Opioid Addiction: Is There a Solution?

IN 2014, an unfortunate record was broken in the United States: Drug overdose deaths reached an unprecedented high, with more than 60 percent of them involving an opioid such as heroin, morphine, hydrocodone or oxycodone.¹ And in 2016, of the 21.5 million Americans age 12 years or older who suffer from opioid addiction, 1.9 million abused prescription pain relievers and 586,000 abused heroin.² Roughly 78 people per day die of opioid overdose in the United States,¹ and since 1999, around the time when opioids became a popular painkiller, the amount of prescription opioids sold has almost quadrupled, as have deaths from prescription opioid overdoses.³

Former U.S. Food and Drug Administration (FDA) commissioner David Kessler, MD, told CBS News that overprescribing opioids “has been one of the great mistakes of modern medicine. FDA has responsibility, the pharmaceutical companies have responsibility, physicians have responsibility. We didn’t see these drugs for what they truly are.”⁴

With these numbers and such sobering insight from a leading physician, it’s easy to see that opioid addiction is a deadly and growing epidemic. The problem often seems out of control since even legally prescribed amounts of opioids can be easily and severely abused. Access is easy, and addiction can be virtually instant for some. And, the problems of drug abuse extend well beyond merely the user, because entire families are devastated by the effects, fetal harm is catastrophic during users’ pregnancies, crime and violence often accompany drug use, and hepatitis C and other illnesses are more common among users.¹

Opioid Addiction Intervention

But is there hope? And is there a proverbial light at the end of the tunnel for millions of healthcare providers who try to help addicts daily?

One sign of hope is that the U.S. government, medical schools and healthcare providers are recognizing the importance of training addiction specialists. Todd Korthuis, MD, MPH, associate professor of medicine at Oregon Health Sciences University and program director of the school’s addiction medicine fellowship, says, “Addiction medicine is an emerging specialty in the United States that didn’t exist 10 years ago. The idea is to train up healthcare providers from very diverse backgrounds, not just psychiatry, to be able to assess from a medical standpoint addiction issues in people who run into problems with prescription opioids. It’s one thing to diagnose that someone is addicted to their pain medicine; it’s quite another to treat that while you’re safely managing their pain.”

According to Dr. Korthuis, recent government initiatives to solve the opiate problem have also been helpful. For example, he says, the Centers for Disease Control and Prevention’s (CDC) pain management guidelines “distill recent research about the negative impacts of opioid prescribing for chronic pain, both in terms of side effects and risks for patients, and also the risk at precipitating opioid use disorder and addiction issues in people who start taking them for pain.” In 2016, Dr. Korthuis headed a policy meeting in Washington, D.C., on how to channel these CDC recommendations into medical training.

But, the guidelines have caused controversy. “One thing everybody is worried about with the guidelines is that they’re recommending a target of no more than 90 morphine equivalents per day,” Dr. Korthuis explains. “So, why 90? Because somewhere between 50 and 90 is where the risk of an unintentional overdose starts to increase. That’s why people are dying of overdoses in the U.S. It’s not that doctors are giving three Vicodin once a month to someone with arthritis. It’s that we’re giving elephant doses to people who build tolerance over time and may or may not be responding to it. We’re also largely ignoring the much more evidence-based approaches such as cognitive behavioral therapy, myogenesis therapy, complementary and alternative approaches to pain management, and maximizing serotonin and norepinephrine with medications.”

As doctors learn more about such alternative approaches, there is also the hope offered through various types of recovery programs and pharmaceuticals designed to ease physical dependence on opioids.

Drug-Related Treatment Options

There are medications that can assist with opioid addiction. But, do they always work?

According to Dr. Korthuis, “Medications such as methadone, Probuphine [buprenorphine] and naltrexone help decrease cravings and help the brain reset so addicts are not driven by cravings and withdrawal symptoms. What we know is detox doesn’t work on its own for opiates. The death rates and relapse rates are off the chart. Around 96 percent of people will relapse within six months after opiate detox alone. But starting on either methadone in an opiate treatment program or buprenorphine in an office-based setting decreases the risk of relapse to somewhere around 40 to 50 percent.”

Chris Borgeone is a good illustration of how medication can assist recovering addicts in their transition. He hopes Probuphine will allow him to beat his dependence on pain killers and help him live a normal life without the urge to use every day. Because Probuphine is implanted in the upper arm, patients don’t need to worry about missing a dose or two and potentially relapsing as a result. Borgeone told CBS News that his Probuphine implants are helping him tremendously: “I’m hoping at the end of treatment, I’ll be able to move forward without any medication whatsoever.”⁵

Such drugs have been shown to help patients’ social functioning and reduce the risks of overdose, contracting diseases such as hepatitis C and criminal activity.⁶ How people on these medications transition to life without them is also key in their recovery. For many, a cognitive-based therapy or a 12-step program is a helpful supplement during that transition.

Nonspiritual Recovery Programs

SMART Recovery, a leading self-empowering addiction recovery support group, exists to help people recover from all types of addiction, including alcoholism, gambling, drug abuse and sexual addiction. It focuses on making addicts self-reliant, using what it calls its 4-Point Program: 1) building and maintaining motivation, 2) coping with urges, 3) managing thoughts, feelings and behaviors and 4) living a balanced life.⁷

It is not a 12-step program, which some consider one of its benefits. Instead of a step involving surrender to a higher power, it emphasizes patients’ self-reliance and ways to modify their behavior. It encourages the belief that patients do have control over their choices and, ultimately, their lives.

Hank Rob, PhD, a board-certified psychologist in Portland, Ore., is an enthusiastic proponent of SMART Recovery. “The program doesn’t tell people that they have to abstain, but it is a program for people who have chosen abstinence. I really want to underline that,” he says. “One of its central tenants is exerting your power of choice. So, if you choose to abstain, then the program is there to help people who make that choice.”

A significant difference between SMART Recovery and 12-step programs is that SMART Recovery views any spiritual aspect of healing very differently than the latter. “I think it depends on what is meant by spiritual,” Dr. Rob explains. “If you take the first step of the 12 steps seriously — that you are powerless over your behavior — then you are certainly going to need something that will allow you to control yourself. If you don’t start with the premise that you’re powerless, then finding something that is powerful and can help you takes a different flavor. One point about SMART Recovery is not that you’re powerless, but that you’re not exerting your power in a way that works for you over the long term. Most people think about willpower as something that allows you to abstain. But abstaining is how you get the willpower to abstain. It’s like building muscles. How do you build strong muscles? By working them out! You don’t get the strength by having the muscles first.”

Cognitive behavioral therapy is used extensively in SMART Recovery, which Dr. Rob says includes “accepting (not necessarily approving) and willingly being who you are instead of grudgingly being who you are or putting yourself down.” Accepting others and the world in general is equally important. “If you really approach yourself and people and the world with that kind of acceptance, instead of demanding that the world be a certain way, namely your way, that itself is what I would call a spiritual transformation,” he says. “And if that’s what the importance of a spiritual aspect means, then I certainly agree that SMART Recovery is spiritual. But if you mean a higher power that’s required because you’re powerless, then that’s a different kind of an idea.”

“There’s a lot of hope for treatment,” he adds. “And, one thing we know is that change is a function of efforts to change. So, what really matters is continually making the effort to change. If you keep at it and keep at it and keep at it, eventually, you do change. The nature of habits is we do them quickly and effortlessly and without much awareness. So, if you’re going to change a habit, the first thing is consciousness raising. You’ve got to get more aware of it.”

No one is immune to lapses, and SMART Recovery also teaches addicts how to deal with them. “The only effective mechanism, since you can’t get rid of that [urge to return to addictive behavior] is to learn to recognize the temptation and then refuse to go along with it,” explains Dr. Rob. “SMART Recovery advocates a technique called DISARM, which stands for ‘destructive imagery self-talk and refusal method.’ So, you recognize your destructive thinking and self-talk and refuse to go along with it. The more you practice this, the better you get at it. The more you give in, the better you get at that.”

As for results, SMART Recovery reports that it is as effective as 12-step programs and other programs that employ cognitive behavioral therapy.⁸

12-Step Program Groups

Unlike SMART Recovery, Narcotics Anonymous (NA), like other 12-step programs, identifies itself as a spiritual fellowship. The organization offers a recovery process and peer support network that are linked together. According to NA, its success is the therapeutic value of addicts working with other addicts. In a 2015 survey, participants in NA have an average length of “cleantime” of 8.32 years.⁹ Two examples of this are recovering addicts Emberlee and Judith (NA prohibits its members from revealing last names).

After two suicide attempts and multiple attempts to stop using, Emberlee claims she would not have recovered without the steps. “I am sober today,” she says. “I never thought that was possible. The 12 steps is where I found hope. I had to do something, and I’d heard for so many years that the only thing that worked was doing the 12-step program. And it did. The difference is that there are steps. I was told it’s not a drug problem, it’s a thinking problem. For me, addiction is entirely a thinking problem. Until I understood that I needed to change my way of thinking, I continued to revert back to drugs. I thought that was my solution. I’m not saying that drugs aren’t addicting, because they are. But without a 12-step program, I would always go back to drugs. And without being institutionalized, I didn’t know how to stop, and I couldn’t stop. I literally was physically dependent on an opioid to get up out of bed in the morning.”

Emberlee adds that the spiritual solution in the program is what gave her a temporary reprieve. “So as long as I stay in fit spiritual condition, I don’t have to use today, and I won’t use today,” she explains. “But it requires me to take action every single day to do something for my recovery, to work a step, to talk to another addict, to go to a meeting. It requires me to do things every single day for my recovery.”

Judith, an attorney and recovering addict who now operates clean-and-sober-living facilities in the Midwest, believes that rehab is an important part of recovery, but it’s not the only component. Many addicts, she says, are most vulnerable after rehab, and without a 12-step program and the support of caring people, treatment has only a 3 percent success rate.

For her, mere abstinence was insufficient as well. After 11 months of being clean and sober, without a daily program and nothing to change her unhealthy thinking, Judith says, “I was just a hair away from suicide. When I was abstinent, I could not feel meaning or fulfillment. I could not function. I would have gone back to drugs because I hadn’t changed my thinking yet. And the longer I was away from the drugs, the more horrible it was. But when I finally did the 12-step program, and really worked through, completed and followed the steps, I got a connection with a higher power. Call it God, call it whatever. That’s when I recovered.”

Judith realizes that many people don’t want to acknowledge the existence of a power greater than themselves. They want a medical or purely science-based solution. But, she firmly believes that recovery must be spiritually (but not necessarily religiously) based. “What we say is a drugs and alcohol problem is but a symptom of someone’s spiritual malady,” she explains. “That does not mean there is not a physical component. There very much is a physical component of addiction.” The problem, she says, is that many doctors and treatment centers don’t acknowledge the spiritual component. Instead, they focus only on the physical element.

An Epidemic of Hope

With addiction specialists such as Dr. Korthuis becoming better trained and more prominent, improved opioid addiction drugs such as Probuphine helping addicts to be weaned off substances, the government’s dedication to ending the opioid addiction epidemic, and devoted recovering addicts who strive to help other addicts successfully navigate recovery programs, there are hopeful solutions to opioid addiction. But no matter what form the solution, it requires hard work, daily commitment and constant support from family, friends and the medical community. For addicts who are ready to accept help, work for it and commit to it, there is great hope.