Compounding the Heroin Epidemic
I don’t follow the mainstream media, especially local news, much anymore. Occasionally, however, a story that catches my attention will show up in my Facebook feed. Recently I’ve noticed more than a few stories about the “heroin epidemic” and articles knocking alternatives to heroin addiction like methadone- or suboxone-assisted treatment. Almost every time these articles are filled with misinformation or biased opinions that not only add to the stigma drug users and those of us in recovery already face, they can be downright dangerous.
Heroin use only garners attention when it reaches the suburbs. When people of color in large cities or poor white folks use heroin and other street drugs there’s no public health scare. When Johnny-football-hero gets strung out, suddenly it’s an epidemic. Even then, stories about heroin and how heroin it’s used, who’s buying and selling it, and the effectiveness of medication-assisted treatment (MAT) programs are teeming with misinformation, propaganda, and outright lies.
I was on methadone-assisted treatment for 3 years. Without a doubt methadone saved my life. I transitioned from methadone to suboxone about 18 months ago and, for the first time in my life, I feel like I’m able to live a normal life. MAT has allowed me to finally seek psychiatric care for the mental health issues I was self-medicating with heroin.
It’s telling that all journalists and politicians looking for attention paint heroin as an epidemic out of one side of their mouths, but then knock proven treatment methods out of the other. Methadone treatment is considered the gold standard for treating opiate dependence according to the NIH, CDC, SAMHSA, and a majority of doctors who specialize in addiction and psychiatry. What, then, is the purpose of spreading misinformation about methadone and suboxone and adding to the tremendous stigma drug users already face? If those treatment options weren’t available, users would almost certainly continue taking heroin or other street drugs — which creates a much greater social burden and a substantially increased risk of lethal overdose. MAT is not trading one addiction for another. I was physically dependent and addicted to heroin. I’m now physically dependent on suboxone, but I’m also much more healthy than I was during the 11 years I used heroin.
Methadone and suboxone, when used correctly, are extremely safe and effective. They allow those of us dependent on opiates to lead normal, healthy lives, something that’s impossible while trying to support a $100-200 (or more) daily habit. It’s extremely unlikely someone will overdose on methadone if they’re in a daily treatment program and don’t mix it with other drugs, like benzodiazepenes (xanax, valium, ativan, etc.). Methadone clinics test for these and other drugs and almost universally have a strict policy against clients using these benzos, even when they’re prescribed by a doctor. It is almost impossible to overdose on suboxone, even in combination with other drugs. All this information is available from SAMHSA in their TIP 40 and TIP 43 guidelines.
Everyone’s brain chemistry is different. Suboxone has worked wonders for me, but it doesn’t work well for some people (98% of MAT patients take methadone, compared to 2% for suboxone). Some people can be in MAT for a year before stopping and some will need to be on medication the rest of their lives (I’m in the latter group, and that’s OK). Methadone has a history of proven success dating back to the 1960s. Now that the medical and substance abuse treatment communities have recognized that 12-step and abstinence-only approaches are rarely effective, we’re being hit with a deluge of anti-methadone propaganda from journalists, politicians, and those a financial stake in outdated treatment programs. This, despite the fact that 12-step and abstinence-only programs have an abysmal rate of success and a high risk-to-reward ratio (especially when users relapse and have lost their tolerance after leaving those programs).
The Gold Standard for Heroin Treatment
In their book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Zachary Dodes, MD and Lance Dodes cite peer-reviewed studies that place the success rates for Narcotics Anonymous at 5-10%. By contrast, the California Society of Addiction Medicine reports a 60-90% success rate for methadone treatment. The fact that myths about the ineffectiveness of methadone treatment persist likely result from a combination of anti-methadone propaganda and a handful of methadone patients who abuse their medication.
Methadone patients who comply with their treatment protocol garner much less attention from the media or general public than those who abuse the system and cause problems. During my methadone treatment I noticed 3 or 4 fellow patients consistently loitering in the lobby or outside the clinic. Their behavior reflected poorly on the rest of us, who moved in and out of the clinic practically unnoticed. We took our medicine and went about our business, causing fewer problems (if any) than we did while using illegal street drugs. Likewise, those causing problems at the clinic would likely continue causing problems while using street drugs. The problem in this situation isn’t methadone or methadone patients; these issues could be easily resolved if clinics took a harder stance on patients who loiter and cause trouble — which many do.
The stigma against patients in methadone and suboxone treatment and propaganda that claims people in MAT programs are simply “trading one drug for another,” that the withdrawals are worse (they usually aren’t), or that overdose deaths from methadone are in any way comparable to those from heroin or prescription drugs creates a barrier to treatment that prevents at-risk people from seeking help — and that undeniably results in greater health problems and a greater risk of death for drug users.
According to the National Institute on Drug Abuse, a government agency that researches drug abuse and addiction, patients in MAT programs are:
- Less likely to use illicit street drugs like heroin
- Less likely to commit crimes
- Less likely to share needles and more likely to seek medical care for HIV or hepatitis C
- At much lower risk for suicide or lethal overdose
- More likely to maintain steady employment
Most of these benefits are ignored by those who wish to promote an abstinence-only agenda or seek to poke holes in methadone and suboxone treatments’ record of success. The 12-step and abstinence only approach not only have a lower rate of success (if success means any of the items listed above) they can, in some cases, prove dangerous or even lethal.
When someone who was dependent on opiates has been in a program long enough to lose their tolerance (usually a week or more), they’re at much greater risk of a fatal overdose if they relapse after leaving those programs. If they’ve been on methadone or suboxone and relapse, even though this might be considered a failure, they’ll still have a tolerance for opiates, placing them at a much lower risk of overdose.
Drug Courts and the Legal System Making Matters Worse
Support for methadone in the medical community is extremely strong and the drug treatment community is steadily becoming more open to methadone and suboxone treatment for opiate-dependent people. Unfortunately, the legal system seems stuck in the 1950s. In an effort to find alternatives to incarceration for drug users the US justice system has turned to drug courts.
These courts are designed to coerce active drug users into stopping drug use through a series of threats, including jail or prison. This method is effective for some people, especially those with more to lose. If a teenger or college student is caught with marijuana or unprescribed pain pills, their encounter with the legal system might be enough to scare them back into line. Drug courts and ill-suited, however, to handle people dependent on opiates or habitual users of other “hard” drugs like cocaine and methamphetamine. Drug users who are homeless or are diagnosed with a mental health condition are rarely accepted.
Drug courts almost exclusively forbid participants to enter or continue methadone treatment. Most drug court judges and administrators view methadone, and even suboxone, as another illicit drug. This creates a dangerous situation whereby participants are at a substantial risk of lethal overdose if they do relapse. It also forces them to rely on 12-step programs that are not as effective and, by their own admission, aren’t designed to handle people who have been forced into attending.
Drugs courts also fail to encourage users to seek adequate mental health treatment. Considering a large segment of the opiate-dependent population is self-medicating mental health issues or emotional trauma, this poses a serious problem. Judges and prosecutors continue to rely on the archaic idea that 12-step programs, an abstinence-only approach, threatening drugs users, and pushing them back into work or school (whether they’re ready or not) is the best method for rehabilitation.
For those who are accepted into drug court, the looming threat of incarceration or further punishment if they fail creates an additional level of stress and anxiety, factors that are most likely to cause relapse. Not to rely too strongly on anecdotal evidence, but several friends I used to take drugs with have drug court horror stories. Several spent more time in jail, ended up with legal problems that marginalized them even further, and developed worse drug habits as a result. My closest friend Nick died while he was in drug court.* There’s no shortage of stories like his.
If anyone involved in this system had a solid understanding of the issues habitual drug users face there’s no way they’d operate the way they do. Unfortunately, those most impacted by drug courts and many rehab programs programs are rarely consulted on how they should function. The voices of those who know best about, and who are meant to be helped by, these programs are ignored. This is persistent attitude in the justice system and the rehab industry.
Nothing About Us Without Us: Harm Reduction as a Tool for Rehabilitation
Journalists and who previously had no interest in heroin, methadone, suboxone, or harm reduction, suddenly fancy themselves experts on drug use now that it’s affecting people they find newsworthy. Politicians are suddenly experts now that they’re able to frighten white suburban voters, most of whom know nothing about addiction outside the state’s drug war propaganda, into voting for them. They cherry pick experts who support their position and ignore the majority who don’t. Those of us with years of firsthand experience using and trying to kick drugs, on the other hand, struggle to make our voices heard.
Harm reduction is a concept that aims to make drug use safer for those who we know will continue to use. It meets drug users where they’re at. Rather than coerce them into programs that are likely to fail, harm reduction advocates make treatment options available to those who want to pursue them, provide health care and screening to active users, and provide things like condoms and clean syringes to make sex work and drug use less dangerous. These practices were born out of the AIDS crisis in the 1980s and have proven effective at reducing HIV and Hepatitis C transmission in at-risk communities.
The first harm reduction conference I attended introduced me to the slogan: “Nothing about us without us.” The drug using community, and the loved ones who suffer along with us, is probably the group best-situated to offer advice and find solutions to these “epidemics.” Unfortunately, what we have to say continues to be lost in a society that places profits and political power over the lives of people it views as disposable.
Harm reduction groups also distribute naloxone, the drug that reverses opiate overdoses, and educate drug users, police, and community members on its use. Naloxone is reported to have saved at least 10,000 lives since 1996 (after which the CDC stopped recording data). In Georgia, the state where I live, naloxone kits distributed by local harm reduction groups have reversed over 260 overdoses since April 2014. I’ve been fortunate enough to be involved with groups that pushed for laws making naloxone more readily accessible and advocating for medical amnesty laws that prevent people who call 911 to report an overdose from being arrested if the police show up and find drugs at the scene. We were able to craft one of the most comprehensive laws in the country.
Harm reduction advocates are generally grassroots organizations made up of volunteers, former drug users, people who have lost loved ones to overdose, active or retired police, and social workers. They support MAT, but don’t push treatment on drug users who aren’t ready to quit. To quote a friend from Georgia Overdose Prevention, “If they’re still alive, there’s hope.” If drug users die from an overdose, there’s no hope they’ll ever recover; if we can keep them alive and healthy, there’s a good chance they will. If we place any value on human life, we have an obligation to support harm reduction, MAT, and other programs that make life safer for drug users.
Preventable Overdose Deaths Continue to Rise
Without question, deaths from heroin overdose have increased substantially in recent years. With tightened restrictions on prescription pain medications and stronger heroin (which often includes fentanyl, a synthetic opiate that’s 40-100x stronger than morphine), heroin use is more dangerous than at any time in recent memory. When articles criticizing methadone and suboxone treatment use deaths from methadone to back up their claims, they rarely compare these numbers to deaths from street drugs. They also fail to take into account how many methadone-related deaths are a result of those in MAT (versus those who obtain the drug illegally) or whether those deaths resulted from a combination of drugs (which most do).
With all the data from the CDC, SAMHSA, NIDA, and other government agencies in mind, it would seem the media, politicians, and the rehab industry would promote treatment methods that are proven to be effective. Instead, they push the failed “tough love” and abstinence-only approach that we know don’t work. The “war on drugs” treats drug users, many of whom suffer from mental health issues or pain, as criminals. This stigma marginalizes users, compounding public health problems and preventing them from seeking help. Prohibition creates dangerous conditions for drug users, which leads to the transmission of diseases and more overdose deaths.
In many US states, drug paraphernalia like syringes are criminalized, forcing IV drug users to reuse or share needles (some cities even criminalize women carrying more than one condom, further demonstrating where their priorities lie). Street drugs are unregulated, which means users don’t know what they’re getting or how potent it is. One day they might have something that barely affects them and the next they might have something that will kill them. And that’s not even considering the crime created by those trying to get money for drugs or selling drugs. Criminalization has failed miserably and we all know it.
Portugal decriminalized all drugs in 2001. Drug addiction there is treated as a health problem rather than a crime. Instead of jail, drug users are usually given a fine and/or ordered community service. They’re also offered treatment. The result has been a reduction in drug use and the number of people dependent on drugs has fallen, there are fewer drug-related health problems, and drug-related crime has decreased. Meanwhile, in the US, we continue to pursue policies that increase crime, deter drug users from seeking help, and make drug use incredibly dangerous.
Some places, like Switzerland, Denmark, Germany, the UK, and some cities in Canada and Belgium even offer heroin-assisted treatment. That might sound ridiculous, but it provides a safe environment and a controlled dosage that provides many of the benefits of other forms of MAT. It’s a second-line treatment intended only for drug users for whom methadone or suboxone have failed and is proven to be effective.
Setting Our Priorities: Valuing Human Lives
It’s difficult to imagine drug decriminalization or heroin-assisted treatment finding acceptance in the US, where the rehab industry has political clout and drug users and MAT are still stigmatized. At some point, though, we’ll have to support MAT and harm reduction on a large scale if the lives and suffering of drug users matter to us. We know these programs are effective, that they save lives, and that they improve conditions for everyone, even those who don’t use drugs.
We can’t permit the media and politicians to scare us with outdated rhetoric, inaccurate stereotypes, and policies that have failed drug users for decades. If we sincerely want to reduce drug use, rather than exploiting drug users for political or financial gain, we have an obligation to educate ourselves and each other. If we continue to provide a platform for those who spread lies and misinformation about drug users, drug treatment, drug-related crime, transmission of deadly diseases, those problems and overdose deaths will continue to rise.
Many in the media have made it clear they’re only interested another story they can use to sell ad space before they move on to the next story aimed at scaring us into paying attention to them. Politicians have a long history of placing their interests above those of drug users, their families, and our communities. The rehab industry is beginning to come around. More healthcare professionals and addiction specialists are accepting proven treatments like methadone and suboxone treatment and programs that use evidence-based approaches like SMART Recovery and cognitive-behavioral therapy.
If we care at all about those who are dependent on street drugs, if we sincerely wish to help them, then we are have a duty not only to educate ourselves about effective treatment options, but to listen to their experiences. No one knows better what drug users need than drug users themselves. Ultimately we have to decide which is more important: maintaining control over failed programs or policies that provide material benefit to a privileged few, or the lives of our friends, neighbors, and loved ones who are struggling to survive.
For more on this topic, check out these articles and essays:
Surviving Dangerous Drugs: Lessons From a Former Drug User
Naloxone and Medical Amnesty: Saving Lives and Offering Hope
Don’t Run, Call 911: Naloxone and Medical Amnesty in Georgia
The Surprising Failure of 12 Steps
*Nick’s story and mine: Nick was one of my closest friends and 3 years later it’s still difficult to accept that he’s gone. We met in prison, where he was nearing the end of a 4-year sentence. He’d been using heroin for over 10 years when we met and, after receiving no care for his addiction in the corrections system, picked it right back up when he was released. He was later caught breaking into a Coke machine and charged with a felony. He accepted 18 months in drug court and 5 years probation (in contrast, the person he was with at the time refused drug court and was released from jail after 1 year).
Within the first month Nick was tossed back into the county jail for losing his job. They mandated him to enter a religion-based rehab (despite him being an atheist) which was apparently designed to to make the operators wealthy at the expense of their clients. He left the program within two weeks, opting to spend his time in the county jail over being exploited and abused. Later that year the rehab was the subject of an FBI sting and several of the operators were convicted.
Eventually we were able to find a rehab in another part of the state that would accept him. He was doing well, working, and remained completely abstinent from drugs for almost a year. One night he had a few drinks and was booted from the program, even though alcohol was not his drug of choice. He ended up back in the county jail. After a few weeks we managed to get him accepted back into the program. He never made it.
Nick left the jail with all the money he’d earned working and was found dead from an overdose in his mother’s yard. He was obviously with someone, who preferred to dump him out somewhere rather than seek help and risk problems with the police. There was no money on him when he was found. Of course, the drug court can’t be held responsible, but their lack of understanding created a huge risk. If Nick had been on methadone or suboxone treatment he might not have relapsed; even if he did it’s unlikely he would have died.
Nick’s story is what motivated me to get involved with overdose prevention and harm reduction. I credit that work with helping me stay abstinent from street drugs. I continue my suboxone-assisted treatment and have accepted that I might have to remain on suboxone for the rest of my life. I don’t have a problem with that. My suboxone is prescribed by a psychiatrist who also treats my mental health issues. The suboxone not only manages by opiate dependence, it also treats my anxiety and stabilizes my mood. I’m much better on suboxone than I was off it and that would likely be the case even if I’d never used heroin.