Denial can be deadly. When teenagers aren't educated about sex because adults insist that it's not happening in schools, the outcomes are unplanned pregnancy and sexually transmitted diseases. When we don't teach kids about designated drivers because we deny they would drink underage, the next casualty of drunk driving may be our own. This denial is especially apparent when it comes to drugs and addiction. We know that drug overdose is now the leading cause of accidental death in the United States. We know that people are at the greatest risk for overdose if they relapse after a period of abstinence - such as right after leaving a drug detox, treatment center, or methadone clinic. We also know that most people do relapse, usually many times, during their recovery period. Common sense would dictate that if we value human lives, we should provide people with the education and tools to prevent an overdose, which kills many before they get a chance to recover. And yet, not only do few detox facilities, treatment centers, and methadone clinics in the U.S. provide overdose education, most are outright hostile to the idea. How has this relapse denial persisted within the treatment system? And more importantly, how can we change it before more lives are lost?
For Dr. Andrew Kolodny, Chief Medical Officer of the Phoenix House Foundation treatment centers, the explanation lies in history.
"Originally, treatment programs were built on long-term models with people living in residential programs up to a year at a time," he explains. "The expectation was that after completing treatment, clients would be abstinent from drugs for the rest of their lives, so there was no need for overdose prevention education. But in the current climate, insurance companies won't pay for long-term treatment, so people are detoxed for 30 days or less and then released. Not only does this treatment model not help people with addiction, it sets them up for an overdose."
Because drug tolerance drops during periods of detox and recovery, relapse is especially dangerous. If the person returns to using the same amount of drugs he was using before, the chances of a potentially fatal overdose increase dramatically, particularly if opioids such as prescription pain relievers, heroin or methadone are involved. According to a study in the New England Journal of Medicine, inmates who detoxed in prison are 129 times more likely to die from an overdose than the general population during the first two weeks after release.
Given the inadequate levels of treatment for addiction, high incidence of relapse, and widespread availability of opioid prescriptions, one would think that the treatment system would devote a fair amount of resources to educating clients about these risks. Not so. Instead, the majority of substance abuse programs and methadone clinics resist allowing overdose prevention education into their facilities. Most are also against programs such as naloxone distribution, which provides people at risk for overdose with naloxone, a safe, effective medication used to reverse opioid overdose.
Much of the resistance to overdose education lies in the fact that most treatment programs are based on an abstinence-only model. Because providing overdose prevention education and/or naloxone suggests that relapse is a possibility, many facilities exclude overdose education over concerns that it clashes with the abstinence message. But to many treatment providers, such thinking not only goes against empirical evidence about the behavior of people who struggle with addiction, it has also cost countless lives.
"It is unrealistic to expect someone to come into treatment one time and be cured," says Stephanie Almeida, founder of Full Circle Recovery Center, a harm reduction-based treatment center in Franklin, North Carolina. "The norm is for people to engage the system multiple times."
So why does relapse denial persist? Dr. Kolodny says that inertia and resistance to change are largely responsible for the reluctance of the traditional treatment system to incorporate overdose prevention. "Getting people to do things differently is always a challenge," he says.
For Pam Lynch, Co-Director of the WhoSoEver Collaborative in Michigan a nonprofit that works to reform the way society treats addiction and mental health, the reasons are more sinister.
"Our current system has done a largely ineffective job of handling the disease of addiction...many [state-funded treatment centers] are essentially subsidiaries of the criminal justice system," she says. "The treatment system needs an overhaul, in a big way. We cannot simultaneously punish and heal people living with this disease."
The causes of addiction are complex and layered, as are its solutions. It's clear from the alarming statistics on relapse and overdose death that the current treatment model is not working. Reform, however, is an enormous and daunting task. In the meantime, we should make every effort to keep people struggling with addiction alive until the broken treatment system can be fixed.
The good news is that overdose prevention education and naloxone programs are spreading all over the country. Getting treatment centers on board will be critical to success, and already a number of them are moving towards a model that includes such programs. With 125 recovery centers throughout the country, Phoenix House Foundation is in the process of equipping every residential program with naloxone in case relapse happens while a client is still in treatment. Under Dr. Kolodny's leadership, Phoenix House has launched a pilot program in their Rhode Island facility to teach overdose prevention education and instruct clients on where to get naloxone when they leave.
"We are moving away from the silly idea that everyone who leaves residential drug treatment will be abstinent for the rest of their lives," says Dr. Kolodny. "We educate them on how tolerance changes after a period of abstinence, the increased risk of relapse after release, the dangers of mixing different types of drugs, and how to respond when witnessing an overdose."
After the pilot program is tested and evaluated, it will be replicated in other facilities throughout the country. Dr. Kolodny says that state regulations that mandate overdose prevention in treatment centers are the most effective way of moving towards a model that allows for overdose prevention and naloxone distribution.
For Almeida, the whole treatment philosophy needs to change before centers will start to accept overdose prevention.
"I think it will take grassroots efforts from people affected by overdose deaths or people who have engaged in the treatment system and had poor outcomes," says Almeida. "With enough of their voices, we might see change."
Almeida's program at Full Circle Recovery Center provides overdose prevention training in-house and also distributes naloxone kits to clients with training on how to recognize and respond to opioid overdose. She receives the kits courtesy of the North Carolina Harm Reduction Coalition, whose naloxone distribution program distributed over 2500 kits between August 2013 and June 2014 and reported 95 successful overdose reversals during that time.
Drug overdose is currently the most urgent public health crisis in the United States. Advocates and people who have lost loved ones to a relapse should unite to urge detox programs, treatment centers and methadone clinics to provide overdose prevention education and naloxone to every client leaving their facility. Treatment centers are at the forefront of the fight against addiction and we need them on board if we hope to save lives. Even worse a tragedy than losing so many people to overdose is losing them just as they seek help. It doesn't need to happen. And it won't if we stand up and do something about it.