We’re in the midst of an opioid epidemic. In the U.S., deaths spiked from 10,000 in 2002 to more than 49,000 in 2017. Canada’s steady uptick in opioid-linked deaths is highest for ages 30-39.
Treatments vary, and most of them use faith-based initiatives to attempt to stem addiction in the bud, and rely on an abstinence-only method.
The problem, say a growing number of scientists, is that these faith-based options don’t work—especially given new knowledge about how addiction affects our bodies through our brains.
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The movement to redefine and understand opioid use disorder, or OUD, is welcomed by Peter Grinspoon.
A little more than a decade ago, Grinspoon had the veneer of success. He had a medical degree, a family, and was doing well in his practice. But, as he chronicled in his 2016 memoir, Free Refills: A Doctor Confronts His Addiction, he was hiding a secret: he was addicted to opioids.
Now Grinspoon, who is 11 years sober, is advocating for medication-assisted treatment, called MAT, which combines behavioral therapy with FDA-approved medications to help stem addiction.
Last month, Grinspoon published a post on Harvard Health Blog that questioned the very medical basis of addiction. Titled “Does Addiction Last a Lifetime?,” the post questions what mental health professionals understand about an “addictive personality,” a concept that he argues saddles people with lifelong vulnerability to relapse, or to re-addiction to new substances.
Grinspoon sees no scientific evidence that being diagnosed with addictive personality is effective in treatment.
For one thing, he supports the use of buprenorphine. Drugs like buprenorphine lessen withdrawal symptoms and the cravings that lead to relapse and overdose.
While in rehab, Grinspoon was told, ‘A drug is a drug is a drug.’ “This mentality does not allow for a difference between the powerful opiate fentanyl, which kills thousands of people every year, and buprenorphine, which is a widely-accepted treatment for OUD,” he posted.
Grinspoon also sees a problem with the abstinence-only approach many rehabilitation centers have adopted.
“I have come to believe that an uncompromising ‘abstinence-only’ model is a holdover from the very beginnings of the recovery movement, almost 100 years ago, and our understanding has greatly evolved since then,” Grinspoon said. “The concepts of addiction and recovery that made sense in 1935, when Alcoholics Anonymous was founded, and which have been carried on by tradition, might not still hold true in the modern age of neurochemistry and functional MRIs.”
Given the opioid-overdose death rate, “uncompromising” is the key word.
“It seems as if it’s just what we’ve been doing since 1935 because there was nothing else,” he told the Daily Beast. “Now we have multi-faceted approaches to treatment, including the use of drugs like buprenorphine, which fuels OUD recovery."
The problem, according to Grinspoon, is the very basis by which we think about and treat opioid addiction. “You treat opiate withdrawal differently than you treat alcohol withdrawal,” he said. “Yet the rehabs tend to treat every addiction the same. Most rehab centers are not using cutting-edge science.”
MAT could change that. It includes not only buprenorphine for opioid addiction, but also acamprosate for alcoholism, and naltrexone for opiates and/or alcohol. None of these drug treatments were discovered until recently, and definitely weren’t known in 1935.
But implementing change here is difficult, thanks to court-mandated NA and AA meeting attendance. Courts and probation officers, as well as police, prosecutors and local, state and federal agencies, often order OUD-related offenders to attend abstinence-only, faith-based NA or AA meetings, and have done so for decades. Yet people within the U.S. criminal justice system experience high rates of OUD and overdose, according to a recent Johns Hopkins University study.
That study, published last December in the journal Health Affairs, looked at 72,000 adults in an OUD treatment program, including 17,000 referred by criminal justice agencies.
The researchers found that less than 5 percent of OUD-related offenders ordered into treatment received MAT. In contrast, 40 percent of people referred by employers or healthcare providers received MAT.
That potentially set them up for failure. The study authors found that MAT’s behavioral therapy-fueled approach could decrease overdose risk within the court-ordered population, many of whom lack homes, jobs, medical care or other factors that contribute to OUD upon release from jail. Despite its promise, researchers found that courts were unlikely to refer misusers to MAT.
That doesn’t surprise Grinspoon.
“Judges are vastly under-educated about modern addiction, both the disease and the treatment,” Grinspoon said. “I was forced, by my professional medical society, into a pretty religious 12-step rehab program for 90 days and, as an atheist, I found it counterproductive at best. Judges need to enable people to access modern treatments, not the old-fashioned, non-evidence-based mush that is called ‘treatment’ at many rehab centers.”
Nora Volkow, the Director of the U.S. National Institute on Drug Abuse, agrees. “In general, studies show abstinence-only programs do not work with opioids,” Volkow told the Daily Beast. “There may be some misusers for whom it does work, but in the majority of cases it does not. People with OUD have a very high rate of relapse in abstinence-only programs, and the death rate during relapse can be as high as 90 percent.”
Volkow said that many treatment options don’t take into account the fact that OUD acts differently from that of other disorders from common addictive substances. “What opioids do is to kidnap the system that drives our motivation for survival,” she explained. “For example, if you have not eaten for days your brain will make getting food a priority, for survival. But when you are opioid-addicted your brain is not able to do any of the things we normally do to survive.”
Laura Schmidt is a University of California San Francisco School of Medicine professor who recently wrote a paper published in Drug and Alcohol Review on alternative methods of opioid addiction treatment. She says addiction remains surprisingly misunderstood.
“The addictive-personality concept has pretty much been debunked by research,” Schmidt told The Daily Beast. “The biggest problem now is capacity. We simply don’t have enough treatment slots for everyone who needs them.” Analyses have shown OUDs far exceed treatment need: in 2017, more than 450,000 people with OUD were unable to access treatment.
Schmidt, like Grinspoon, points out that addiction has been freighted by history, ever since the 19th century temperance movement that saw alcohol consumption as abhorrent. “With that framework in place, treatment providers strategically deploy what’s called a moral/medical model, depending upon the patient,” Schmidt explained. “When providers decide patients need to be held morally accountable, they get patients to stay sober by shaming them.
“In the very process of doing that, they continue to promulgate the idea that addiction is the addicts’ fault,” Schmidt added. “Providers think by shaming patients they can get them clean.”
That approach is problematic, and leads to a vicious circle of further stigmatization, which Schmidt said could also lead to the significant barrier to funding treatment patients face in dealing with insurance companies.
It’s something Schmidt has, in fact, seen in her own work.
“I worked on a study of a healthcare organization offering OUD treatment to their members,” Schmidt said. “There was a waiting list, and while people were waiting to enroll in our study, a few were able to receive MAT. They told others on the waiting list that MAT had helped them stay off opioids, and eventually through word-of-mouth, OUD misusers began asking us if they could get into MAT. So the word spread that it helped to quell craving and withdrawal sickness.
“This was really notable to me,” Schmidt continued. “The misusers themselves were more open-minded about treatment alternatives than NA suggestions. They wanted what works.”
Advances in MAT grew out of investigation into the science of brain imaging. Scientists were able to see inside the brain of an addicted person and pinpoint parts affected by drug abuse. The discovery of brain circuits underlying addiction has resulted in development of effective medications — including buprenorphine, naloxone, and acamprosate. One study actually mapped out what appear to be relapse pathways in the brains of opiate-dependent users.
New research has shown how those neural circuits are detectable via functional magnetic resonance imaging, or fMRI. fMRI can show whether oxygen levels and electricity flows inside a misuser’s brain are normal or abnormal. fMRIs have shown how craving contributes to cocaine relapse, for example. Cocaine users’ own feelings of craving matched their fMRI images, which showed activity in the craving area of their brains.
It’s a critical discovery in the science of addiction, one that Schmidt said was “hard to deny.”
Multi-pronged approaches that combine fMRI, recovery program meetings and MAT, along with other new techniques, are beginning to gain acceptance. They’re already in place in states from Washington to Vermont.
But will that actually stem the deaths resulting from the opioid crisis? “There is a pervasive bias in the rehab network against this kind of medicine-assisted treatment,” Grinspoon said—but he's optimistic that MAT and other medically based treatments might help reverse the upward spike of opioid deaths every year.
