The last column that I wrote was about five months ago as I planned my re-entry into aNewsCafe with a discussion about my frustration with our divisive political climate. My column was poised and ready to go when a lack of raking our forests set Redding ablaze. Politics no longer seemed so important. Now, as life returns to normal in Redding, I’ve decided to follow the advice of the NRA and stay in my lane. Don’t worry, I will still take a few political jabs from my lane. After a recent mass overdose left one dead and twelve in the hospital, it’s time to talk about drugs. This column is about the treatment of opioid use disorder – addiction to heroin or other opioids, usually pills.
Methadone has always seemed like a joke to me. My view of methadone clinics was that they are a place where addicts could gather, trade drugs and exchange information on how to work the system. Instead of using heroin, they were just using another drug, getting high on the government’s supply. If I were asked to picture a methadone patient, it would be an unemployed, disheveled addict nodding off on a street corner. It turns out that I was wrong.
First, it’s important to understand what addiction really is. Deep in your brain lies the nucleus accumbens, the part of your brain that is responsible for pleasure. The main neurotransmitter, dopamine, is released in response to pleasurable activities. This makes sense from an evolutionary standpoint as activities that encourage us to thrive as an organism and reproduce give us pleasure. Did you also just have to re-read that word to see that it’s organism and not orgasm? If you have a good meal, the amount of dopamine released in these synapses may increase to 150 percent of baseline levels. If you have sex, they may rise to 200 percent. Perhaps you would like to combine both activities and push the needle a little past twice baselines levels. Perhaps you want to up the ante and indulge in some of your favorite Kentucky bourbon and watch those levels climb to three times the baseline level. Does heroin look like fun? That will get you to five times your baseline levels of dopamine in the pleasure center of your brain, far higher than any experience in life can provide naturally. Even when using it alone, it will give you a sense of well-being and connection. Enjoying your perfect teeth and hair? Methamphetamines will get you to over ten times your baseline dopamine levels. These substances quickly hijack the pleasure center of your brain. Because your body constantly strives for homeostasis, those synapses and receptors change with repeated drug exposure and your baseline levels without the drug are really low, making you feel awful and unable to function without the drug. Then you find yourself using the drug just to try and feel normal again. That drug has hijacked your brain and your prefrontal cortex, the part of your brain that makes decisions, is powerless against your nucleus accumbens.
According to the American Society of Addiction Medicine, “Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” This means is that you’re not addicted to a substance just because you have physical symptoms when stopping it. You’re not addicted to metoprolol although stopping it after taking it for some time will cause increased heart rate and blood pressure. That also means that you’re not addicted to pain pills if you feel sick and hurt worse when you stop taking them. If you then throw a brick through the window of Walgreen’s to get your next fix, then you’re addicted.
Addiction has a strong genetic component. Studies of twins that were separated at birth show us that about half of addiction is because of genetic factors and half is environmental (the actual number varies by substance). We know that adverse childhood experiences (ACEs) are associated with addiction and people with 4 or more ACEs have a much higher rate of addiction. When I hear stories of many of my patients’ childhoods, I can’t imagine how they would not have become addicted to something. I hear stories of physical abuse, neglect, sexual abuse, parental substance abuse, and some of my patients never had much of a chance of sobriety.
Medication Assisted Treatment (MAT) is the use of buprenorphine, methadone, or naltrexone for the treatment of opioid use disorder (OUD). For the purposes of this article, I won’t discuss naltrexone, a medication that is not optimal for most patients. Methadone is a typical opioid and has been used for many decades in the treatment of OUD. For the treatment of addiction, it can only be given by a methadone treatment program (MTP). Buprenorphine (the main component of Suboxone, Subutex, Zubsolve, etc.) is also an opioid but doesn’t have full effect on the receptor. Because of this, it has a ceiling effect on respiratory depression and alone will generally not cause a lethal overdose in adults. It’s affects also have a ceiling affect, making this a safer medication. It can be lethal to children and has packaging that makes it difficult for children to open. These medications, when taken appropriately, do not get people “high” but they do keep them feeling normal again, able to function in daily activities with little to no cravings to use opioids. I’m definitely biased towards buprenorphine/naloxone because it doesn’t get my patients with OUD high and has a lower risk of overdose. The naloxone doesn’t have any clinical effect unless it’s inappropriately injected where the naloxone blocks all opioids. When it’s diverted (sold or given to others), it’s diverted to prevent withdrawal or even treat addiction, not usually for intoxication.
MAT is effective. If we simply get someone off of opioids, even without them being in withdrawal, and provide standard drug and alcohol counseling, most studies show less than ten percent are abstaining from opioid abuse in a year. However, with MAT, the numbers are greater than fifty percent. Methadone and suboxone have been demonstrated consistently to reduce criminal activity, transmission of diseases such as HIV and hepatitis C, increase employment, and improve quality of life. They work well to treat addiction to opioids. Although counseling/therapy is part of treatment, it is ineffective without medication. This is why the treatment of OUD is a medication first model.
How long patients stay on MAT is individual. Usually we recommend at least six months to a year in order to have the opportunity to respond to stressors in life, anniversaries of traumatic events, and time for the brain chemistry to normalize. Some people need to stay on medication longer in order to maintain sobriety. We don’t tell a diabetic that we will put them on insulin for a year and then wean them off and see how they do. For some people, addiction is a disease that they must deal with all of their lives. For others, they may successfully wean off of MAT.
Put aside your biases and stigma of people with substance use disorder and look at the science. Putting them all on an island, locking them up, or trying to shove them into someone else’s back yard won’t work. Treating their addiction with evidence-based treatment, however, does work. A lot of them are nice, caring people who want nothing more to be responsible citizens and contributing members of society but find their prefrontal cortex hijacked by a drug that has turned their nucleus accumbens into a real asshole. Before you throw out the age old argument that they chose to take a drug in the first place, what do you say to the 10 year old whose father was high and decided to shoot him up with meth or the 11 year old who was given heroin to shut her up while she was being pimped out by her mother for drugs? If you have ever tried an alcoholic drink, experimented with a drug, took a pain medication that your doctor told you was safe, took a medication to help your anxiety, you should be thankful that your genetics and childhood experiences didn’t predispose you to get addicted. We’re the lucky ones and we should try to help those who are not so lucky.