Currently, there is an epidemic of opiate addiction in the USA that is primarily being fueled by the overly liberal use of narcotics in the treatment of non-malignant pain. Deaths due to opiate overdose doubled between 2001 and 2005 (see the accompanying post on this page entitled: “The Epidemic of Opiate Addiction due to Prescription Drugs”). Opiate addiction is notoriously difficult to treat owing to the highly addictive nature of opiates. Opiates (or their synthetic cousins, Opioids) are one of only two drugs that stimulate release of dopamine at both pleasure centers within the brain. This fact, combined with the extremely uncomfortable opiate withdrawal syndrome, compel the user (on a neurobiological basis) to persist in the use of narcotics–even when they no longer get high from using them. On top of this, non-prescription use of opioids is illegal (unlike alcohol which is easily obtainable) and the stigma surrounding narcotic addiction is much worse than that of alcoholism. Obviously, there are some good reasons for the stigma since opiate addicts will: manipulate doctors, forge prescriptions, deal drugs, commit murders, steal, or prostitute themselves to obtain their drugs. Once the addiction takes hold, the addict becomes a tornado ripping through the lives of family, friends, and society. To make things worse, the treatment of narcotic addiction is extremely controversial. Many people are opposed to the use of Methadone or Suboxone because they see this as the substitution of one addiction for another. Also, many people in the sober community (i.e., those recovering in 12 step programs) are opposed to the use of Suboxone because they do not consider that to be consistent with sobriety.

How can we make sense of this difficult problem and what are the facts surrounding this difficult issue? The medical approach to disease is to consider the biological, psychological, and social impact of the disease in question. Let’s begin with the biology. The most addictive drug on the planet is nicotine (with 33% of smokers becoming addicted) and a close second is opiates at 27%. The relapse rate for opiate addicts without treatment with Suboxone or Methadone is 85%. The relapse rate with treatment with Suboxone or Methadone drops to 50%. Suboxone is essentially “Son of Methadone”–it does the same thing that Methadone does except that its pharmacologic properties are different in a manner that enhances its safety. The purpose of these “substitutive therapies” is three-fold: 1) Eliminate drug craving; 2) Eliminate “Dope Sickness” (i.e. the uncomfortable opiate withdrawal syndrome); and 3) If the patient is on the right dose and they do short-acting opiates—they won’t get high.

The problem with the strict biological approach to opiate addiction is that it does nothing to address the psychological aspects of the illness. The disease of the addict is within the mind. Mere substitution therapy, without addressing the thinking and behavior of an addict, is not the answer. At this point in the discussion the reader needs to be aware of the difference in dependence versus addiction. Dependence means that the patient is dependent on Methadone or Suboxone such that, if he does not have the medication, he will go into withdrawal. Addiction is both dependence and the behaviors associated with active addiction: lying, manipulating, drug seeking, theft, prostitution, etc. The long-term data obtained from the Methadone experience shows that 50 % of those on Methadone maintenance are still active in their disease of addiction. They are just using Methadone or Suboxone as a backstop until they can get their drug of choice. In the case of Methadone (a full agonist at the mu narcotic receptor in the brain), an active drug addict will walk into the Methadone clinic, get his dose of Methadone, and upon leaving the clinic will supplement it with alcohol, Xanax, Cocaine, or other drugs in order to “get a boost.” The other 50% of those treated with Methadone are evenly divided into two groups (each comprising 25% of the total): 1) this group will eventually get completely off of Methadone and go on to an otherwise normal life; 2) this group will be dependent on Methadone indefinitely and will not abuse anything stronger than nicotine or caffeine. Both groups will go on to work, have families, pay taxes, and do everything else that otherwise normal people would do. Meanwhile, the unrecovered 50% will go on to insanity, incarceration, or death. The key to healing in the 50% who are no longer displaying “addict behavior” is a complete psychic change. For discussion of this aspect of recovery, please see the article on this page entitled “Addiction Medicine: The Intersection of Science and Spirituality.”

Finally, we come to the social aspects of the disease. By now everyone reading this is well aware of the stigma and judgment surrounding the addict or alcoholic population. Why is it that a Methadone or Suboxone provider would continue to prescribe to someone that is still an active addict? The answer is that some do and some don’t. It is usually based on a pre-existing policy agreement between the provider and the patient, federal regulations, and a case-by-case assessment. From a social perspective, treatment with Methadone or Suboxone is consistent with a “harm reduction” approach to the management of disease. Harm reduction is essentially reducing the harm to society caused by the addicts’ use of Heroin or other illegal narcotics. Every time a clinician in a Methadone clinic gives a Heroin addict Methadone he is taking a thief, a drug dealer, or a prostitute off of the streets. This reduces crime and the spread of diseases such as HIV, Hepatitis C, and other STD’s. Likewise, furnishing sterile needles and condoms is consistent with efforts at harm reduction. The reasoning is that since you are powerless over other people’s addictions (or sexual behavior) the best way to protect society as a whole is to use half measures which reduces morbidity and mortality. This is very common in the medical setting. For instance, the disease of type 2 diabetes is caused by obesity. Getting people to lose weight is extremely difficult, but providing them with pills that reduce their appetite, decrease their blood sugar, and control their cholesterol and blood pressure is relatively easy to do. Are these ideal solutions? No. We don’t live in an ideal world. In an ideal world, all addicts or alcoholics would get clean and sober through 12 step programs and all type 2 diabetics would lose the weight and get fit. This doesn’t happen. The reality is that half of the addicts out there will eventually wake-up and begin to change their mind set (usually through a spiritual awakening or psychic change) and the other half will continue doing the same thing over and over and expecting different results. Insanity=doing the same thing over and over and expecting different results.