Never before have so many tools been available
In Dandridge, Tenn., 16 women sat in a jailhouse cinderblock classroom. Clad in black-and-white striped uniforms reminiscent of those worn by 1950s chain gangs, the women were about to hear a presentation that was anything but old-fashioned.
“We’re happy to see you,” Sherrie Montgomery, the director of the Jefferson County Health Department, told the women, according to the Tennessean’s Anita Wadhwani. “We want you to relax, and we want you to listen,” Montgomery continued. She then showed the women, some of whom had been arrested on drug-related charges, Born Hurting, a video on the effects of a mother’s opioid addiction on her newborn.
Dandridge, like thousands of other communities, has seen a wave of infants suffering from neonatal “addiction” — babies who are physiologically dependent on opioids, though not technically addicted, and who require careful weaning with small doses of methadone, an anti-addiction drug. After the video, Montgomery led a pointed discussion about the benefits of birth control. She made a lot of sense in this context: If you don’t get pregnant after you’re released, you won’t have a drug-addicted baby.
Neonatal addiction is just one facet of America’s opioid crisis, which now claims the lives of between three and four people every hour. The term “opioid” refers to narcotic prescription medications, such as oxycodone (the narcotic in Percocet and OxyContin) and hydrocodone (Vicodin), as well as heroin and synthetic drugs such as fentanyl, which is 25 to 50 times as potent as heroin. In 2015, more than 35,000 Americans died of overdoses (13,000 from heroin, 9,600 from synthetic opioids, and 12,700 from prescription pills) — nearly equal to the number of deaths from car crashes.
Naturally, politicians and health professionals are calling for more treatment. Last year, President Obama urged action, and Congress allocated $1.5 billion for treatment expansion and other services. President Trump recently told police chiefs and sheriffs that “prisons should not be a substitute for treatment.” “We will fight to increase access to life-saving treatment to battle the addiction to drugs,” the president said, “which is afflicting our nation like never, ever before.”
As an addiction psychiatrist, I applaud these efforts. I also share the anxious concerns over what repeal and replacement of Obamacare might mean for addiction-treatment coverage. At the same time, I think that politicians and public-health experts have overlooked a major impediment to the promise of treatment: how hard it is to get a patient to seek treatment and stay committed to kicking a drug habit.
While the situation is extremely serious, there is hope: a developing synergy of tools ranging from new anti-addiction medications to newly developed treatment methods (including those conducted within the criminal-justice system, e.g., in drug courts) to a new openness to involuntary civil commitment in the most serious cases. Call it all a necessary benign paternalism or a carrot-and-stick approach to addressing America’s opioid crisis.
How did we get here? In the mid and late 1990s, campaigns by patient advocates and some clinicians for more-liberal use of narcotic painkillers in treating pain gained ground. This led to doctors’ over-prescribing long-acting, high-dose narcotics in large quantities to treat nasty toothaches and minor injuries that required only a few days of pain relief. Aggressive marketing by narcotic manufacturers abetted this trend.
As more opiate medications entered circulation, more opportunities arose for patients — and especially non-patients — to abuse them. And as opioid-prescribing increased, so did deaths from these drugs.
The average abuser of prescription painkillers is not a person being treated for pain (though, to be sure, some patients do get addicted). The average “non-medical user,” as epidemiologists call abusers, typically obtains pills from friends, shady doctors, or street sellers. He may “doctor shop” in search of a compliant prescriber or help himself to the medicine chests of unsuspecting relatives suffering from cancer, who often receive large quantities of opioids for their pain.
Heroin use had been simmering for many years. But it began to grow in the mid 2000s and jumped sharply over the last three to five years owing to the combination of an accelerated influx of heroin from Mexico around 2007 or 2008 and the heavy crackdown on illegal sale and abuse of painkillers by law-enforcement and health professionals that began in earnest around 2010. Subsequently, heroin-related overdose deaths surged threefold, in large part because the drug was laced with the much stronger fentanyl and fentanyl analogues that are now mixed undetectably with heroin. (Notably, while many current heroin users begin their use of opioids with painkillers they obtained outside the medical system, only a small subset of such painkiller abusers progress to heroin.)
At New Jersey’s RWJBarnabas health clinic in West Orange, 200 patients who had had their overdoses reversed by Narcan were offered treatment. (Narcan, or naloxone, is the fast-acting antidote that works by shoving drug molecules off receptors in the brainstem and jump-starting a person’s breathing.) Over two years, only two of them agreed to enter detox programs, which precede actual treatment and rehabilitation, and both dropped out within a couple of days. In Camden County, a program offered revived patients $15,000 vouchers for detox and intensive outpatient treatment. Only nine of the nearly 50 patients who had been offered the vouchers since October 2015 entered treatment — and four of them quickly dropped out.
Those who do enter treatment will likely receive anti-addiction medication. Buprenorphine, or “bupe,” is most commonly prescribed. Bupe usually comes as a film strip that dissolves under the tongue. Like methadone, the classic addiction medication, bupe is itself an opioid. That means it can produce euphoria (though less effectively than most other opioids). Bupe also prevents withdrawal symptoms and suppresses drug cravings.
Moreover, bupe’s chemical properties make it less risky than methadone if taken in excess. It can also be prescribed by any qualified physician from his office. (To qualify, doctors must take a government-sponsored eight-hour course — a good idea, by the way.) In contrast, methadone must be administered in clinics tightly regulated by the Drug Enforcement Administration (DEA). I work in such a clinic.
Bupe’s relative safety and the restrictions on methadone account for the popularity of the former. Even though the drug is in such demand, however, it can sometimes be difficult to find a doctor to prescribe it. To some extent, this is a matter of uneven Medicaid coverage. But I see it more as a matter of physician enthusiasm. Busy primary-care doctors and psychiatrists see how challenging it is to provide good care — which includes counseling and observed urine collection — to addicted individuals on an outpatient basis.
In fairness, I should add that some of my colleagues have had great success with bupe. But they also tell me that too many of their patients continue to use illicit opioids. Bupe is also the third-most-diverted prescription opioid, after oxycodone and hydrocodone, according to the DEA — and most of that supply of bupe comes from well-meaning clinicians. Its availability is especially dangerous for people who are not already tolerant to opioids, or children, for whom a dose will be fatal.
So on the whole I’m relieved to work in a methadone clinic. Our nurses watch patients swallow the cherry-flavored liquid medication daily for at least the first few months. If a patient resumes using heroin, we can provide more-frequent counseling, do more-regular toxicology screening, and suspend any take-home doses of methadone. Such careful monitoring accounts for very low rates of diversion of methadone from clinics.
A similar system could be developed for bupe. Rhode Island hopes to develop one. It will establish “centers of excellence” around the state where Medicaid and privately insured patients needing bupe will be seen.
Staff will disburse prescriptions for a few days of medication at a time and provide counseling. As patients progress in treatment, supervision will loosen. The goal is to get patients transferred to local clinicians within six months to a year. Should patients relapse, the plan wisely allows community doctors to refer them back to the center for stabilization.
More-intensive involvement with patients early in recovery is essential, but it won’t completely solve another major problem with any kind of drug treatment: dropout. Forty to 60 percent of patients leave treatment within a few months of admission. Return to drug use typically follows.
This should come as no surprise. Users have habits in every sense of the word. Over months and years, they have become conditioned to think about drugs and crave them at the first feeling of distress. That’s because opioids have helped them cope with anxiety, despair, loneliness, emptiness, boredom, and hopelessness. What’s more, addicts are not particularly good at delaying gratification. Economists would call them “steep discounters.” So when the siren call of craving hits, they often act.
The less time patients have spent in treatment, the less exposure they have had to vital recovery strategies, such as identifying the specific circumstances in which they are most vulnerable to craving and devising strategies for subduing the urge to use. Leverage to keep patients in treatment is therefore necessary. Most of the time, such leverage comes from the addict’s own life. Many patients, if not most, come to treatment because someone — a spouse, boss, child, or parent — mightily twisted their arm. At the very least, such pressure gets them in the door.
Incentives provide another kind of leverage. A vast literature exists, for example, on giving patients redeemable vouchers for making progress in programs and submitting clean urine samples. The gift-card vouchers have monetary value that patients can exchange for food items, movie passes, or other goods or services that are consistent with a drug-free lifestyle.
In one incentive model, a research team from Johns Hopkins offered addicts $10 an hour to work in a “therapeutic workplace” if they submitted clean urine. If the sample was positive or if the person refused to give a sample, he or she could not attend work or collect pay for the day. Workplace participants provided significantly more opiate-negative urine samples than controls did, worked more days, and reported higher employment income and less money spent on drugs.
Clearly, incentives make a difference. The question for policymakers and health professionals is how to most effectively provide material encouragement for addicts in cash-strapped clinics.
There is one venue in which leverage is built in: the criminal-justice system, with its accent on monitoring and accountability. In fact, some of the most promising treatment and rehabilitation models can be found there.
Take drug courts. There are roughly 3,000 such courts, which typically offer offenders dismissal of charges for completion of a twelve- to 18-month treatment program. Critically, the courts impose swift, certain, and fair consequences when participants fail drug tests or commit other infractions, such as missing meetings with probation officers or skipping work-training classes. The sanctions can escalate, depending on the number of infractions committed, ranging from warnings from the judge to community service to more-intensive probation supervision to flash incarceration (temporary stays in jail of one to ten days).
These courts are more effective than conventional corrections options, such as mandatory jail time or traditional probation. According to the National Association of Drug Court Professionals, offenders whose cases are handled by drug courts are one-half to one-third less likely to return to crime or drug use than those who are monitored under typical probationary conditions. On average, nearly two-thirds of drug-court participants graduate drug-free at 18 months. What’s more, if carrot-and-stick approaches are scrupulously applied and perhaps combined with anti-addiction medication, it is very possible that not every opioid addict will even need rehabilitation treatment.
The Hawaii Opportunity Probation and Enforcement program shows how sanctions such as flash incarceration and incentives alone can work, without the need for outpatient care or expensive residential treatment. It treats people addicted to the stimulant methamphetamine, an addiction for which there is no medication, and offers treatment only to those who haven’t quit using after being either threatened with penalties or offered incentives. The savings from not having to pay for treating all comers mean that those who do need intense intervention get more supervision and higher-quality care.
A randomized study found that, after one year, the Hawaii program’s clients were 55 percent less likely to be arrested for a new crime than were those on traditional probation, and 72 percent less likely to use drugs. They were also 61 percent less likely to skip appointments with their supervisory officer and 53 percent less likely to have their probation revoked. Programs modeled on this approach are being adapted for other locations and are already having success in Washington, Alaska, Texas, South Dakota, and elsewhere.
The most paternalistic form of leverage is, of course, involuntary commitment. Most states have some form of involuntary substance-abuse treatment. Traditionally, such statutes aren’t deployed much, but the appetite for using or refining them may be growing. In January, a New Hampshire state senator introduced a bill that would expand the state’s list of mental illnesses qualifying for involuntary commitment to include “substance-use disorders” as defined by the American Psychiatric Association.
These approaches — incentives, drug courts, swift-certain-fair punishment, and civil commitment — will be even more effective when combined with medication. In addition to methadone or buprenorphine, both opioids, there is another addiction medication, called Vivitrol (naltrexone), that should be used more widely. Offered as a monthly injection, it is an opioid blocker, which means that if a person were to use painkillers or heroin while on Vivitrol, he would get no effect. This medication has a major role to play for people who have already been detoxified, such as inmates who will soon be released from jail.
Never before have there been so many different therapeutic elements to apply in combination to promote recovery. The nation saw many drug epidemics in the 20th century, and today both politicians and police chiefs are putting a strong emphasis on treatment over punishment. This is a healthy development, but it will work only if we are clear-eyed about the nature of addiction and the demands of recovery — an appreciation that inevitably leads us to the virtues of benign paternalism.
– Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.