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Americans are Puritans when it comes to dealing with drug addiction. They get their spines all straight and spout righteous claims like "just say no" or "why coddle an addict?" How much more proof do we need before the rational presides over irrational? How long before those that promote punishment realize this is a disease that needs treatment? Before those with addictions get what we know can help?
Stuart was not what you would expect in an addict. He was a white, suburban, middle class teenager who played sports, had an intact family, friends and good grades. After college, he began his own business and was soon making a six figure annual income. But the process of addiction had begun: there is an expression, man takes the drug, drug takes the drug, drug takes the man. In college it was the club scene, with alcohol, pot and club drugs like ecstasy and ketamine. But they lost their appeal. Then there was the "game changer" - that moment I have heard many a time from people who become drug dependent - when he tried Vicodin™ and Percodan™. Stuart described to me that when the opiate in the pill started to course through his blood to his brain that he felt a sense of well-being, of "... being complete ... this is how life should feel ... something was missing and it wasn't anymore." Man takes the drug.
It was not long before Stuart was on to OxyContin™ as he began to chase the feeling that got him hooked in the first place. He needed this stronger pill -- and lots more of them -- even grinding them up and sniffing them to achieve the same effect because his body was becoming tolerant of the opiates. Drug takes the drug.
When he didn't feed his habit he began to experience withdrawal -- another consequence of addictive substances when not having a drug provokes a lot of really uncomfortable feelings in the body and mind. He was spending $100/day on pills and his business suffered the same neglect as just about everything else in his life. For Stuart it was then only another small step to heroin -- first sniffing then shooting. That doubled the cost to $200/day and his life collapsed about him. The drug takes the man.
Stuart's mother told me she first went through denial of his addiction, even though she saw the obvious signs of avoiding everyone, losing weight, being abrupt, wearing long sleeve shirts in hot weather. Then she said she blamed herself: she should have handled things at home differently. She covered up for Stuart, tried to pick up the pieces of his strewn life. But then she too discovered that denial and blame don't work. She started to attend Alanon meetings and ask herself how she needed to be different with Stuart for herself and for him. That worked.
This story has a good ending. Stuart now has marked over three years without any drugs, unless you count buprenorphine ("bupe") which he takes every day. He is back working, earning good money and rebuilding relationships that were battered by drug abuse. You too probably have never heard of buprenorphine, or its brand name Suboxone™. Burprenorphine is a prescribed medication that became available, with harsh limits on how it could be prescribed, in 2002 in the US. Yet it was the first truly novel (and safer) treatment for narcotic addiction -- for heroin as well as narcotic pain pills -- since methadone was introduced in the early 1960s. From a public health viewpoint, when bupe was introduced in Europe and Australia many years earlier it reduced overdose deaths dramatically (by over 80 percent in France). Three people, on average, were dying of narcotic overdoses in NYC every day in 2002. This seemed like a treatment that NYC needed and it was my job, as its mental health commissioner at the time, to set about trying to introduce bupe to the City.
Buprenorphine works differently and is distributed differently than methadone, or heroin. As a person takes more methadone (and heroin and narcotic pain pills), their breathing is increasingly slowed until eventually they stop altogether. This how death occurs in these types of overdoses. With bupe, there is a "ceiling" effect, so taking more does not get a person higher, nor does it slow the breathing. This means buprenorphine is far less likely to be abused, and to cause preventable fatalities.
It is also available in a very different way. Methadone is only distributed (for addiction) at "Methadone Maintenance Programs (MMPs)' where a person must go every day, give a urine sample to test for other drugs, and be observed by staff to swallow the usually red-pink colored liquid. MMPs often become crime zones in their communities as drugs and stolen goods are bartered in the blocks that surround the site. Bupe is picked up at a pharmacy with a doctor's prescription (which can be for up to a month). It tends not to produce the nodding that methadone does; with a clearer mind a person is more able to function and work.
Stuart was clear about bupe: "It is not a cure for drug addiction. It is a pill, a medication that allowed me to do the work of recovery." He mentioned that early on, when he relapsed (the rule, not the exception with drug addiction -- so be patient) he went to a respected Rehab Program that wanted him to stop the medication; they were old fashioned and thought that taking any kind of drug, even a prescription medication, was not the "right" way to do recovery (this is called the abstinent treatment model). He and his doctor protested, saying he would do better on it than off. Their prediction has proven true. Even (some) rehab programs have a thing against bupe. Stuart said:
Recovery takes dedication, you have to make it happen. I learned a lot from 12-step programs like AA from my psychiatrist, and from my family who have been so supportive -- even when I was trouble. I knew I had to get back to work, that work is part of recovery. I don't want to take this medication forever, but it's a lot better than being an addict.
The use of buprenorphine throughout the USA has been slow in its growth despite the most recent National Household Survey on Drug Abuse (NHSDA) estimating 2.9 million lifetime heroin users and over 600,000 who used this drug in the past year. Heroin use is growing in young people. And this is just heroin: estimates of narcotic pain pill abuse and dependence are higher and growing faster. Why has buprenorphine use been so limited when those who could benefit are so many?
First, doctors have not been prescribing it: Federal rules require that doctors must take an eight hour course and pass a test to be allowed to use it -- the only medication in this country with that requirement; and many doctors are biased against addiction, not wanting "addicts" in their offices, as if they weren't there already. Second, the methadone "industry," a nationwide largely for-profit group of providers, makes a lot more money from MMPs than they would from bupe. Their business interests are squarely contrary to the provision of buprenorphine, which in other countries is being used far more than methadone by a long shot. Third, there has been far too little public education and information, reflecting Puritan views that Americans don't promote addictive drugs, even if they are prescribed and work.
The consequence of not providing this treatment is that many people who could be helped are not. We are not only shunning people with the disease of addiction we not helping ourselves. Untreated narcotic addiction means crime to support habits, greater incidence of HIV/AIDS and hepatitis, and havoc in the lives of those affected, their families and their communities despite having a treatment that enables people, like Stuart, to work, rejoin their families and rebuild their lives. The National Household Survey alerts us to how many more people there are who may benefit from this sort of new treatment.
To find a physician or program that provides buprenorphine go to the National Institute on Mental Health agency site: http://buprenorphine.samhsa.gov/bwns_locator/
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Lloyd I Sederer, MD
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