication-assisted treatment, others prohibit it as part of their demand for total abstinence. The research shows this is a particularly bad idea for opioids, for which medications are considered the standard of care.<\/p>\n There are different kinds of medications for opioids, which will work better or worse depending on a patient\u2019s circumstances. Methadone, for example, is only administered in a clinic, typically one to four times a day \u2014 but that means patients will have to make the trip to a clinic on a fairly regular basis. Buprenorphine is a take-home drug that\u2019s taken once or twice a day, but the at-home access also means it might be easier to misuse and divert to the black market.<\/p>\n One rising medication, known as naltrexone or its brand name Vivitrol, isn\u2019t an opioid \u2014 making it less prone to misuse \u2014 and only needs to be injected once a month. But it doesn\u2019t work in the same way as methadone or buprenorphine. It requires full detoxification to use (usually three to 10 days of no opioid use), while buprenorphine, for example, only requires a partial detoxification process (usually 12 hours to two days). And instead of preventing withdrawal \u2014 indeed, the detox process requires going through withdrawal \u2014 it blocks the effects of opioids up to certain doses, making it much harder to get high or overdose on the drugs. It\u2019s also relatively new, so there\u2019s less evidence for its real-world effectiveness.<\/p>\n One catch is that even these medications, though the best forms of opioid treatment, do not work for as much as 40 percent of opioid users. Some patients may prefer not to take any medications because they see any drug use whatsoever as getting in the way of their recovery, in which case total abstinence may be the right answer for them. Others may not respond well physically to the medications, or the medications may for whatever reason fail to keep them from misusing drugs.<\/p>\n This isn\u2019t atypical in medicine. What works for some people, even the majority, isn\u2019t always going to work for everyone. So these are really first-line treatments, but in some cases patients may need alternative therapies if medication-assisted treatment doesn\u2019t work. (That might even involve prescription heroin \u2014 which, while it\u2019s perhaps counterintuitive, the research shows it works to mitigate the problems of addiction when provided in tightly controlled, supervised medical settings.)<\/p>\n Medication can also be paired with other kinds of treatment to better results. It can be used in tandem with cognitive behavioral therapy or similar approaches, which teach drug users how to deal with problems or settings that can lead to relapse. All of that can also be paired with 12-step programs like AA and NA or other support groups in which people work together and hold each other accountable in the fight against addiction. It all varies from patient to patient.<\/p>\n It is substituting one drug for another, but that\u2019s okay<\/strong><\/p>\n The main criticism of medication-assisted treatment is that it\u2019s merely replacing one drug with another. Health and Human Services Secretary Tom Price recently echoed this criticism, saying, \u201cIf we\u2019re just substituting one opioid for another, we\u2019re not moving the dial much. Folks need to be cured so they can be productive members of society and realize their dreams.\u201d (A spokesperson for Price later walked back the statement, saying Price supports all kinds of drug treatment.)<\/p>\n On its face, this argument is true. Medication-assisted treatment is replacing one drug, whether it\u2019s opioid painkillers or heroin, with another, such as methadone or buprenorphine.<\/p>\n But this isn\u2019t by itself a bad thing. Under the Diagnostic and Statistical Manual of Mental Disorders, it\u2019s not enough for someone to be using or even physically dependent on drugs to qualify for a substance use disorder, the technical name for addiction. After all, most US adults use drugs \u2014 some every day or multiple times a day \u2014 without any problems whatsoever. Just think about that next time you sip a beer, glass of wine, coffee, tea, or any other beverage with alcohol or caffeine in it, or any time you use a drug to treat a medical condition.<\/p>\n The qualification for a substance use disorder is that someone is using drugs in a dangerous or risky manner, putting himself or others in danger. So someone with a substance use disorder would not just be using opioids but potentially using these drugs in a way that puts him in danger \u2014 perhaps by feeling the need to commit crimes to obtain the drugs or using the drugs so much that he puts himself at risk of overdose and inhibits his day-to-day functioning. Basically, the drug use has to hinder someone from being a healthy, functioning member of society to qualify as addiction.<\/p>\n The key with medication-assisted treatment is that while it does involve continued drug use, it turns that drug use into a much safer habit. So instead of stealing to get heroin or using painkillers so much that he puts his life at risk, a patient on medication-assisted treatment can simply use methadone or buprenorphine to meet his physical cravings and otherwise go about his day \u2014 going to school, work, or any other obligations.<\/p>\n Yet this myth of the dangers of medication-assisted treatment remains prevalent \u2014 to deadly results.<\/p>\n In 2013, Judge Frank Gulotta Jr. in New York ordered an opioid user arrested for drugs, Robert Lepolszki, off methadone treatment, which he began after his arrest. In January 2014, Lepolszki died of a drug overdose at 28 years old \u2014 a direct result, Lepolszki\u2019s parents say, of failing to get the medicine he needed. In his defense,\u00a0 Gulotta has continued to argue that methadone programs \u201care crutches \u2014 they are substitutes for drugs and drug cravings without enabling the participant to actually rid him or herself of the addiction.\u201d<\/p>\n This is just one case, but it shows the real risk of denying opioid users medication: It can literally get them killed by depriving them of lifesaving medical care.<\/p>\n The myth is also a big reason why there are still restrictions on medication-assisted treatment. For example, the federal government still caps how many patients doctors can prescribe buprenorphine to, with strict rules about raising the cap. This limits how accessible the treatment is. A Huff Post analysis found that even if every doctor who can prescribe buprenorphine did so at the maximum rate in 2012, more than half of Americans with opioid use disorders could not get the medication. That\u2019s on top of barriers to addiction treatment in general. According to a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report attributed the low rate to severe shortages in the supply of care, with some areas of the country, particularly rural counties, lacking affordable options for treatment \u2014 which can lead to waiting periods of weeks or even months. Only recently has there been a broader push to fix this gap in care.<\/p>\n The medications used in treatment do carry some risks<\/strong><\/p>\n None of this is to say that the medications used in these treatments are without any problems whatsoever. Methadone is tied to thousands of deadly overdoses a year, although almost entirely when it\u2019s used for pain, not addiction, treatment \u2014 since it\u2019s much more regulated in addiction care. Buprenorphine is safer in that, unlike common painkillers, heroin, and methadone, its effect has a ceiling \u2014 meaning it has no significant effect after a certain dose level. But it\u2019s still possible to misuse, particularly for people with lower tolerance levels. And there are some reports of buprenorphine mills, where patients can get buprenorphine for misuse from unscrupulous doctors \u2014 similar to how pill mills popped up during the beginning of the opioid epidemic and provided patients easy access to painkillers.<\/p>\n Naltrexone, meanwhile, can heighten the risk of overdose and death in case of full relapse. Overdose and death are risks in any case of relapse, but they\u2019re particularly acute for naltrexone because it requires a full detox process that eliminates prior tolerance. (Although this would typically require someone to stop taking naltrexone, since otherwise it blocks the effects of opioids up to certain doses.)<\/p>\n But when taken as prescribed, the medications are broadly safe and effective for addiction treatment. For regulators, it\u2019s a matter of making sure the drugs aren\u2019t diverted into misuse, while also providing good access to people who genuinely need them.<\/p>\n The fight over medication-assisted treatment is really about how we see addiction<\/strong><\/p>\n Behind the arguments about medication-assisted treatment is a simple reality of how Americans view addiction: Many still don\u2019t see it, as public health officials and experts do, as a disease.<\/p>\n With other diseases, there is no question that medication can be a legitimate answer. That medication is not viewed as a proper answer by many to addiction shows that people believe addiction is unique in some way \u2014 particularly, they view addiction as at least partly a moral failing instead of just a disease.<\/p>\n I get emails all the time to this effect. Here, for example, is a fairly representative reader message: \u201cDarwin\u2019s Theory says \u2018survival of the fittest.\u2019 Let these lost souls pay the price of their criminal choices and criminal actions. Society does not owe them multiple medical resuscitations from their own bad judgment, criminal activity, and self-inflicted wounds.\u201d<\/p>\n This contradicts what addiction experts broadly agree on. As Stanford psychiatrist and Drug Dealer, MD author Anna Lembke put it, \u201cIf you see somebody who continues to use despite their lives being totally destroyed \u2014 losing their jobs, losing loved ones, ending up in jail \u2014 nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual\u2019s control on some level.\u201d<\/p>\n Many Americans may understand this with, say, depression and anxiety. We know that people with these types of mental health problems are not in full control of their thoughts and emotions. But many don\u2019t realize that addiction functions in a similar way \u2014 only that the thoughts and emotions drive someone to seek out drugs at just about any cost.<\/p>\n Some of the sentiment against medications, as Hansen can testify, is propagated by people suffering from addiction. Some of them believe that any drug use, even to treat addiction, goes against the goal of full sobriety. They may believe that if they got sober without medications, perhaps others should too. Many of them also don\u2019t trust the health care system: If they got addicted to drugs because a doctor prescribed them opioid painkillers, they have a good reason to distrust doctors who are now trying to get them to take another medication \u2014 this time for their addiction.<\/p>\n The opioid epidemic, however, has gotten a lot of people in the addiction recovery world to reconsider their past beliefs. Funeral after funeral and awful statistic after awful statistic, there is a sense that there has to be a better way \u2014 and by looking at the evidence, many have come to support medication-assisted treatment.<\/p>\n \u201cI remember sitting there,\u201d Hansen said, speaking to his experience at a funeral, as a mother sang her dead son a lullaby, \u201cthinking that we have to do better.\u201d<\/p>\n Source:\u00a0 German Lopez@germanrlopezgerman.lopez@vox.com\u00a0 Jul 20, 2017<\/em><\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" Medication-assisted treatment is often called the gold standard of addiction care. But much of the country has resisted it. If you ask Jordan Hansen why he changed his mind on medication-assisted\u00a0treatment for opioid addiction, this is the bottom line. Several years ago, Hansen was against the form of treatment. 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