At the end of November, the Centers for Disease Control and Prevention (CDC) released new numbers on the opioid epidemic: More than 70,000 Americans died of drug overdoses in 2017, a higher number than any other year on record, and higher than deaths for car crashes, HIV, or gun violence. Opioids accounted for around two-thirds of those overdoses.
“The numbers are so staggering,” Joshua Sharfstein, a vice dean at the Johns Hopkins Bloomberg School of Public Health, told the New York Times.
With more than 70,000 people killed, the ripple effects of this crisis are also getting larger. At Tonic, we’ve written a guide to help find treatment for addiction, but what what if your family member or friend isn't yet ready to seek treatment?
I spoke with Joji Suzuki, an addiction psychiatrist at Brigham and Women's Hospital and the director for addiction education for the medical students, residents, fellows, nurses at several hospitals across Boston. Suzuki addressed some common concerns and misunderstandings about opioid use disorder (OUD), and offered some advice on how best to support your loved ones.
If my loved one has opioid use disorder, shouldn’t it be easy for them to find treatment? We’re in the middle of a crisis after all.
The opioid crisis may be front-page news, but it can still be extremely challenging to find doctors who will treat people with OUD. Suzuki tells me that only a tiny fraction of people who have a substance use disorder—around 7 percent—receive specialty care, like detox, outpatient treatment, or buprenorphine (a medication treatment option). “The vast majority of people are not accessing treatment or are unable to access it, can't afford it, don't know where to go,” he says.
Most people first approach the healthcare system in other ways and can get turned away. Suzuki says the bulk of his clinical research is focused on finding and identifying people with OUD at any point in their medical care, an approach he calls: “No Wrong Door.”
“It doesn't matter what door they're knocking on: primary care clinic, emergency room, hospital, psychiatry clinic, it could be the pain clinic, it could be your obstetrician,” he says. “If someone needs help, any doctor should be able to provide it and never tell them that they're knocking on the wrong door.”
For Suzuki, it’s a sad reality that with the prevalence of OUD, there aren’t more ways for people to access the care they need. It’s not the case for other diseases, he tells me. Let’s say you went to a hospital with chest pains—anywhere you went could diagnose you with a heart attack, and get you surgery or treatment.
“You can't imagine a hospital saying to a patient, 'Well, we don't really treat the heart disease,'" Suzuki says. "It would be unthinkable. But that's exactly what we do with substance use disorders. If we really want to treat substance use disorder as another medical problem and not just a criminal justice problem we should expect every physician to have the basic competencies around treating substance use disorders.”
Why isn’t my loved one quitting cold turkey?
Medication-Assisted Treatment, or MAT, is when people are given certain medications to reduce cravings, lessen withdrawal symptoms, and dramatically reduce the risk for relapse and overdose.
The commonly used drugs are methadone, buprenorphine, and naltrexone. Naloxone, or brand-name Narcan, is a life-saving drug that can be administered in the case of an overdose.
Medication isn’t a standalone fix. Behavioral therapy is crucial too to deal with any underlying mental health issues, life stressors, or to deal with stress. But while it can be tempting to want your loved one to give up all opioid-like substances altogether all together, these medications work extremely well, Suzuki says, and he regularly advises the use of buprenorphine.
“Really, the critical thing is to get people onto medications as soon as possible,” he tells me. “That's probably the most important message that I'd have for patients is that, with opioid use today, the next relapse could be a fatal one. Especially with fentanyl. This has completely changed the landscape. The [overdose] risks are sort of enormous. And once you get on buprenorphine, your overall risks go down dramatically and that gives you time to then plan the other elements of treatment.”
Isn’t my loved one just replacing one drug with another? Can’t they get high off buprenorphine too?
There are potential downsides and harmful effects from any treatment. But Suzuki tells me that buprenorphine is as close to a “miracle drug” as we’re going to get. Are there people who misuse buprenorphine and get high from it? Sure, he says. But it’s a tiny number of people compared to those who benefit from it.
Buprenorphine is an opioid partial agonist, which means it can produce opioid-like effects, but those effects reach a maximum, and then plateau. When taken at low doses, it can reduce the withdrawal symptoms and cravings that lead a person to use again. Unlike methadone, it doesn’t have to be given under watch in a clinic, and can be prescribed to be taken at home.
Addiction is more complicated than just physical dependence. If you use opioids, you become physiologically dependent on them, which is defined by having a tolerance to the drugs and experiencing withdrawal symptoms if you stop taking them. Physiological dependence can happen with all sorts of substances, from opioids and alcohol, to blood pressure medication.
Suzuki says he defines addiction not by physical dependence alone, but with the “Three C’s”: loss of control, cravings, and negative life consequences. When a person starts taking buprenorphine, they regain control, Suzuki says. They can take what’s prescribed and not more. Their cravings go down and their life gets better, and there are less negative consequences.
“Does physiologic dependence continue when they go from heroin to buprenorphine? Absolutely," he says. "But are you still addicted? Absolutely not. I understand that people have fears about it. But it's important to try to reduce the stigma around taking medication, and encourage your loved one to give it a try, he says.
My loved one can’t find a doctor that prescribes buprenorphine or naltrexone. Does that mean this isn’t the best course of treatment?
Doctors have to take an eight-hour course to get the license to prescribe drugs like buprenorphine, but they’re not required to make that choice.
“It's an opt-in system, it is absolutely insane,” Suzuki says. He thinks the opioid epidemic is so widespread and enough of a public health issue that all doctors should receive this training. “When medical students go to medical school they don't get to say, ‘I'm gonna go into primary care but can I skip the surgery rotation? I'm really not gonna need that so I'm just gonna skip it.’ We don't let students opt in to sort of core requirements for their training.”
He agrees that when it’s hard to find providers who prescribe drugs for OUD, it can stigmatize the treatment itself and push people toward abstinence-only treatment plans. Maybe that works for a minority of people, but for a lot, it doesn’t.
Buprenorphine, in particular, has been well studied in recent years, and Suzuki says it is the best option for reducing overdose fatality and overall mortality, by over 50 percent. “This is a highly effective medication,” he tells me.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has a website with national listings for buprenorphine prescribers per state. You can search by name, location, and zip code to look for doctors who prescribe it.
My loved one has been on buprenorphine for a few months. Can they come off it now?
Addiction is not an acute problem, like an infection, Suzuki says. You can’t just take the medicine for a few weeks and be better. It should be thought of as a chronic disease, like diabetes—even if the symptoms are managed, it doesn’t mean you’re cured. Some people will have to do MAT for several years or longer.
There is no shame in being on these drugs for longer periods of time, and Suzuki again stresses that they can work really well. “They're actually probably more effective than things like nicotine replacement for tobacco, beta blockers for heart disease, and cholesterol medications for all this other stuff,” he says.
Suzuki likes to think of it like losing weight: “If you work out, and you lose weight, you’re not done forever," he says. "I would love that, but it's not the case. Same thing with addiction. You have to continuously work at it each and every day, make the right decisions every day. You have to make the right choices, not just once, not just twice, not just one day, or even a week or a month. You have to sustain it for a considerable amount of time and that's why it's so hard. I had a patient say to me once, the hardest thing he does every single day is to not use drugs. Everyday you have to make that choice to not use drugs, and that's not easy.”
There’s not great data available for exactly how long people should stay on MAT. Anecdotally, Suzuki says that after about four years, about half of patients come off it and are doing okay. In practice, it probably changes a lot per patient. Some people are on it their whole lives. Others can come off it quickly—but quickly means about a year, in Suzuki’s experience.
It’s all about the behavioral changes and learning a person undertakes while the medication is suppressing their cravings and physical symptoms. Can they learn, when they’re triggered, not to reach for opioids? “Even if you have a bad day, or if you have a good day, your response needs to be not using drugs. Go for a walk, call your friend, watch a movie, have dinner, you know? And can you feel adequately rewarded and satisfied from those behaviors? That takes time. For some people that might happen more quickly than others and so there's no easy way to say at the outset of the treatment: 'Oh for you, if you're on buprenorphine for three months you're good to go.”
When Suzuki weans patients, he does it slowly over time and sees how people respond. If there are no cravings, they keep going. If they start to feel withdrawal, they stop.
“I do acknowledge that nobody wants to be on medications forever, but the reality is it takes a long time for the brain to relearn how to live without drugs," he says. "These cravings are hardwired into the brain and it can't just snap out of it. So it takes time for people to learn and each person learns at a different pace.”
Did my loved one become addicted to opioids because they have no willpower?
About 50 percent of the risk of getting addicted is entirely genetic, Suzuki tells me. So it’s not whether a person is weak or not, it’s what genes they were born with. The other 50 percent is personal experience and environmental context: Were they surrounded by other users? Do they have a history of trauma or depression? Certain factors, like psychiatric disorders, trauma, PTSD, mood disorders, anxiety disorders, might also increase the risk for developing addiction.
“So many things go into your own risk of developing these problems," he says. "Trying to simply say, 'You're just a weak person,' doesn't capture it at all. People with very strong wills still will get addicted. People who are poor, people who are rich, people who come from ‘good’ families, people who come from ‘bad’ families. Addiction does not discriminate.”
My loved one told me they were seeking treatment and wanted to get better. Then they used again—were they lying to me?
When someone says, “I really want to get better,” and a few months later they’re using again, it’s tempting to think they were deceiving you, that they weren’t sincere, or that they didn’t care. But the reality is more complicated.
“The brain has changed, probably permanently, by the drug use and these memories of the drugs actually are hardwired into the brain,” he says. “What's so problematic is that the brain remembers it really, really well because heroin was so good and anything that can remind them of it, or any stressor—it could be a positive or negative thing,it could be a friend, it could be a location— some reminder that could trigger that craving and once you get those cravings it can be really, really hard to resist it.”
It’s an extremely powerful feeling, and people with drug addictions will continue to feel cravings for years after they stop using. Just because someone is motivated and wants to quit doesn’t mean they’re going to be successful the first time they try.
“I think friends and family have to understand that, you know, despite high levels of motivation, being successful immediately is not likely,” he says. “Relapse is part of the recovery process, not a failure of recovery.”
The difference between a person who succeeds in recovery and one who doesn’t isn’t the occurrence of a relapse, it’s that the person who succeeds never stops trying to quit.
Should I force my loved one into treatment against their will?
Suzuki says he sees a lot of families pushed into tense relationships, where there’s a lot of blame and coercion going on. But at the end of the day, a person has to want to change, and you can’t force them. It can feel like a slow-motion car accident, he says. It feels like watching someone you love heading towards a wall, and if they don’t change course they’ll die, but you don’t have the power to stop them.
“That's why we end up acting [in] ways that are counterproductive by trying to force them into treatment or confronting them and those things can actually backfire,” he tells me. “When the external ways of changing things exceed the internal motivation, there's a mismatch in that, there's a tendency for people to then reject you even further and reduce their own motivation for change. So it can backfire when applied sort of too strongly.”
Yelling at someone or telling them to change is unlikely to work. (If it did, Suzuki says, he’d be telling everyone to do it.) It’s important to affirm people’s efforts and good outcomes, and not focus only on the bad—don’t overly fixate on the failed attempts. Pay attention to the side of your loved one that wants to be better and is trying. “Every step in the right direction should be applauded, affirmed, validated, cheered, and rewarded because we need more of that," he says.
He thinks that while it's important to be non-judgmental and non-confrontational, it’s also crucial to be honest and direct. (Those things shouldn’t cancel each other out.)
“I think ultimately being able to show empathy and support for a sustained period of time and I think it's very critical to be direct when needed,” he tells me. “I think there's some sense of humility around that it's okay as well. I've hammered away at the importance of medication, but if somebody truly believes that they don't want mediation I think it's okay to honor that. There are ways to get better without it. It's much, much harder but I think honoring people's' autonomy to make those choices, including their choice to not get help. Respecting people's' autonomy to make good and bad choices and being willing to support that person regardless is a critical thing. We can disagree with their choices but still respect their autonomy.”
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