By Peter Chow
OBSTACLES TO ADDRESSING OPIOID ADDICTION IN SAULT STE MARIE
1) MISCONCEPTIONS AND BIASES ABOUT OPIOID ADDICTION AND TREATMENT
2) INADEQUATE PROFESSIONAL EDUCATION AND TRAINING
3) LEGAL AND REGULATORY BARRIERS
4) CONCERNS ABOUT DIVERSION OF TREATMENT MEDICATIONS
5) LACK OF SPECIALISTS IN ADDICTION MEDICINE
These are some of the misconceptions and biases blocking progress toward evidence-based treatment of opioid addiction in Sault Ste Marie.
1) “Drug addiction is a lifestyle choice.”
Addiction is not a lifestyle choice and it does not occur in isolation.
A range of contributing contextual factors – including genetic vulnerability, stress, mental health problems and particularly psychological trauma – puts us at higher risk of substance misuse and relapse.
The greater the environmental stress, as in the case of trauma, the greater is that discomfort and the need to escape it – a desperate need to just change how you are feeling.
Although the first intake may be reckless or voluntary, a bad mistake, the “choice” to “just stop” doesn’t apply when it comes to addiction.
Addiction is not about a person’s character, nor is it apersonal choice.
Getting rid of the idea that people choose to become addicted is a crucial step to understanding and helping people with addictions.
2) Opioid addiction is just a psychological disorder and people who are dependent simply need better willpower.
Or from the 12 Step perspective (Alcoholics Anonymous / Narcotics Anonymous), a spiritual or moral failing.
Or worse, that drug addiction is simply a crime.
3) It’s ok if we call people with opioid use disorder (OUD) “addicts,” “users,” “meth-heads,” or “junkies” or worse.
The words we use to describe addiction and people with addiction are important.
Negative terms such as “addict”, “user”, “junkie”, and phrases such as “need to get clean” contribute to our stigma against people with opioid use disorder and create barriers to accessing effective treatment – a factor in people with OUD being reluctant to engage the medical system.
This ultimately contributes to increased harms and overdoses and death.
When we talk about people with diabetes, we don’t talk about them being “dirty,” and “needing to get clean”; we talk about their sugars.
Similarly, we should focus on measurable changes to health for people with opioid use disorder (OUD).
Studies have shown that people who were referred to as “substance users” were more likely to be considered to be responsible for their condition, that they “got what they deserved”, whereas people who were referred to as having “substance use disorder” were more likely to be seen as people needing help.
This is a really key component to getting people into treatment and stemming the opioid crisis.
A person is not defined by their disease.
Even medical professionals, nurses and physicians (myself included) are often guilty of this, treating and referring to these people as “less than”, an underclass.
Many clinicians, pharmacists, and support staff have stigmatizing attitudes toward patients with opioid use disorder and toward medications for opioid use disorder.
Imagine if smokers who develop lung cancer or end-stage COPD were treated with the same disdain as people with opioid use disorder………or people with obesity who develop type 2 diabetes or have a heart attack.
As a community, we can continue to work on the stigma associated with substance abuse and offer support and guidance.
Just because someone is struggling doesn’t mean he or she is a “bad” person.
Many people don’t seek help for fear of feeling judged or rejected.
Keep in mind that just as there are many high-functioning alcoholics, there are plenty of people with opioid use disorder who are high-functioning.
They are “respectable”, work, pay bills and spend time with friends and family, but inside, they’re fighting a battle no one knows about.
4) The best way to combat an opioid addiction is without medication – “Just say no.”
The idea of treating opioid addiction without medication is attractive, especially because programs such as AA can be effective for some patients with alcohol use disorder.
A lot of people think that the initial goal of treatment for opioid use disorder should be total abstinence, not taking any medication at all.
However, the medical evidence is that almost all people in abstinence-only detox programs for opioid use disorder will invariably relapse.
Worse yet, if they have abstained for any length of time, their tolerance to opioids has become much lower and when they do relapse, they are much more likely to die of overdose.
Medical evidence shows that medication-based treatments (MATs) are the most effective treatment.
Opioid use disorder is a medical condition just like depression, diabetes or hypertension, and just like those conditions, it is most effectively treated with a combination of medication and counseling.
5) Medication Assisted Treatment just substitutes one drug for another.
There are two common medications used to treat opioid use disorder: methadone and suboxone (buprenorphine/naloxone) – opioid agonist treatment (OAT).
These medications help address patients’ withdrawal symptoms and block the reward or the “high” that people get from using opioids.
They help restore “normal” brain functioning.
Buprenorphine and methadone are opioids agonists.
This means that they bind to the same opioid receptors in the brain that opioids like oxycodone, heroin and fentanyl do, and provide relief from withdrawal symptoms.
Some people misinterpret that to mean that we’re just replacing one addiction for another.
However, this is not the case.
Buprenorphine and methadone help patients avoid withdrawal symptoms, such as body aches, nausea, vomiting, diarrhea, cramping, muscle aches, insomnia, abdominal pain and anxiety, but don’t offer the high, which means they are less addictive.
Their effects also last much longer (24-36 hours), which allows patients to get on with their day without having to think about their opioids – allowing them to work, take part in family life
In addition, with buprenorphine and methadone, the risk of overdose is much lower.
Patients who strongly object to using maintenance opioid agonist treatment may choose naltrexone for opioid use disorder.
Naltrexone, also known by brand name Vivitrol, is not an opioid drug, but is a once-a-month injection that blocks opioids from working for up to one month.
Unfortunately, Vivitrol costs US$1000 a dose and is not available in Canada.
6) Medication Assisted Treatment is a bad moral choice, inferior to recovery without medication.
Some of the negative stigma of MAT comes from different ways of understanding addiction.
12 Step programs like Alcoholics Anonymous and Narcotics Anonymous have dominated addiction treatment for decades until recently.
Some in the 12 Step community, still view drug addiction as a moral and spiritual failing, rather than as a medical disease.
In this view, medical treatment with suboxone is a “crutch,” or a weak moral choice because a patient is continuing to use an opioid on a daily basis.
Medication-free total abstinence should be the treatment plan for drug addiction in this view of addiction.
MAT’s ability to make addiction recovery easier and less painful is therefore seen as a benefit, but means that a patient “isn’t serious” about quitting.
MAT patients do not meet 12-step programs’ definitions of abstinence because of their use of opioid medications, and they are often excluded and shunned from these groups.
Individuals attending 12-step groups may be criticized as having “traded one drug for another” if they reveal that they are seeking treatment with buprenorphine or methadone.
This is not always the case, as many AA and NA members now understand the role of MAT in recovery.
7) MAT is not effective because it does not immediately end drug dependence – OUD is not “cured” by the use of MAT.
Addiction is a chronic disease.
Medical treatment for addiction can be compared to medical treatment for other common chronic conditions like diabetes or high blood pressure.
Aside from infectious diseases, almost all medical conditions, especially chronic diseases, are never “cured,” but instead are “managed.”
Just as diabetes is not “cured” by the use of insulin, and people with high blood pressure continue taking medications for the rest of their lives, so people with OUD are not “cured” but instead managed by MAT.
The ultimate aim can be to wean off the maintenance medication, but the treatment provider should make this decision jointly with the patient and tapering the medication must be done gradually.
It may take months or years in some cases.
Just as body tissues require prolonged periods to heal after injury and may require external supports (e.g., a cast and crutches or a wheelchair for a broken leg), brain circuits that have been altered by prolonged drug use and substance use disorder take time to recover and benefit from external supports in the form of medication.
In cases of serious and long-term opioid use disorder, a patient may need these supports indefinitely.
MAT makes it possible for the patient to function normally, attend school or work, and participate in other forms of treatment or recovery support services to help them become free of their substance use disorder over time.
8) “I’ve known a few people who could stop using opioids without help from any kind of medication. MAT is only for the weak.”
Though opioid abuse may begin with a series of poor judgments or risky decisions, addiction involves real, physical changes in neuronal circuits in the brain.
While some people are eventually able to quit using opioids on their own, the overwhelming majority of patients who try to abstain without MAT go though many dangerous cycles of relapse and recovery, risking harms, overdose and death..
MAT can make the recovery process much safer, and has saved many lives by preventing death from overdose or dangerous behaviors associated with unregulated “street” drug use.
9) Tolerance, dependence and addiction to opioids are the same thing.
When taking opioid medication to relieve pain, it’s possible your body will get used to the drug after a while.
You may need a higher dose to get the same level of relief.
This means you have developed a tolerance for it.
If you stop taking the medication altogether, although you may have increased pain, you shouldn’t feel any other ill effects.
Dependence, or physical dependence, occurs when you experience physical symptoms in addition to pain if you suddenly stop taking the drug. These symptoms may include nausea, vomiting and sweating.
People are addicted when they are dependent on the drug and continue to compulsively use the drug despite harmful consequences.
In the 20th century, when the UK made injectable morphine widely legally available, several highly respected physicians became dependent on morphine for their entire professional lives, completely unbeknownst to their colleagues, their patients or their families….dependent but not addicted, their drug dependence only revealed upon retirement.