Why Opiate Addiction and Dependency Has Us All Stumped
If you’re an opiate addict (or physically dependent on opiates) today, nobody is quite sure what to do with you. You buck the trend, you don’t quite fit into any of the “pre-defined” categories of substance abuse and your dependency doesn’t progress in a linear and predictable fashion. You’re different and that makes you very difficult to treat…or rather, it makes “The Opiate Addict” in general very difficult to treat. Most of the drug-rehabilitation community has no clue how to treat your dependency the way that you need to be treated and it’s driving everybody nuts…especially you. Opiate detox and the resultant withdrawal symptoms are at the root of the problem yet the syndrome receives far less attention than it should.
Let me explain. Have you heard the term “evidence-based medicine” before? Well, I could write a long, nauseatingly boring essay on the central tenets of evidence-based medicine but I’ll spare you and just give you the basics. As a result of numerous factors including, managed care, litigation, legislation and a plethora of other issues that don’t have to do with you, doctors have been “forced” to adopt treatment protocols as opposed to being able to treat you based on their intuition and what their experience has taught them.
For instance, if you go into your doctor with a variety of symptoms, your doctor will most likely diagnose and treat you based on what the “data” has shown to be clinically effective as opposed to what his or her experience has taught them. The “data” that I’m talking about includes, clinical trials, abstracts, medical publications, clinical advisory panels etc. etc. The data is the “evidence” in evidence-based medicine. Most of the time, these clinical protocols work…but sometimes you could be the odd man out. It’s all about risk-avoidance and not necessarily about good medicine. Again, I don’t necessarily fault the doctors for protecting themselves against malpractice lawsuits; in their defense they are simply following clinical protocols because that provides you with the best chance of getting your treatment paid for by your insurance plan. If the insurance company determines that your doctor is not practicing “evidence-based medicine” they are not going to pay for it.
The same clinical protocols are also applied to the treatment of addiction and dependency. However, there’s a bit of a problem. Opiate addicts are a unique breed and do not follow the same “rules” that an alcoholic might. By the numbers, alcoholics follow a pretty reliable pattern of behavior therefore, the treatment follows the same reliable pattern. “John Doe” begins drinking, John drinks more, John blacks out occasionally, John crashes car and eventually, John either dies of liver failure or by accident unless he gets help. “Help” can come in the form of jail or hopefully treatment. Regardless of where, how or why John begins his alcoholism, John usually ends up in the same place as other alcoholics…”the bottom.”
As a result of John’s inexorable slide towards “the bottom,” it’s much easier for rehab and addiction centers to determine what type of treatment John is going to need when he is admitted. In fact, his treatment is predetermined. The “data” says that John will need 30-90 days in-patient treatment in a rehab facility, complete sobriety for the rest of his life and some type of cognitive or psycho-therapy to prevent relapse. By and large, most of the patients that enter rehab receive the same treatment protocol…evidence-based treatment. So what makes opiate addicts so tough?
Opiate dependency has a much wider spectrum of severity relative to other addictive substances. Some could simply be physically dependent as a result of being prescribed meds after knee surgery. If they take opiate pain medications as prescribed for more than a month, they can easily become physically dependent but not addicted. On the other end of the spectrum, you could have a heroin addict who shoots up 10 times a day and lives under a bridge. At this moment, both have only one treatment option for detox and the painful withdrawal symptoms that will surely manifest themselves when/if either one of them stops taking opiates.
The person who unwittingly became physically dependent on prescribed medications has the same treatment options as the addict shooting heroin. Both need -and deserve- care, but it is safe to assume that both need different treatment. This is what is commonly referred to as a “gap in care.”
That’s where I believe the addiction and rehabilitation community finds itself now when it comes to opiate addiction and dependency. All of these people could be taking the same drug yet have profoundly different levels of dependency and therefore completely different therapeutic and clinical needs. The simple answer would be to just go ahead and throw out the evidence based medicine that is currently employed for other addictions. But that’s not what has happened and it’s not that simple. Most treatment centers and detox facilities treat every opiate addict the same way because they cling to the notion that evidence-based treatment is still the best way to approach opiate addiction and dependency. Without clinical protocols, the whole system breaks down. In fact, most opiate addiction treatment facilities don’t even HAVE an opiate dependency treatment protocol; they base their treatment on alcoholism! This is not good medicine and it’s not consistent with reality. People dependent on opiates deserve better and they need something tailored to their specific needs.
We live in a “12-step” world where there are no grey areas; either you are addicted or you are not. With respect to opiates, we must accept the fact that there is a sliding scale of physical and psychological dependency. Many people who are now dependent on opiates (physical and/or psychological) had an injury or an accident and began taking opiate medications as directed. Tolerance for opiate pain meds increases rapidly and eventually the medications no longer adequately treat the pain. As tolerance rises, patients take more to keep the pain at bay…many could care less about the “high”. Then there are those who do have addictive personalities and all they care about is the high. Are you telling me that the construction worker that has been taking Vicodin for 2 years due to a back injury and is now physically dependent on his medications would require the same treatment as a person who snorts Oxycodone? Absolutely not.
Again, the key difference between opiate addiction and something like meth addiction is that the VAST majority of those people who are addicted or physically dependent to opiates today are began using prescription drugs for legitimate reasons and took them as prescribed. Nobody begins using Meth for a toothache. So you have millions upon millions of people out there who truly want to stop taking opiates but see no viable or appropriate options for them within the addiction/rehab community. They need help with withdrawal! I read news article after news article talking about the rising tide of opiate addiction and how alarming it is that these addicts aren’t getting help when all of the rehab centers stand arms outstretched waiting to heal them. Why aren’t these people checking into their nearest rehab? Is it denial? For most of the people dependent on opiates, denial has nothing to do with it. Most of these folks are scared of the withdrawal, can’t afford to pay for treatment and certainly cannot take 30-90 days off from work for in-patient rehab. I’ll go even farther out on the limb and suggest that most don’t need this acute level of care to begin with.
Note to Administrators of recovery centers: it’s not denial that is withholding the run-of-the-mill opiate dependent person from your $40,000, 30-day inpatient treatment program; it’s the fact that your “product” is not what they want or need. For every person who is an opiate addict in denial, I’ll show you ten that are aching to be rid of their pills. I’ll show you ten people that would give their right arm to get off these pills if they could find a way to do so comfortably without having to resort to some outrageously expensive, slightly-tweaked alcoholism treatment just to get through the withdrawal. Most of the people that I talk to on a daily basis are more than willing to accept their predicament and to accept that they need some help. However, they need the right kind of help and for the most part, the addiction and recovery community is not offering or providing it. So… most people just keep taking their pills bracing themselves for the other shoe to drop. And if they have to keep waiting, how much are we contributing to the problem by not intervening before people really get hooked? If you want evidence just take a look at the resurgence of heroin addiction; pills are the definitive gateway drug. I believe that the solution for early intervention is obvious; if we can provide reasonable, discrete access to detox and withdrawal treatment we can significantly stem the tide of opiate addiction and overdose deaths now plaguing the U.S.
There’s evidence that a few rehab and detox centers are willing to accept opiate addiction and dependency as a truly unique pathology. Intensive outpatient detox and recovery programs are a good start. These types of protocols are far more appropriate and accessible for the many different types of people who suffer from opiate addiction and dependency. We must be willing to accept the fact that opiate detox is the primary deterrent for many who want to stop but can’t. For many, opiate withdrawal is simply too painful and too debilitating to endure; especially with work and family matters that cannot be neglected. If we can help people detox comfortably, it will be far easier for people dependent on opiates to transition from a life that once revolved around pills to one that revolves around things that matter.
Opiate addiction is a BIG deal these days for a good reason; it’s the fastest growing substance abuse category…by far. I can only hope that the clinical community begins to truly appreciate how different opiate dependency is from other types of substance abuse and make meaningful, progressive changes to their treatment protocols. Otherwise, those of you who are desperate to get off pain killers comfortably and get the treatment you need might be in for a long wait.
Updated: March 2016