On the abysmal state of current heroin addiction treatment

Since I haven’t posted in a while, I’m going to kick things off by quoting a post written by the interesting-as-always Scott Alexander over at Slate Star Codex. The man’s a wellspring of cool that never seems to run dry. Here’s Scott reviewing the Huffington Post’s fantastic 20,000-word article Dying To Be Free on the current state of heroin addiction treatment, and as usual it starts gnawing away at that part of me that says the world is broken, and it needs fixing:

The article’s thesis is also its subtitle: “There’s a treatment for heroin addiction that actually works; why aren’t we using it?” To save you the obligatory introductory human interest story: that treatment is suboxone. Its active ingredient is the drug buprenorphine, which is kind of like a safer version of methadone. Suboxone is slow-acting, gentle, doesn’t really get people high, and is pretty safe as long as you don’t go mixing it with weird stuff. People on suboxone don’t experience opiate withdrawal and have greatly decreased cravings for heroin. I work at a hospital that’s an area leader in suboxone prescription, I’ve gotten to see it in action, and it’s literally a life-saver.

Scott continues, and here’s where I get angry:

Conventional heroin treatment is abysmal. Rehab centers aren’t licensed or regulated and most have no interest whatsoever in being evidence-based. A lot are associated with churches or weird quasi-religious groups like Alcoholics Anonymous. They don’t necessarily have doctors or psychologists, and some actively mistrust them. All of this I knew. What I didn’t know until reading the article was that – well, it’s not just that they try to brainwash addicts. It’s more that they try to cargo cult brainwashing, do the sorts of things that sound like brainwashing to them, without really knowing how brainwashing works assuming it’s even a coherent goal to aspire to. Their concept of brainwashing is mostly just creating a really unpleasant environment, yelling at people a lot, enforcing intentionally over-strict rules, and in some cases even having struggle-session-type-things where everyone in the group sits in a circle, scream at the other patients, and tell them they’re terrible and disgusting. There’s a strong culture of accusing anyone who questions or balks at any of it of just being an addict, or “not really wanting to quit”.

I have no problem with “tough love” when it works, but in this case it doesn’t. Rehab problems make every effort to obfuscate their effectiveness statistics – I blogged about this before in Part II here – but the best guesses by outside observers is that about 80% to 90% of their graduates relapse within a couple of years. Even this paints too rosy a picture, because it excludes the people who gave up halfway through.

Suboxone treatment isn’t perfect, and relapse is still a big problem, but it’s a heck of a lot better than rehabs. Suboxone gives people their dose of opiate and mostly removes the biological half of addiction. There’s still the psychological half of addiction – whatever it was that made people want to get high in the first place – but people have a much easier time dealing with that after the biological imperative to get a new dose is gone. Almost all clinical trials have found treatment with methadone or suboxone to be more effective than traditional rehab. Even Cochrane Review, which is notorious for never giving a straight answer to anything besides “more evidence is needed”, agrees that methadone and suboxone are effective treatments.

Yep, that’s the Cochrane Review people, which strives for accuracy and hedges its bets on everything.

So why aren’t we already prescribing suboxone as widely as it should be?

The first roadblock is the #@$%ing government. They are worried that suboxone, being an opiate, might be addictive, and so doctors might turn into drug pushers. So suboxone is possibly the most highly regulated drug in the United States. If I want to give out OxyContin like candy, I have no limits but the number of pages on my prescription pad. If I want to prescribe you Walter-White-level quantities of methamphetamine for weight loss, nothing is stopping me but common sense. But if I want to give even a single suboxone prescription to a single patient, I have to take a special course on suboxone prescribing, and even then I am limited to only being able to give it to thirty patients a year (eventually rising to one hundred patients when I get more experience with it). The (generally safe) treatment for addiction is more highly regulated than the (very dangerous) addictive drugs it is supposed to replace. Only 3% of doctors bother to jump through all the regulatory hoops, and their hundred-patient limits get saturated almost immediately. As per the laws of suppy and demand, this makes suboxone prescriptions very expensive, and guess what social class most heroin addicts come from? Also, heroin addicts often don’t have access to good transportation, which means that if the nearest suboxone provider is thirty miles from their house they’re out of luck. The List Of Reasons To End The Patient Limits On Buprenorphine expands upon and clarifies some of these points.

(in case you think maybe the government just honestly believes the drug is dangerous – nope. You’re allowed to prescribe without restriction for any reason except opiate addiction)

The second roadblock is the @#$%ing rehab industry. They hear that suboxone is an opiate, and their religious or quasi-religious fanaticism goes into high gear. “What these people need is Jesus and/or their Nondenominational Higher Power, not more drugs! You’re just pushing a new addiction on them! Once an addict, always an addict until they complete their spiritual struggle and come clean!” And so a lot of programs bar suboxone users from participating.

This doesn’t sound so bad given the quality of the programs. Problem is, a lot of these are closely integrated with the social services and legal system. So suppose somebody’s doing well on suboxone treatment, and gets in trouble for a drug offense. Could be that they relapsed on heroin one time, could be that they’re using something entirely different like cocaine. Judge says go to a treatment program or go to jail. Treatment program says they can’t use suboxone. So maybe they go in to deal with their cocaine problem, and by the time they come out they have a cocaine problem and a heroin problem.

The whole post (of which I’ve quoted nearly two-thirds) is worth reading, but I’ll end the quotes with this last paragraph, a point Scott has expounded upon in other posts and which I find attractive mainly because it’s counterintuitive and is evidence-based etc:

Society is fixed, biology is mutable.

People have tried everything to fix drug abuse. Being harsh and sending drug users to jail. Being nice and sending them to nice treatment centers that focus on rehabilitation. Old timey religion where fire-and-brimstone preachers talk about how Jesus wants them to stay off drugs. Flaky New Age religion where counselors tell you about how drug abuse is keeping you from your true self. Government programs. University programs. Private programs. Giving people money. Fining people money. Being unusually nice. Being unusually mean. More social support. Less social support. This school of therapy. That school of therapy. What works is just giving people a chemical to saturate the brain receptor directly. We know it works. The studies show it works. And we’re still collectively beating our heads against the wall of finding a social solution.

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