V – “Best Practice” Treatments – or Are They?:
Working class white Americans are now finding themselves caught up in adverse circumstances comparable to those in which working class black Americans, indeed all poor Americans, regardless of ethnic heritage, have been mired for the past 50 years.
Methadone was first used on a large scale in New York, particularly in New York City, during the early 1970’s when the first wave of heroin abuse swept over the City’s black neighborhoods. In the New York State plan to combat the current opioid epidemic announced by Governor Cuomo in June, $189 million of the State’s $1.5 billion drug treatment budget will be dedicated to improve and extend opioid abuse outpatient and inpatient treatment programs throughout the state. Methadone, together with suboxone, will be the treatments of choice, known as medication assisted treatment or MAT, employed in OASAS’s new opioid treatment centers and in its expanded treatment programs.
Methadone is a synthetic opioid and, as such, is addictive. The medical rationale for its use was and continues to be its apparent efficacy in the detoxification of persons addicted to heroin and opioid analgesics and as a deterrent to opioid overdose since it is administered orally, not intravenously, under medical supervision. Suboxone is a drug comprised of two other drugs: buprenorphine, another synthetic and addictive opioid purportedly designed to disrupt the brain’s dopamine receptor system and thereby curb craving for the illegal opioid on which the addicted person has become dependent; and naloxone, brand name narcan, which is an opioid antagonist and is increasingly employed nationwide, either nasally or intravenously, to offset opioid overdose and prevent death. The latter is a drug regarded as a life saver by emergency services personnel, and was used to revive Prince from a life-threatening fenatyl-induced stupor at the stopover his private plane made as he was heading home to Minneapolis after a concert in Atlanta. The use of these drugs is regarded as a step forward by many treatment professionals, since OASAS programs have historically followed the AA 12-step or drug-free treatment model and required that all patients cease using all psychoactive medications, including anti-depressants and neuroleptics, upon admission.
When methadone was initially introduced, it was presented not so much as a treatment option but as a tool of social control, whose objective was to put a clamp on the addicted person’s craving for her/his illegal drug of choice and so reduce the incidence of crimes committed by the addicted person to support her/his habit. I had friends in the 1970’s who lived in New York’s East Village, then a poor neighborhood ravaged by drugs, who always carried a few dollars in their jeans, particularly late at night, to give to anyone who stopped them and demanded money. They referred to the small change in their pockets as “mugging money.” Interestingly, research later conducted revealed no statistically significant effect for methadone maintenance in reducing crime, only for the suppression of an addicted person’s use of heroin. The latter, i.e., suppression of use, is reportedly enhanced when methadone is combined with traditional individual psychotherapies, particularly cognitive behavioral therapy. Finally, methadone is far from risk-free. In 2011, methadone poisoning or overdose accounted for over 4,000 or 26% of all deaths from opioid overdose, mainly from methadone sold on the streets.
Little is yet known about the long-term outcomes associated with suboxone, save for anecdotal reports from patients and professionals that it does reduce
craving. This presumed outcome puts “craving” front and center as key to understanding the nature and causes of addiction. It supports the popular notion that persons who become opioid dependent are those whose long term use of an opioid has altered their brains’ dopaminergic receptors, i.e., the brain’s pleasure center, to the point where their craving for the illegal opioid never ceases. Like most assertions regarding the centrality of brain functions in determining behavior, to the exclusion of environmental influences, there are no long-term controlled studies to substantiate that which seems to make intuitive sense. Similarly, most Americans continue to give credence to the belief that persons who become addicts suffer from character or moral defects, particularly if those persons are black or Latino. It is certainly easier to believe that black Americans have fundamental character deficiencies and come from pathological families after the assertions made in the Moynihan Report have gained unassailable credibility since its publication. Who can forget the scene in The Godfather, Part I (1972) when one of the Mafia dons gives his OK to sell heroin to blacks since “they’re all animals”? And what about the strength of moral character of persons, black or white, who willingly exchange one addiction for another? Interestingly, both drugs, methadone and suboxone, including its component drugs, buprenorphine and naloxone (narcan), are products of America’s Big Pharma, perhaps explaining their appeal to government funding agencies and the American treatment establishment despite their equivocal or uncertain outcomes.
Will white Americans, unlike black Americans, escape moralistic judgments? Once again, little mention is made of the structural changes in American society that appear to be a root cause of many Americans’ opioid addictions. Cuomo’s recommendations designed to combat opioids do make passing reference to employment and job training services, but indicate little awareness of the difficulty facing those in recovery in finding jobs and the consequent need to create them and the job training that will actually teach pertinent skills. In short, the key interventions recommended by Cuomo’s Heroin & Opioid Task Force are all medicalized and require the continuation of the addicted person’s addiction for an indefinite and possibly prolonged period of time. Will addicted Americans, white and black, be designated as superfluous to the American economy and consigned to a future as permanently disabled individuals living on Federal disability payments? Such has been the fate of many Americans unfortunate enough to have been designated as seriously mentally ill.
Fortunately, some folks, professionals and persons who have been addicted, have begun thinking outside the box. Often the first question they ask is
why those seeking help with their opioid addiction must trade one opioid addiction for another, i.e., methadone or suboxone. The rationale invariably offered is two-fold, both related to the unceasing “craving” addicted persons are presumed to have for the class of drugs to which they first became addicted. First, without a substitute opioid, the addicted person would continue using his or her drug of choice and run the risk of overdose and death; which contention appears to be supported by the high relapse rate, as high as 80%, for those who participate in drug-free treatment programs. Accordingly, an opioid delivered under the supervision of a physician systematically, i.e. same dose at the same time or times day in and day out, is necessary to reduce those risks as well as the risk of overdose.
Let’s consider the latter argument first. It’s hard to argue with the life-saving potential of methadone or suboxone when provided under medical supervision, which could well be essential before and during the first days of a person’s sobriety; but I regard it as unconscionable that treatment providers believe and communicate to their patients that they might be taking suboxone or methadone for a long time, perhaps a lifetime. Or, once an addict always an addict. Ironically, Maia Szalavitz, author ofUnbroken Brain (2016), which I’ll discuss at some length below, reports that as many as one-third of all methadone providers fail to provide their patients with doses adequate to achieve successful detox, neglecting to individualize their patients’ treatment. She recounts that, during her first methadone detox, her provider started her on half the dose necessary and titrated it down so quickly that she found herself increasing her heroin use on her own to relieve her withdrawal symptoms. Her methadone provider explained that the relatively modest length of her heroin addiction warranted the lower dose and shorter detox.
Suboxone is not without its critics. To cite just one example, Mark Mitchell, the police chief of Lebanon, Virginia, questioned, in a Times article (NY Times, May 29, 2016) the modus operandi of his town’s suboxone clinics: “I know people suboxone has helped , but unfortunately a lot of the clinics are not forthright in trying to taper people off.” The Times reporter concluded that “for some clinics, losing customers means jeopardizing profits,” a charge often leveled at methadone clinics. One of the three clinics in the town was shut down for poor record-keeping and excessive prescribing. Chief Mitchell goes on to ask, “for a town of 3,000 people to have three clinics? That’s absurd.” Some enterprising patients have learned to separate buprenorphine, or the opioid half of suboxone, from the naltrexone, or opioid antagonist part, dilute the former in water and inject it, creating a suboxone black market in the process. Oh, capitalism! Accordingly, Judge Jack Hurley, who chairs the operations committee for Virginia’s statewide drug court advisory committee, allows suboxone to be prescribed for only those applicants screened by the court’s psychiatrist. Which effectively limits the number of persons prescribed suboxone, as the court intends. To quote The Times, “In a region where suboxone seems to have replaced coal as the economic driver, 80 to 90 percent of all crimes in Russell County are drug-related, most involving black-market suboxone …” In sum, the MAT drugs may be effective and even essential for an addicted person’s recovery and survival, but they must be administered in a manner that is respectful of the person and her/his right to fully informed consent if the addicted person’s cooperation is to be secured.
During my own 40 years+ experience in the public mental health system, I witnessed the same indifferent treatment approach with virtually all persons who are presumed to have a serious mental illness and are given a pejorative or socially-damning diagnosis, usually schizophrenia. They are invariably prescribed powerful psychoactive drugs, usually a neuroleptic like zyprexa, seroquel, or risperdal, and are advised by their treating psychiatrists that full compliance with their prescribed medications is essential to their well-being. The price of non-compliance is a return of the psychotic symptoms that got them into a psysch hospital and earned them pariah status with family and friends. Folks caught up in the mental health system are rarely if ever told that the meds they’re prescribed scramble their brain chemistry and are addictive, and that non-compliance doesn’t result in a resumption of psychotic symptoms but rather in symptoms of withdrawal. Bob Whitaker, in Mad in America: Anatomy of an Epidemic (2002) and in all his subsequent books, describes this phenomenon in depth. Long-term compliance with neuroleptics is known to cause metabolic syndrome – diabetes, heart disease, impaired kidney and liver function – and reduce life expectancy by up to 25 years. The individuals prescribed these meds are never told of those risks. No psychiatric treatment program and only the rare methadone treatment program holds out as a treatment goal for their patents the attainment of a drug-free life. Only very knowledgeable and determined individuals, assisted by the few empathic and progressive drug counselors, physicians and psychiatrists, pursue and attain these goals while in treatment. Most of their comrades are more likely to stop taking their meds and to drop out of treatment, with many never returning.
Rarely do drug treatment programs set as a priority the teaching of addiction management or coping skills that would lessen their reliance on medications and promote their pursuit of discontinuing all medications. I’m referring to yoga, exercise and the skills of emotion regulation taught in Dialectical Behavior Therapy, which include meditation mindfulness and distress tolerance and interpersonal effectiveness. As I indicate below, the latter, which promotes the capacity of an addicted person to make decisions that support one’s sobriety and one’s ability to connect with others, are consonant with Ms. Szalavitz’s theory of addiction as a developmental and learning disorder. Unfortunately, and the complaint of many private practitioners seeking to introduce these skills to their patients, neither commercial insurance nor Medicaid or Medicare provide coverage for them. More significantly, drug treatment programs never offer explanations as to why their patients became addicted in the first place beyond the habitual craving theory. Perhaps the new opioid treatment programs being established by the state, despite their reliance on methadone and suboxone, will be driven by a more patient-centered philosophy.
VI – Outside the Box:
A Developmental Learning Disorder: Again, folks other than medical providers have begun to think outside the box. The afore-mentioned Ms. Szalavitz, a journalist and a person who has overcome heroin and cocaine addictions, and who, as a child, suffered from what she describes as an autism spectrum disorder, argues in her new book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction (2016), that persons who become addicted – to drugs, gambling, sex, etc., — do not have addictive personality disorders, do not have disordered brains, but are primarily suffering from developmental learning disorders. How else to explain the vulnerability of younger people, those in their teens and twenties, to addictive behavior and the ability of the majority of them to simply stop the behavior without medical intervention as they grow older and mature.
As Szalavitz explains, addiction is best understood as a learning and developmental disorder for the following specific reasons:
- the behavior that follows from addiction has psychological purposes: emotional protection and social comfort;
- it is a coping strategy that becomes maladaptive when the behavior persists in the face of negative consequences;
- specific learning pathways in the brain become engaged to make the addictive behavior nearly automatic and compulsive;
- addictive behavior doesn’t stop when it is no longer adaptive;
- ultimately, overlearning makes addictive behavior resistant to change.
She reminds us that her understanding of addiction from a developmental perspective is not new but has been studied and known by addiction researchers and scientists for years. What has been ignored are the implications of such an understanding. Specifically, it doesn’t fit into either of the two historical models for conceptualizing addiction: the moral or characterological model, which is highly stigmatizing and usually reserved for individuals and groups viewed as defective or depraved, usually poor persons, persons of color and persons considered mentally ill; and the medical model, or addiction as a disease model, erroneously regarded as normalizing and as de-stigmatizing the addicted person’s behavior. Unfortunately, it’s ultimately indefensible since addiction’s symptoms are behavioral and “no unique neurological or genetic pathology has [yet] been identified” as causative (Szalavitz, 2016). In short, there is no scientific evidence that addiction is an illness. If anything,addiction as learning disorder resolves this dialectic of moral vs. medical by discarding both models in favor of a developmental model, which sees addiction not as a choice but as profoundly affected by cultural factors and the addicted person’s own life experiences, both of which can impair effective decision-making. Implicit in this model is the understanding that free will in the addicted individual does exist, that decision-making varies from person to person and situation to situation, and that one continues to have control over one’s behavior but less than a non-addicted person. Finally, addictive behavior is more likely to appear in adolescents and young adult at a time when the brain is beginning to change and to prepare for adult sexuality, adult responsibilities and the development of commensurate coping strategies (Szalavitz, 2016).
As regards treatment, Szalavitz favors a harm reduction approach, more about which below, and the need for strong social supports, similar to that sometimes found in the rare 12-step groups that are non-judgmental, to enable persons in recovery to maintain their sobriety and fashion a satisfying, even happy, life.
Social Alienation: If you live a happy life, believe yourself to be a good person living a purposeful life and have those beliefs validated by others whom you trust; and if you have a strong network of family and friends on whom you can count in times of trouble, you will not become addicted to drugs. Johann Hari, contends in Chasing the Scream: The First and Last Days of the War on Drugs (2015), that “It isn’t the drug that causes the harmful behavior—it’s the environment. Addiction isn’t a disease. Addiction is an adaptation. It’s not you—it’s the cage you live in.”
A notion not too far removed from Maia Szalavitz’s learning disorder theory; but here, Hari starts not from his own personal experience with drugs but with experiments with rats exposed to heroin or cocaine. In the early 1980’s, Partnership for a Drug-free America circulated an ad advancing the “craving” theory of addiction. The ad depicted a rat in a cage with two water spigots, one laced with cocaine, the other with only water. Time and again, the rat chose the cocaine water and drank from that spigot incessantly until it died. The narration accompanying the short video intoned, “Only one drug is so addictive, nine out of ten laboratory rats will use it. And use it. Until dead. It’s called cocaine. And it can do the same thing to you.” A good dose of fear, which appeared to have little impact on the general public.
About the same time, Bruce Alexander, a professor of social psychology in Vancouver, conducted a controlled study, again using lab rats, but with two significant twists. First, he housed the rats in a setting he called Rat City – a cage replete with everything a rat might need to live a good rat life, equipped, as in the Partnership experiment, with two drinking spigots, one just water, the other containing cocaine mixed into the water. Next, he put one rat alone into one Rat City and, in another, several rats. The solitary rat replicated the behavior of the Partnership rat, drinking the cocaine water incessantly until it died. In the second cage, all the rats tested both spigots, but soon ignored the cocaine spigot and drank only the uncontaminated water. As Hari describes it, Bruce concluded that “an isolated rat will almost always become a junkie. A rat with a good life almost never will, no matter how many drugs you make available to him.” Again, “It’s not you—it’s the cage you live in.”
When it comes to human beings, Hari learned, after speaking to the researchers, treatment providers, government officials and ordinary people he met during thousands of miles of travel, understanding addiction is a bit more complicated. Yet, it still remains directly connected to addicted persons’ life experiences and the environments in which they find themselves. To list some of the quotations from his book that have become popularized aphorisms …
“ … for each traumatic event that happened to a child, they were two to four times more likely to grow up to be an addicted adult.
… child abuse is as likely to cause drug addiction as obesity is to cause heart disease…”
He has little confidence in America’s addiction treatment system, which he views as punitive — and, in my own professional experience, culturally quite similar to our penal and mental health systems …
“ … punishment — shaming a person, caging them, making them unemployable — traps them in addiction. Taking that money and spending it instead on helping them to get jobs and homes and decent lives makes it possible for many of them to stop… ”
And … “Wouldn’t it be better to spend our money on rescuing kids before they become addicts than on jailing them after we have failed?”
As the subtitle of his book suggests, The First and Last Days of the War on Drugs, he is opposed to the War on Drugs and finds the amount of resources devoted to it and to the criminalization of drugs now branded illegal as wasteful, fundamentally discriminatory and racist…
“ … More than 50 percent of Americans have breached the drug laws. Where a law is that widely broken, you can’t possibly enforce it against every lawbreaker. The legal system would collapse under the weight of it. So you go after the people who are least able to resist, to argue back, to appeal—the poorest and most disliked groups. In the United States, they are black and Hispanic people, with a smattering of poor whites… ”
And … “When alcohol was legalized again in 1933, the involvement of gangsters and murderers and killing in the alcohol trade virtually ended. Peace was restored to the streets of Chicago. The murder rate fell dramatically, and it didn’t rise so high again until drug prohibition was intensified in the 1970s and ’80s.”
Finally, to return to the theme he cites throughout …
“The opposite of addiction isn’t sobriety. It’s connection. It’s all I can offer. It’s all that will help [you] in the end. If you are alone, you cannot escape addiction. If you are loved, you have a chance. For a hundred years we have been singing war songs about addicts. All along, we should have been singing love songs to them.”
That last line – “love songs to them” – is probably hard to fathom, particularly when we’ve been fed such lurid pictures and stories of persons addicted by the media and from friends and acquaintances. Perhaps many of us have had sad and bitter experiences with family members or others close to us. The message of the War on Drugs is to shun persons addicted who won’t change their ways, send or put them away, declare them irrelevant to us, so as to relieve our own pain and discomfort. In his post on The Power of Humanity, “The Likely Cause of Addiction Has Been Discovered and It Isn’t What You Think” (Jan. 25, 2016), Hari references Bruce Clark, creator of the Rat Park, who had told him that to talk about individual recovery from addiction is to go down the path that reinforces the addicted person’s isolation and, accordingly, her/his addiction. It is also to fail to recognize and accept that it’s our collective social recovery that’s at issue here – “how we all recover, together, from the sickness of isolation that is sinking on is like a thick fog.
That’s essentially the message of Sebastian Junger’s new book, Tribe: On Homecoming and Belonging (2016). Junger is not a researcher or treatment provider. He’s a journalist and the Academy award-winning co-producer of Restrepo (2010), a documentary that depicts the experiences of a group of soldiers posted to a remote mountain area in Afghanistan and explores the intense bonding that occurs between them as they seek to support one another and survive in a thoroughly hostile environment. Junger uses Restrepo as his starting point and describes the sense of loss that the soldiers who fought there experienced once they returned home: they came home changed by their war; felt themselves unwelcome and unwanted in a world they found strange and unknowable; found no one willing to extend a welcome or a helping hand. Offered only the innocuous “Thank you for your service” by strangers, they found themselves alone, unable to sustain relationships with wives and family and friends, unable to find gainful employment, without their tribe and unable to find or make or join a new one. Remember, 22 veterans of all our wars dating from Viet Nam kill themselves daily; 1 Iraq or Afghanistan vet kills herself or himself daily. According to a National Institute of Drug Abuse study released in 2013, 30% of those suicides were substance abuse-related, principally involving alcohol and, to a lesser extent, prescribed opioid analgesics. The report also estimated that 11% of all returning Iraq and Afghanistan veterans are misusing or abusing intoxicants, highly co-morbid with depression and post-combat duty trauma. (The latter is officially and popularly known as post-traumatic stress disorder, a descriptive term I regard as problematic.)
Junger’s message is that many if not most Americans find themselves in the same fix. Parallel to the surge in opioid abuse that I referenced above, data show a dramatic surge in suicides by middle aged white American men and women largely attributable to the loss of their workplaces, or their tribes, after they were laid off, and of family and friends after they grew despondent and isolated. From 1999 to 2010, the suicide rate among white Americans aged 35-64 increased by 28% and for those aged 55-64 by 40%. Ironically, the suicide rate for black Americans is much lower than that for whites; the rate of opioid addiction and overdose deaths is substantially lower; and life expectancy for black Americans has risen.
Junger’s anti-dote for those alone and isolated is simple and direct — connectedness, very much like the two authors whose books I just described, an indication to me that many folks are arriving at the same conclusion at the same time. Family and friends must reach out to those they’ve lost touch with and who they know or suspect might be troubled. Churches and community-based service organizations must do the same for absent members and seek and welcome new ones. Social welfare organizations cannot let any of their clients go missing. The VA and the Federal government must help our veterans and we must insist on it. The only persons addicted to drugs that I know personally who gained and have maintained their sobriety were surrounded by family and friends who never abandoned them no matter how odious their behavior, who never stopped singing songs of love and acceptance.
I’ll leave the final word on American anomie or alienation and the marginalization of returned vets to Matthew Crawford, who wrote an impassioned review of Junger’s book, entitled “No Place for Warriors,” in the May 29, 2016, issue of The NY Times Book Review:
“ … A society with less false consciousness about these matters would reintegrate soldiers returning from battle by putting them to work (emphasis mine). Doing so would tacitly affirm the continuity in their contribution to the common good. Instead, Junger points out, such is the misalignment of our culture and military service that someone who has fought is regarded as fundamentally damaged(emphasis mine). The way we receive combat veterans returning home is by treating them as victims and putting them on disability (emphasis mine). Victim status confers the only form of moral redemption we know, and we offer this freely – on condition that a veteran submit to therapy. If the therapy is successful, he will come to accept the obsolescence of precisely those traits that made him a good fighter. With the help of a little medication, they will wither, like a limb that has been tied off to prevent an infection from spreading. Only then can the veteran hope to claim his prize, which is to become a well-adjusted consumer and cog in the corporate economy… ” (emphasis mine).
Written By Dr. Jack Carney
Originally published at: http://www.paddlingupstream.org/america-addiction-a-primer-from-the-war-on-drugs-to-the-opioid-epidemic/
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