We highly commend the reporter Jason Cherkis for his extraordinary in-depth and comprehensive article focusing on heroin and opioid overdose deaths primarily in Kentucky, which was posted on January 28, 2015. It is an exemplary job of reporting that has brought national attention to this crisis, and stimulated changes in federal and some state policies that will save lives.
And what he reports without labeling it as such is an epidemic of suffering. Suffering is the underlying issue. We've known for many decades that the abuse of substances and activities, whether alcohol, opioids or non‑ingestibles like gambling and sex can relieve suffering, if only temporarily. Heroin and opioids are the most effective pain killers -- whether psychological or physical.
If we can reduce human suffering, we can reduce addiction.
We have known for decades that addiction is almost always co-morbid with underlying mental illnesses, such as anxiety disorder, ADD, PTSD. If the underlying causes and conditions of addiction are diagnosed properly and treated effectively, we can manage addiction.
One of the most important points that Jason reports is that courts often mandate people to attend 12-step programs, usually Alcohol Anonymous (AA) or Narcotics Anonymous (NA). Although this has been challenged successfully in many jurisdictions as a violation of the Establishment Clause of the First Amendment, this practice continues.
Narcotics Anonymous (NA) is the program most experienced in helping people seeking freedom from opioids. NA often does not have meetings in locales close to those who seek help; often NA doesn't have as many meetings as the original 12-step program, Alcoholics Anonymous (AA). This results in AA becoming the default 12 program for heroin and opioid dependent people struggling with addiction. These 12-step programs don't work for everyone because the resources are limited. Unfortunately, this circumstance might not yield the anticipated results.
Long ago, people discovered that creating a warm human community to support one another when facing cancer, kidney dialysis, heart transplants -- whatever the common condition is -- saves lives. But the important factor is that it has to be apples-to-apples and oranges-to-oranges. Meaning, if a patient undergoing treatment for pancreatic cancer is put in a support group for irritable bowel syndrome sufferers, the identification and similarity of experience is less than ideal. So sitting someone with opioid dependence in a room full of people who struggle with alcohol dependence is often not helpful and might not be healthy for anyone.
Twelve-step programs do not work for everyone, actually fewer than most would think if the anecdotal reports are correct. The fact is we do not know -- 12-step programs have no accurate data about their success rates; we should not expect a fellowship, based on anonymity, to collect, much less disclose, this kind of information.
In fact, it's not just the judges who are ill-equipped to remedy addiction, but too often doctors are undereducated about addiction. Most medical schools today do not provide in-depth courses focusing on addiction even though doctors are often on the frontline witnessing the results of addiction; they are first responders and often are in a unique position to intervene.
Until we discover remedies for addiction that allow more people to recover and have productive lives, the courts need to be very careful about ensuring that they don't contaminate self-help groups that already are successful for some with a particular expression of addiction, like alcohol, heroin and opioids or gambling.
We believe strongly that every state and legal system should adopt the drug court solution. Further, we suggest a necessary addition to the courts: a physician with an expertise in addiction should be available to the court either in person or via telephony; just as Drug Courts often try to provide experienced medical guidance for the court so too should all courts. We also suggest that the field of addiction needs to provide more evidence-based solutions for the courts.
We also need to answer the questions that Jason so powerfully posed: Why are teenagers dying disproportionately to their numbers, why are veterans committing suicide at an epidemic rate, and why are the elderly using more painkillers? Tragically, it seems that the answer is the level of suffering among teenagers, veterans, and the elderly is far too high. Suffering of the elderly is probably one of the greatest silent epidemics in America today.
Knowing the answer to suffering is not enough. We need to learn more about addiction so we can design effective treatments that result in long-term recovery. We must decide that the cost of addiction in lives and money is not acceptable to our society in the 21st century.
Again, we highly commend Jason for his extraordinary article, and thank him for the lives he has saved.
Howard J. Shaffer, Ph.D., Morris E. Chafetz Associate Professor of Psychiatry in the Field of Behavioral Sciences, Harvard Medical School & Director of Division on Addiction, Cambridge Health Alliance.
Peter V. Emerson, Associate-Public Policy, Division on Addiction, & Chairman of College Task Force on College Gambling and Alcohol Polices
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