Abstinence,
Death, and How to Change the Opioid Epidemic
By
Charles
Atkins, MD
(First published in the CT Mirror October 25, 2019)
I chair death reviews. It’s part of my job as a medical
director for a mental health and substance abuse agency. In recent years the
bulk of deaths have been from opioid overdoses, now mostly fentanyl. The most-common
themes are people who just left rehab, a detox program, or were released from
prison. What has become clear is that abstinence-only approaches and programs
for opioids don’t work, yet we continue to promote, practice, and pay for models
that are ineffective and deadly.
While some opioid data is open to interpretation, certain
figures hold up. Over the course of a year, about 80 percent of people who want
to be substance free will have at least one slip, closer to 90 percent for
people with more severe problems with drugs and alcohol and for those who also
have mental health issues or have been incarcerated.
These lapse rates hold true regardless of the drug, from
tobacco to heroin. But a lapse doesn’t equate to failure. It could be a one- or
two-time thing and then they’ll return to their earlier goal to be substance
free.
Here’s
the disconnect. A lapse with alcohol, tobacco, or cocaine might be unwanted, but
it probably won’t kill you today. Yes, cigarettes will eventually give you cancer, heart disease, and a stroke, and after
forty years of hard drinking, your liver dies… and so do you. But not today.
This
is where opioids differ and why abstinence approaches in the age of Oxycontin,
black tar heroin, and now fentanyl are dangerous and, in the face of hard data,
possibly immoral.
Studies that have looked at 30-day abstinence programs
for opioids show that over half their graduates relapse within a week of
discharge, often on the ride home. Forty years ago, when the heroin on the
street was less than 10 percent pure, that might not have killed you. But in
our current epidemic, which involves high-octane fentanyls that start at 50 to100
times more potent than morphine and carfentanil that can be over 10,000 times
stronger, all it takes is two bags that cost six bucks on the streets of New
Britain, Hartford, or New Haven and we have another death.
Daily opioid users become dependent on the drugs and
develop tolerance. They need to take more drug to achieve the same effect, and
should they go even a few hours without, they experience withdrawal symptoms that
leave them sick, incapacitated, miserable, and craving. With traditional detox
programs, people are weaned off the opioids, kept in a sheltered environment,
and then discharged, often back to the same environment, stresses, and people
with whom they used. Their tolerance to the drugs is gone, and a dose they once
found safe is now fatal. Many parents who’ve lost children echo stories of how
their child used a bag of fentanyl-adulterated heroin on the way home from
treatment and it killed them.
But people like abstinence. I do too. How lovely if
someone could take a problem behavior and just stop. And in those 80 and 90 percent
relapse rates are 10 and 20 percent minorities who manage to quit and stay quit—some
on the first try, some on the fiftieth. But preferences and likes that are not
supported by data have no place in medicine and public health policy. Yet we
continue to promote models of care that kill people with opioid use disorders.
Even
though we know these are chronic conditions that will have lapses, we deny and
restrict treatment based on positive drugs screens and the very behavior (drug
use) that brings the person in for help. Nowhere else in medicine do we take
such a punitive stance. I can’t imagine telling a person with insulin-dependent
diabetes that if they continue to binge on Ben and Jerry’s, we’ll withhold
their medication because by giving it to them we’re “enabling” their
destructive behavior. We don’t do that. We work with that person—provide
education, help them establish workable treatment goals, and nudge them along.
It’s a harm reduction, risk-lowering strategy.
For those unfamiliar with harm reduction, it describes
public health approaches to risky behaviors. Every time you put a seatbelt on,
you’ve performed an act of harm reduction. Yes, there’s still the chance that
you’ll get hit on the highway, but you’ve improved your odds of survival. Harm
reduction strategies for people who use drugs—including opioids—have been
around for decades and include sterile needle exchange, rapid access to
effective medications for opioid use disorders (methadone, buprenorphine,
naloxone), overdose kits (naltrexone/Narcan), decriminalization of low-level
drug-related behaviors, education, free condoms, and safe and supervised places
for people to use their drugs so they don’t die if they get in trouble.
Outcomes
from many studies are overwhelmingly positive, especially in countries who’ve
used these approaches for decades. Results include greatly decreased rates of
disease transmission (HIV/AIDs, Hepatitis), lower medical problems related to
injection drug use, fewer deaths, fewer incarcerations, higher quality of life,
and lower overall cost to the taxpayer. In
our current avalanche of overdose deaths treatment algorithms must consider the
reality that most people will relapse. But they need not die because of it.
So,
as we face a central question of our opioid epidemic, how do we turn back this
tide of death? Answers stare back at us. We have to step away from abstinence-only
approaches, such as arbitrary “three-strikes and you’re out” policies and detox
protocols that don’t include the use of proven medications. And for those who
continue to use street drugs and are not at the point of entering treatment,
community outreach is key, and it needs to include access to sterile needle
exchange, overdose kits (naloxone/Narcan), education about safer drug use, an
open invitation to treatment that is readily available, and safe places for
people to use their drugs.
Bio—
Bio: Charles Atkins, M.D. is a
psychiatrist, author, clinical trainer, and member of the Yale volunteer
faculty. His most recent book on this
topic is Opioid Use Disorders: A Holistic
Guide to Assessment, Treatment and Recovery. His web site is www.charlesatkins.com
