It is ten below zero in what seems like the middle of nowhere in Pennsylvania. The sun is as bright as the air is crisp. Michael is outside wearing only his lacrosse pinny and a pair of shorts.
“What are you doing out there?” a voice shouts from the doorway.
“I’m okay,” Michael assures his counselor. “I can’t remember the last time I felt cold, that’s all.”
Michael is in his third week of a twenty-eight-day stay at a residential treatment center. At twenty-three, he is already a hard-core opioid user. Completely drug- and alcohol-free for the first time since the eighth grade, Michael is testing the waters. Feeling cold, he decides, is nothing to complain about. It is exhilarating.
Michael first approached drug use like many adolescents do. At twelve or thirteen, he tried beer and vodka and then progressed to pot. He was the first of his high school friends to try ecstasy and cocaine. He liked being the first. It meant he was good at what he did.
An honor student and athlete, playing on his high school hockey and lacrosse teams, Michael, despite his love of drugs, did not suffer any seriously negative consequences. He came close—like the time when he and his friends were pulled over by police—but he talked his way out of any potential trouble and glided through high school unscathed. By age nineteen, he was already bored with the bar scene in his hometown. He was ready to start college, where he had made the hockey and lacrosse teams.
In the spring of his freshman year, the college notified Michael that he was being kicked out for failing or dropping out of four classes, but he convinced the school he would turn his grades around. He returned in his sophomore year and picked up club sports as his poor grades made him ineligible for the college teams. When he injured his foot playing the precarious position of goalie for his lacrosse team, the doctor prescribed OxyContin, which Michael dutifully took. His next thought was that nothing should feel this good—and that nothing that feels this good should be in the possession of a twenty-year-old.
Before injuring his foot, Michael had never thought about opioids. He was so naive about the drug that the first time he went through withdrawal, he thought he had the flu. But he quickly became intimately familiar with what opioids can do.
Michael often quipped that his drinking and other drug use left him with a blood alcohol level higher than his GPA. He was kicked out of college before the end of the first semester of his sophomore year. Depressed and anxious, Michael woke up to find himself on the ledge outside his apartment building, between the seventh and eighth floors, with an empty bottle of Jameson in hand. (How he managed to stay atop is a mystery. He remembers nothing of his intentions. He only knows he is grateful he did not roll over in his sleep.)
Michael returned to his parents’ home in New York. At six foot two, he weighed a mere 143 pounds. His Facebook friends posted photos of travel and good times, while he isolated in his room and took drugs. Months after first trying opioids, Michael now needed to crush and snort three Oxys before he could even get out of bed. His first thoughts were not What classes do I have today and who will I meet up with? but Who am I going to rip off and how am I going to get my fix?
Raised in a loving family with solid values, Michael knew that what he thought and did was against everything he was taught and held dear. He started to believe he was some kind of monster and refused to look in the mirror for a solid two years. He was loath to see who he had become. Suicidal thoughts filled his head: He would keep using for as long as he could and then jump in front of a train. (Now, when he recalls this, it is with disbelief.)
Moody and argumentative, he ruined every holiday. When confronted by family about his use, he became violent—throwing objects or yelling. His parents caught him stealing money from them on more than one occasion. The last straw was when he snatched his aunt’s painkillers, given to her postsurgery, during a family weekend at a beach house. A few months later, his family intervened, and Michael was ready—more than eager—to get help.
When Michael entered the residential facility, his physician asked whether he wanted to try buprenorphine. But Michael was done with any drug containing opioids. He was done with dark thoughts. He was done with living a lie and hurting the people he loved. He went through detox and started extended-release naltrexone. And then he went outside in the cold to feel what it meant to be human again.
When Patients Begin to Blossom
There is something inherently rewarding about treating opioid users. Within two to three weeks, they undergo a profound change. They look and feel much better. Everyone around them notices that they are getting well. Helping patients addicted to cocaine or alcohol is also gratifying but different. They experience a lot of ups and downs in early recovery. People coming off opioids, however, quickly start to blossom.
We might attribute the stark difference that takes place in heroin users, in particular, to the fact that most come into treatment looking and feeling emaciated, depressed, and resigned. Most also bear a heavy load of shame. They’ve been through a lot to survive, often on the streets, doing things that defy even their strongest values. Sometimes for years or decades. But it does not matter how much time they have spent wasting away. In just a short time, their senses begin to wake up, and they start noticing and enjoying the little things, as well as some major physical changes. They regain their appetites, bowel functions, and libidos. Women start menstruating again. Mood quickly improves, and they want to go back to interests they abandoned as the addiction took over. They start feeling human again.
With this usually comes a backlog of emotions. Opioids level all emotions, good and bad. Most opioid users in treatment are surprised by the swelling of foreign sensations within—they feel happy, sad, excited, motivated. Sometimes all at the same time. Being witness to this is an honor in some way. It is like watching a child laugh, or just start to walk, for the first time. Then, some of them suddenly remember why they started taking opioids in the first place: social anxiety, depression, rape, no job. This proves overwhelming and produces a mounting urge to use. For some, these feelings are a formative experience. They use their feelings to become wiser, more insightful and more mature. This growth does not happen overnight. Over time, with the help of counseling and behavioral treatments, life starts to look better.
Despite the profound changes that take place early on, relapse is extremely common for people with OUD. We know that relapse is also highly dangerous for those who have detoxified. Their bodies can no longer tolerate amounts previously consumed, and they have easy access to a marketplace full of potent fixes. And so, as you know by now, I am convinced that stabilizing the OUD patient using medication is paramount at this stage, because it helps to prevent relapse, which saves lives and gives people a chance to work on recovery without the constant distraction of cravings.
But stabilization is just the beginning. A major shift has been taking place in treatment circles that embraces the medical model for treating OUD in the long term, which for some people can mean lifelong use of methadone, buprenorphine, or naltrexone.
The Major Shift in How We Treat Opioid Dependence
Over the past century, health-care professionals like myself have learned a lot about what does not work when it comes to treating OUD. Effort went into testing various ways to detoxify opioid users comfortably. We tried short detoxes and long detoxes, and we tried all sorts of remedies, many of them quite dangerous. We gave patients methadone or buprenorphine or clonidine to help wean them off opioids and then gradually tapered them off these drugs (methadone and buprenorphine were used for detoxification before they were thought of as primarily maintenance agents). Over and over again, the evidence showed that it does not really matter how effective the detoxification process is or how smoothly it goes. After we detoxified patients, most relapsed—many of them right after the detox was over. Not only did we not help patients, we heightened their chances of having a deadly overdose, as detoxification took away their tolerance for the drug.
Now we know much better: If we start patients on a medication, such as methadone or buprenorphine, with the intent to keep them on it indefinitely, most patients have a fighting chance. If patients want to change medication or modify dosages, we review their progress and consider working their goals into a treatment plan. If patients want to be fully detoxed, we detox them and then prescribe naltrexone, which is not an opioid agonist. If patients want to stop using medications, we talk about how stable their recovery is, begin to taper the medication, and carefully monitor them. If patients decide to stop their medication themselves, more likely than not they relapse.
Study after study shows medication to be the most effective way to treat OUD. But the shift to using the medical model has been so painfully slow that thousands of people die every year because so few treatment centers offer evidence-based treatment. Equally disturbing is when clinics offer medication but require that patients taper off it on a certain timeline.
Resistance to Change
Resistance to the medical model approach to treating OUD comes from two camps: patients (and sometimes their family members), and treatment providers. Rather than being happy that a medication can keep them alive and well, many patients and their loved ones reject the idea of medication as a necessary evil. Some want nothing more than to leave it behind them as soon as possible. This kind of thinking stems from a deep disappointment and difficulty accepting the loss of health. I have never met a patient who wants to be told they have a chronic disorder that requires lifelong treatment with medication, even if the medication is highly effective. This happens in traditional treatment centers as well: No one wants to hear that they have to abstain from all mood-altering drugs and attend Twelve Step meetings for the rest of their life. The idea of having a chronic condition is a hard pill to swallow. Psychiatrists know it well. It takes many years for people with bipolar disorder, for instance, to accept that they have a chronic illness and need to be on medication for the rest of their lives. Those who do not accept their illness spend their days wrecked by it.
Medication is a gift, a fruit of modern science that not only extends but remarkably improves the lives of people afflicted with OUD, a devastating disorder. If we are to overcome the opioid epidemic, every professional who engages with a person who uses opioids must embrace the individual, the evidence, and the condition for what it is: a lifelong, incurable disorder that can be managed successfully with medication.
The Evidence Is Overwhelming
Preventing relapse is a treatment priority for OUD patients. Intense cravings for opioids may last for months after stopping use, and can be powerful enough to cause a relapse. Detoxed people who take more drugs than their bodies can handle can easily overdose. Relapse prevention is synonymous with overdose prevention, with preventing death.
To win the battle, we must fight fire with fire. Anyone who offers opioid addiction treatment must let go of fanciful notions of a medication-free recovery for every patient. It occasionally happens, yes, but the evidence and the statistics do not lie. The only evidence-based method currently available to help prevent relapse to opioids is a medical model that includes long-term medication as the most essential intervention. The evidence is overwhelming and cannot be ignored. Centers that do not use medication to treat OUD are no match for today’s opioids. Continuing to tout other treatments as effective against OUD is akin to giving patients a death sentence, and has led to lawsuits for more than one treatment center that claimed to offer effective treatment but did not follow evidence-based guidelines.
To some addiction counselors in practice today, using the medical model to treat OUD may sound heretical. But I am not some rogue advocate of this approach. All published treatment guidelines from all the major addiction groups call for using treatment that includes medication, sometimes referred to as medication-assisted treatment, or MAT, to treat opioid addiction. These groups include the US surgeon general, American Society of Addiction Medicine, Centers for Disease Control and Prevention, US Department of Veterans Affairs, and the World Health Organization, as well as a number of guidelines prepared by professional organizations in other countries. All the research literature points to what I am saying. This is nothing new. Yet government funds and insurance, including Medicaid, continue to cover the cost of traditional programs, further perpetuating the problem.
The medical model approach speaks to the current public health crisis, which is a crisis of the treatment gap and opioid overdoses. Initially, one treatment should fit the majority of patients: Stabilize patients using medication, provide support for patients to adhere to the medication, manage coexisting medical and mental health issues, and help patients develop new skills. This approach stalls the addiction and saves lives. Once a patient is stabilized and in the system of care, then we have the luxury of customizing our treatment approach.
Traditional Treatment
Twelve Step–based therapies and meetings are a meaningful path to recovery for many people, who learn to let go of resentments and behaviors that keep them using. Twelve Step meetings, such as Narcotics Anonymous, offer an accepting and supportive community, and people learn they are not alone in their disorder. Those in recovery are fortunate to have Twelve Step meetings and other supports. But for OUD, some flexibility is in order. The traditional nonmedical model of psychosocial treatment involving withdrawal management (detoxification) followed by treatment without medications should not be used as a first-line approach as it has a very high failure rate—on average, greater than 90 percent within the first three months. And detoxification without medication to prevent relapse increases the risk for overdose due to the loss of tolerance for the drug.
When combined with medication, traditional treatment approaches work for OUD. As patients engage with treatment and follow the program, their thoughts move away from craving and using. Some traditional programs, such as the Hazelden Betty Ford Foundation, have adapted their policies to combat today’s formidable opioids by offering medication to their patients with OUD. Some programs have even changed their definition of sobriety to accommodate patients who are abstinent with the help of medication. But only a handful of traditional addiction treatment centers has the medical staff or funds required to administer medications, and some advocate for a short course of medication treatment before the “real” sobriety can set in. Many centers that would agree to offer medications are unable to. Or they face resistance from staff or even alumni and donors.
In the midst of the nation’s worst drug crisis ever, we cannot wait for the costly and time-consuming change in attitudes and methods in treatment centers across America. We cannot wait to train a new generation of treatment providers. We are obliged, instead, to turn to other opportunities to effectively treat opioid users who want help now—namely, an existing and already highly organized system that regularly employs the medical model for chronic disorders.
A Call to Medical Professionals
Medical professionals in health-care settings can fill in the huge gap in evidence-based treatment services that exists today. Opioid users should be able to walk into their local clinic, request help for OUD, receive an assessment and medical checkup, have a conversation about treatment options, and, if the patient agrees and the doctor finds it appropriate, receive a prescription for buprenorphine on the spot. The same could happen every time an opioid user overdoses and lands in a medical setting. At a follow-up appointment, the physician and patient can discuss next options, which are much easier to plan and execute when the patient’s mind is clear, or at least not filled with intense urges to use or physical and mental distress.
Research shows that patients started on buprenorphine on the spot remain connected with treatment and initially fare far better than those who only get a referral to treatment, which is easy to dismiss. Allowing overdose patients to walk out the door is a missed opportunity. One third of opioid users who overdosed in a year did so again the following year. Half of heroin injectors who survived an overdose will have a fatal overdose at some point. These are scary statistics that further accentuate the need for immediate treatment of overdose victims.
Opportunities to start OUD treatment straightaway really should be endless. Primary care physicians, physician assistants (PAs), and nurse practitioners (NPs) do not need to be addiction experts to offer buprenorphine; they need a short course of training. Professionals throughout the health-care system, however, should have at least a cursory knowledge of OUD as a chronic disorder, understand what evidence-based medical treatments for OUD involve, and be aware of who in the area offers evidence-based treatment.
Addiction treatment centers can also refer stabilized OUD patients to community-based health-care practices. Vermont and Baltimore have successfully implemented this very promising system, sometimes known as hub-and-spoke, and other states have begun to implement it as well. Designed to eliminate wait lists for specialty treatment and reach underserved rural communities, hub-and-spoke systems set up regional outpatient treatment centers (hubs) throughout the state or the city. Staffed by board-certified addiction specialists, hubs are responsible for evaluating patients for OUD and other psychiatric disorders and stabilizing them with medication. Once patients are stabilized, the hub refers them to a spoke, a family doctor in the patient’s community who can provide buprenorphine or naltrexone. If patients become unstable, the doctor (spoke) refers them back to the hub. Spokes can consult with hubs and receive ongoing education, which contributes to their proficiency in treating the OUD population.
Training for Medical Providers
Steps Leading up to Treatment
Regardless of the setting, treatment usually begins with the patient answering some screening questions. A more detailed assessment and diagnosis based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria can come next.
Everyone should undergo a brief medical screen to assess any medical or psychiatric concerns. If OUD exists, the provider should offer the patient one of the three medications approved by the FDA for use in treating OUD.
Screening: Screening individuals for opioid and other substance use disorders can take place in a doctor’s office, the emergency room, school, prison, or a social services setting. Routine screening can pinpoint individuals who have experienced problems because of substance use (such as a DUI) or already developed a substance use disorder. Professionals have access to several useful screening questionnaires that patients can complete in a matter of minutes. A frequently used questionnaire is the Drug Abuse Screening Tool (DAST-10), which asks ten simple yes/no questions, such as “Are you always able to stop using drugs when you want to?” Answers are more likely to be accurate if the screener ensures confidentiality.
Brief intervention: When screening reveals problems related to substance use, the screener has an opportunity to discuss those problems openly with the patient. This intervention is part of the SBIRT approach described in chapter 3. The session can be brief, lasting as little as five to ten minutes. The focus is on educating patients about the risks of substance use, without judgment or confrontation, and allowing patients to tell their part of the story and to disagree. With patients who are at risk, the screener ends the meeting with positive feedback and appeals to patients’ values (for instance, wanting to be fit or respected by their children) with a suggestion to consider drinking or using less, preferably with a specific goal (for example, no more than four drinks per night, two nights per week, for a man). The patient can then schedule a follow-up appointment to review those goals in three or four weeks.
If the patient has a significant problem related to drug use, perhaps a substance use disorder, the screener immediately refers the patient for further evaluation and treatment with a medical provider. Not all patients are motivated, so the screener can use techniques proven to increase follow-through with the referral: make the phone call with the patient and set up the appointment at that moment; make frequent follow-up phone calls until the first meeting with a new provider takes place; and involve a significant other, friend, or a patient navigator who can accompany the patient to the evaluation. If trained to provide a more detailed addiction evaluation, the provider can offer treatment on the spot.
Evaluation: An evaluation involves testing for opioids and any other substances in the body and asking about symptoms of opioid withdrawal to confirm physical dependence. Equally important are the patient’s medical and psychological health, motivation to begin treatment, and goals (what does the patient want?). Finally, the provider takes this time to establish a therapeutic relationship with the patient based on trust and respect.
Medical and/or psychiatric evaluation: Acute medical problems, such as confusion, unresponsiveness, fever, or seizures, as well as serious psychiatric conditions, such as psychosis or suicidality, should be addressed before a person begins treatment. Other mental health issues can be addressed at the same time as addiction is treated, preferably in a setting that treats coexisting disorders. (See pages 116–124 for more about treating co-occurring disorders.)
Diagnosis: Diagnosis always comes before prescribing medication, although in urgent cases, a full, Rolls-Royce assessment can come after treatment is started. Professionals rely on the DSM-5 for a list of OUD symptoms, which include cravings to use drugs, failure to stop or reduce drug use, spending a lot of time using and obtaining large amounts of drugs, continuing use despite problems with health or responsibilities, and finally, the presence of drug tolerance or withdrawal symptoms (see a list of diagnostic standards on here). The patient can have mild, moderate, or severe OUD depending on how many criteria they meet.
Education: Patients have a right to be fully educated about treatment options. Providers should explain the three main medications used to treat OUD and cover requirements to start treatment; advantages and limitations of each option; side effects and other risks, including overdose and dropout issues; and duration of treatment for each medication. Providers should also explain the different treatment settings: inpatient units, residential programs, outpatient specialized programs, and treatment at a community health clinic with a primary care doctor. The importance of specialized behavioral approaches, self-help groups, and recovery-oriented activities should be part of the discussion as well. Finally, the patient should thoroughly understand the risks of delaying treatment and the risk of treatment without medication. Providers should inform all patients diagnosed with OUD that they have a chronic disorder that will most likely progress if left untreated and that may result in irreversible complications and even death.
Decision-making: At this point, patients have to make a decision, and they should have all the information needed to evaluate their options and to choose treatment in collaboration with their doctor. Providers need to review access to treatment in the patient’s community and cost. Patients should be given time to think over the decision and ask questions. When available and appropriate, the final discussion should involve a family member or a significant other.
Long-Term Treatment: One Size Does Not Fit All
OUD, like many other disorders, is chronic. The word cure is never used, because the changes in the brain persist, and relapse is always a possibility. When relapse occurs, the brain pathways involved in maintaining a repetitive opioid use reactivate rapidly. Cravings, tolerance, and physical dependence increase accordingly. The goals of treating OUD are the same as they are for other chronic medical or psychiatric illnesses. Medical professionals work to: (1) reduce the severity of symptoms to nonproblematic levels; (2) improve physical health and psychological well-being; (3) improve functioning and quality of life; and (4) teach patients to monitor their disorder, identify threats to relapse, and become responsible for managing their disorder. All four goals are achieved much more quickly if medication is begun as soon as possible.
Not everyone responds the same way to a method of treatment, and anyone charged with determining how a person with OUD should be treated has a responsibility to inform the patient about all the available options—including treatment without medication. Yet this rarely happens. Different treatment centers prefer one form of treatment over another. They create treatment silos. Some, for instance, prefer naltrexone over buprenorphine or methadone over naltrexone. In addition, providers need to expose patients to different aspects of treatment, when needed. Many patients need more than medication.
Evidence-based treatment for OUD involves a combination of several approaches:
Once a patient is stabilized, providers can individualize a range of possible treatment goals for each patient. The ultimate goal is to initiate long-term recovery, which the Betty Ford Institute Consensus Panel in 2017 defined as “[a] voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.”
The New Definition of Sobriety
Medication with psychosocial treatment (counseling and behavioral therapy) and mutual support groups is a powerhouse treatment for OUD. The medication can reduce physical discomfort, improve mood, and eliminate cravings for opioids, all of which helps to prevent relapse—the number one life-saving goal for people with OUD. The three FDA-approved medications proven to help treat OUD are methadone, buprenorphine, and naltrexone. Understanding how they work, how they differ, and which is most appropriate for any given individual is important when deciding on a treatment plan. Prescribers, patients, and family members who understand the pharmacology can avoid making some common mistakes.