“DO YOU THINK YOU CAN handle the whole story? Or do you want the PG version?” Jackson asked me over the phone.*
“Just tell me as much or as little as you feel comfortable sharing,” I responded.
By now I have heard many gritty stories of opioid addiction, which is the compulsive use of opioids despite negative consequences. For the past three years I have spent a significant portion of my time interviewing people in recovery, their families, health care providers, criminal justice system employees, and policy makers. I have conducted more than 120 in-depth interviews and analyzed hundreds of hours of interview transcripts. Not to mention the numerous informal discussions with concerned people, ranging from police officers to twelve-step group leaders to other public health researchers like me.
I wish I could say that the story Jackson went on to tell me was an anomaly—that few Americans experience the kind of early childhood trauma he faced prior to regularly misusing drugs. But according to a world-famous series of studies on adverse childhood experiences, drug use and drug addiction are strongly predicted by trauma during childhood. These events range from sexual assault to emotional abuse to physical battery and neglect. According to one of the most cited peer-reviewed medical studies on the topic, two-thirds of injection drug use is attributable to childhood abuse or trauma.1 The initial adverse childhood experiences study, which involved seventeen thousand participants, mostly white, middle-class individuals with health insurance, found a “dose-response” relationship between trauma and substance use disorder.2 In other words, the greater the trauma, the more intense the substance use disorder. Since that first study, numerous other studies have found similar results in a wide variety of populations.3
From a scientific standpoint, the relationship between adverse childhood experiences and addiction is unsurprising for two reasons. First, adverse childhood events may cause mental illness, such as post-traumatic stress disorder, anxiety disorder, or depression, and people with mental illness may self-medicate with drugs,4 especially if they have not learned positive coping strategies.5 Children raised in harmful or unsupportive homes are less likely than those raised in supportive homes to learn healthy ways of modulating their emotions.5 Second, trauma negatively impacts the parts of the brain, neurological pathways, and behaviors that are implicated in substance use disorders. For example, trauma may increase impulsivity, and impulsivity may increase the likelihood of using drugs.6
For many people, drugs become a coping mechanism for post-traumatic stress disorder or depression. Others experience opioid addiction after repeated exposure to prescription pain medications, such as oxycodone or hydrocodone, following an injury. The latter is called iatrogenic addiction, meaning caused by medical treatment. In the past two decades, the number of opioid prescriptions written by physicians quadrupled for conditions such as chronic pain. This increase reflected a response to unethical marketing by pharmaceutical companies and pressure from the US government to alleviate patients’ pain.7 Not surprisingly, iatrogenic addiction quadrupled during that same time period.7
The United States is facing a health crisis in which more than 115 Americans die daily from opioid overdoses,8 with 500,000 deaths expected in the next decade. The crisis is a result of both supply and demand forces. On the demand side, many people initially exposed to opioids for pain management developed an addiction to opioids, and numerous people with untreated mental health disorders sought opioids as self-medication. On the supply side, opioids became widely available, due to both the overprescribing of opioids for pain management and an influx of readily available, cheap heroin and illicit fentanyl as substitutes.9 Prescription pain medications, opium, heroin, and fentanyl are all opioids and affect the brain in essentially the same way.
Despite the media’s focus on upper-middle-class families exposed to Oxycontin following an injury, most people whom I have interviewed come from a lower socioeconomic background, often with parents struggling with their own addiction, unemployment, or mental health issues. Opioid addiction is often called an “equal opportunity” problem because it can affect anyone of any background. According to the National Institute on Drug Abuse, however, such terminology obscures the fact that the hardest hit populations have been those from lower socioeconomic backgrounds as well as people in rural areas, such as Appalachia.10 A stressful environment, such as one with limited employment opportunities, negatively impacts mental health, increasing the likelihood that an individual will develop a substance use disorder.10 Combine such social disparity with untreated mental health disorders and an influx of opioids and you’ve got a full-blown public health crisis.
Regardless of how addiction starts, the National Institute on Drug Abuse and other scientific institutions call opioid addiction a biopsychosocial brain disease.11 In other words, it is caused by a complex combination of biological, psychological, and social factors. Many other less stigmatized chronic diseases likewise result from these factors, including diabetes, depression, chronic hypertension, and asthma.
Jackson’s story is one of the more harrowing ones I’ve heard. It really starts with his mother’s story, as do many narratives of multigenerational drug addiction. Jackson’s mother, Kelly, was a victim of incest, repeatedly raped by her father in a small Midwestern town in 1970s America, a time when police preferred to look the other way and stay out of “family matters.” At the age of fifteen, she gave birth to Jackson. By then she was already using crack cocaine.
When she was pregnant with Jackson, Kelly moved in with her boyfriend, though the relationship was neither healthy nor stable. The boyfriend also used crack cocaine, along with alcohol and marijuana. Jackson’s first memory of drugs was at the age of three. His mom was throwing a party in their rundown apartment. Lines of cocaine lay ready for snorting on the living room coffee table. Seeking refuge, Jackson climbed over passed-out bodies on the living room floor to reach his mother. Kelly grabbed him and forced a marijuana joint in his mouth, clamping his nose with her fingers, while her friends looked on and laughed at the three-year-old getting high. Jackson’s mother then poured an entire bottle of beer into his mouth, with more laughter ensuing. It’s not hard to understand why Jackson was regularly smoking marijuana and drinking by the age of seven.
When he was six years old, Jackson was raped for the first time. It was his next-door neighbor, who was also his babysitter. Kelly found her son sobbing later that evening. After Jackson told her what the neighbor had done, she marched over to the neighbor’s house demanding an explanation and an apology. She got what she wanted, and the neighbor promised to never rape Jackson again. The next time Jackson’s mother went out and needed a babysitter, she hired the same neighbor.
By the age of ten, Jackson was so neglected that the state’s Department of Child Services took him away and placed him with a foster family. That family was okay—stable but not particularly kind toward the melancholy boy who would sometimes start shaking for no reason. But as often happens to foster children, Jackson was eventually sent to a new family. This family had a blond man who asked Jackson to call him “Dad.” Then, like the old next-door neighbor, “Dad” proceeded to regularly sexually assault Jackson. So, Jackson ran away.
By fifteen, Jackson’s “home” consisted of homeless shelters or friends’ sofas. He was also using every drug he could get his hands on. He had never been to a counselor, let alone a dentist. He hated his life, regularly skipped school, and felt miserable. More than once he thought of killing himself. Arguably, the best thing that ever happened to him was when his girlfriend, Diana, got pregnant at the age of seventeen.
Jackson wanted to be a good father. But he knew this meant not getting high every day or else the Department of Child Services would take his daughter away too, just like they had taken him away from his mother. He’d only ever heard of one resource to stop using drugs: Alcoholics Anonymous (AA). It was also the only recovery method available in his small city. Jackson started attending AA meetings regularly and, for the first time in his life, associated with older men who were not abusive, who did not use drugs, and who seemed to have his best interests at heart. It was like having multiple father figures. Jackson could call his sponsor at all hours, and the sponsor, a selfless, caring middle-aged man, would take Jackson out for a cup of coffee and talk.
Having dropped out of high school along with his girlfriend, Jackson worked odd jobs, mainly in the fast-food industry, to support his young family. But the local fast-food restaurants were flooded with drugs. The local heroin dealer was his coworker. And Jackson, who had still never received any counseling or psychiatric medication, had undiagnosed post-traumatic stress disorder, or PTSD. Almost every night he had nightmares. Sometimes he didn’t want to get out of bed in the morning, hoping to die instead. Heroin, more than anything, made him feel better. It numbed his emotions and gave him a sense of temporary internal peace—until he would experience severe withdrawal symptoms (diarrhea, vomiting, shaking, muscle spasms, and itching) coupled with profound cravings for more drugs. Despite AA and the support of his sponsor, Jackson’s heroin use escalated as he became tolerant to lower doses. He shifted from snorting to injecting heroin so it would have a stronger, faster effect.
When Jackson’s daughter was a toddler, Jackson and Diana broke up. They had never had much in common other than drug use. Diana was in rehab and Jackson was basically homeless, so his daughter moved in with Diana’s mother, someone with whom Jackson had always had a poor relationship. Diana’s mother prevented Jackson from seeing his own daughter more than a few times per month because of his drug use—which was ironic since Diana’s mother seemed to have a drinking problem and Diana herself went in and out of rehab.
Jackson’s life seemed to stand still even though he was aging. He loved his daughter and wanted to be the stable father figure he had never had. But each time he stopped heroin, he would feel depressed and relapse again. It was a vicious cycle of attending AA meetings, followed by internal promises to start on the path of recovery, followed by cravings and withdrawals, followed by depression and eventually relapse. Ten years passed, and he was still working in the fast-food industry. His social network bounced back and forth between the AA group and drug users, depending on whether he was using.
At one point, his AA sponsor, who had long suspected Jackson had PTSD, suggested that Jackson see a counselor. He had no health insurance, something food industry jobs rarely provide, but fortunately he found a public mental health clinic with payments based on a sliding scale of income. The counselor had training in both mental health and substance use disorders and was devoted to her work. But dredging up the painful memories made him want to escape into drugs even more. After every session, he felt so overwhelmed with toxic memories that it took all his courage to avoid heroin. Sometimes, the heroin won. After a few weeks, Jackson quit counseling.
Then something fortuitous occurred. Jackson asked his “friend,” Ryan, to bring him heroin. Ryan explained that he was no longer shooting up. He was trying to quit with the help of a medication-assisted treatment, or MAT, called Suboxone. He was buying Suboxone off the street since he could not find an actual doctor to prescribe it. Ryan would take Suboxone a few times a day, which would prevent him from getting high by blocking heroin’s effects. Plus, Suboxone took away cravings for heroin and prevented withdrawal symptoms. The craziest part was that it did not make him high, it just made him feel normal, even though Suboxone activates the brain’s opioid receptors.12 Suboxone is an opioid but it acts differently than other opioids.
Jackson was interested in this new medication. After all, he had tried counseling and AA. He could not afford rehab. Furthermore, all his friends who went to rehab started using again as soon as they got out. So like Ryan, he started buying Suboxone off the street. Without a doctor, though, it was hard to figure out exactly how much to take to prevent withdrawals and cravings. If he took too little, the Suboxone was worthless. If he took too much, it was a waste of money because Suboxone has something called a “ceiling effect,” wherein after a certain point, any additional Suboxone has no impact on the brain. And Suboxone was expensive, more so than other things sold on the street at the time. But as Ryan had predicted, the Suboxone took away most of Jackson’s cravings for heroin. And even if a fleeting heroin craving did occur, the knowledge that the Suboxone in his system would prevent a heroin high stopped him from shooting up.
Jackson, who was trying to avoid the drug-dealing streets as much as possible, searched for a Suboxone-prescribing doctor. But none existed within a one-hundred-mile radius of his city. He started driving out of town once each month to see a physician who would prescribe a thirty-day supply picked up from a drugstore on the condition that Jackson visit a counselor monthly. Sometimes when his car was out of commission or he lacked gas money, Jackson would pay others to drive him to the doctor. Sometimes the payment consisted of giving them some of his paper-thin Suboxone strips. They reminded him of mouthwash strips, dissolving in your mouth after a few minutes but less tasty, with an orange flavor that sometimes made him a little queasy.
Complying with the doctor’s orders, Jackson found a new mental health counselor at the same public health center he had once attended. The counselor signed a monthly form to confirm that Jackson was going to his appointments and then faxed it to the doctor’s office. The counselor always seemed annoyed with the paperwork and the fact that Jackson was getting Suboxone. Even though a large percentage of the treatment center’s patients had opioid problems, the center did not provide Suboxone, and Jackson felt that any discussions about the medication seemed awkward and inappropriate.
Jackson’s new counselor reaffirmed the first counselor’s diagnosis of PTSD. Treatment included processing painful experiences, realizing that he was not at fault for the abuse he had suffered, and adopting new coping mechanisms. Even though Suboxone had no direct effect on the PTSD, it gave him the physiological stability to do the psychological work. It was incredibly difficult: “The hardest work I’ve ever done,” Jackson told me over the phone. “And I’m still working through [the memories].”
The counseling sessions were excruciating, usually ending in a flood of tears and shaking, something he used to do as a kid. Even if Jackson wanted the temporary peaceful reprieve of heroin, he knew it would be a waste of money with Suboxone in his system. So instead, after a particularly hard session, he would call his AA sponsor or watch TV. And most days when he was not in a counseling session, Jackson had few or no cravings. For once, he could focus energy on reuniting with his daughter and, eventually, finding a new job.
Today Jackson is a peer recovery coach. That means he works for an addiction treatment center as a kind of guide for those who are just starting their recovery processes. He still takes Suboxone daily, though at a lower dosage than when he began the medication. Eventually, he plans to switch to another medication, called Vivitrol, which would block opioid effects without activating the opioid receptors. But it would take a two-week detoxification process, which could be destabilizing. Jackson doesn’t think there is any real need for him to get off the Suboxone; it has been working well for years with few side effects. But he worries that someone at the treatment center will learn of his Suboxone therapy. He knows of other staff who were fired for having Suboxone appear in their employee urine drug screens. Since Vivitrol doesn’t activate the opioid receptors like Suboxone does, it might be a more accepted treatment option.
I ask if he sees any signs of change, if people are becoming more open to the idea of Suboxone or MAT in general. He replies that he hasn’t seen many signs of change in his local recovery community. In fact, Jackson is more concerned about revealing his Suboxone treatment status than his history of heroin addiction: “I don’t feel like there’s enough people right now that view MAT as a legitimate treatment. I think that we’re starting to see it go that direction, but there’s enough of that stigma still left that I’m just too afraid to be open about that . . . It’s kind of like in the nineties, there was still gay-bashing going on, but for the most part people accepted that there were gay people. It wasn’t the fifties, right? But it was still too scary to come out in high school. It’s the same kind of stigma. I don’t feel like this is the time yet for someone who’s on MAT who works in the field to feel 100 percent safe to say, ‘I’m on MAT.’ You know what I mean?”
It’s been over fifteen years since Suboxone was approved by the US Food and Drug Administration (FDA), and the treatment center where Jackson works still harbors the antiquated, misguided view that Suboxone is a sign of personal failure and just another drug of abuse. And it’s not just the treatment center that silences him. Jackson continues to attend AA almost daily, but no one there knows he takes Suboxone either. Why not, I ask? “Because they would think I’m a fake. That I’m not really sober.”
I find this profoundly unfair. Jackson has not touched an illegal drug or misused a legal medication in over three years. He has a job. He finally has shared custody of his daughter, the love of his life. He is afraid to tell people in the recovery community about one of the most important tools in his recovery, even though his job is to guide others on their recovery journeys. It is a common fear that I have heard again and again during my interviews. People who have worked so hard to manage their addiction in the face of insurmountable odds (poverty, trauma, mental health issues), and have triumphed despite these obstacles, keep their stories hidden.
PEER-REVIEWED STUDY after peer-reviewed study shows that medications such as Suboxone and methadone are the most reliable and most effective treatment for opioid addiction.14 They cut the rate of death from overdose in half14 because people stop taking dangerous amounts of heroin or prescription pain medicines. They prevent the spread of HIV/AIDS, hepatitis C, and other communicable diseases because people stop injecting drugs and sharing the needles.15–17 Medication helps decrease criminal activity18 and increase employment rates and social functioning.19
Yet more than 60 percent of US addiction treatment centers fail to provide any FDA-approved medications for treating opioid addiction, sometimes even barring entry to those taking the medications Suboxone or methadone.20,21 Abstinence-only treatment—treatment that explicitly denies the validity and place of medications in managing addiction—is the norm.
This is not to disparage counseling or support groups, such as AA, upon which abstinence-only treatment centers typically depend. Counseling and support groups are critical for addressing underlying psychological and social issues, as they have been in Jackson’s case. But counseling and support groups, collectively called “psychosocial” or “behavioral” treatments, are less likely to address physiological cravings and withdrawal symptoms or prevent the ability to get high. That is why a meta-analysis of studies by Cochrane, a highly regarded medical research organization, has definitively stated that medications for treating addiction are more effective than behavioral treatment alone at preventing relapse and overdose,13,22 though in many cases, behavioral and pharmacological treatment should be combined.23 It’s why the World Health Organization urges every country to provide low-cost medications for treating addiction within prisons and jails,24,25 calling buprenorphine and methadone “essential medicines.” It’s why the US government through the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, and the Food and Drug Administration urges the expansion of medications in opioid addiction treatment.11,23,26 The US surgeon general has called the combination of medications and psychosocial treatment the “gold standard” for opioid addiction.27 After an in-depth review of the evidence, the National Academies of Sciences, Engineering, and Medicine released a statement in 2019 titled Medications for Opioid Use Disorder Save Lives, in which they maintain that withholding MAT for any reason in any facility is unethical.28 Additionally, the National Academies explicitly states that allowing only one form of MAT, such as extended-release naltrexone (i.e., Vivitrol), while forbidding other forms, such as buprenorphine (i.e., Suboxone) or methadone, is unethical.28
What is a successful addiction treatment program? After reviewing hundreds of peer-reviewed studies in medicine and public health and analyzing over 120 interviews, I believe the following:
A successful addiction treatment program is one that offers a wide range of evidence-based treatments backed by rigorous scientific studies, without unnecessary legal and institutional barriers, without stigma, in a client-centric manner.
In other words, addiction should be treated the way we treat other chronic medical conditions with biological, psychological, and social components, such as hypertension or depression.
In 2016 alone, the opioid crisis claimed more American lives than were claimed by the entire Vietnam War,29 and it decreased the average US life expectancy.30 Yet opioid addiction’s most effective treatment is heavily stigmatized, from physicians’ offices, to counselors’ offices and rehabilitation centers, to prisons and jails and drug courts. Perhaps most shockingly, medication-related stigma comes from the recovery community too, including within support groups like AA, which frequently tell people medication means “you are not really sober,” “you are just using a crutch,” or “you’re just replacing one addiction with another”—even if the person has not misused opioids for years.
My initial purpose in writing this book was twofold: to examine the historical, legal, and cultural reasons for limited use of medications in addiction treatment and to identify potential policy solutions to this problem. But over time I have adopted a third purpose: to validate the experience of the hundreds of thousands of Americans who have often secretly undergone recovery from opioid addiction with the help of medication. Their experiences show that US addiction treatment is frequently not based on the latest scientific evidence and is rarely person-centered. Addiction is a chronic medical condition that is still treated in an unscientific manner and outside of mainstream medicine.
LIKE MOST RESEARCHERS, my work is informed by a variety of theoretical frameworks that guide interpretation of what might otherwise be a sea of incongruous data. Specifically, I use the socio-ecological model of health services to understand health services barriers and facilitators identified by interviewees. According to this model, there are four levels of factors that can either push or pull an individual toward treatment.31 Each of these levels is independently important, but they also interact. They help explain how an effective treatment, such as medication, can exist but be grossly underutilized.
The first level is the individual level, which includes a person’s health and social history, demographics, beliefs, values, and behaviors. For example, a female with a history of domestic violence may find it difficult to share her recovery story in a counseling group filled with men. If she has a low income, she may forgo treatment simply because she cannot afford it. If she believes that a certain treatment is ineffective or socially stigmatized, she may not even consider it.
The next level, the relationship level, presumes that one’s inner circle of relationships, such as friends and family, affect whether one seeks and complies with treatment. For example, someone in a relationship with an active drug user may find it difficult to stick with a treatment method when constantly faced with drug use “triggers” pulling him or her back toward drug use. Alternatively, relationships can propel someone toward treatment. In Jackson’s story, it was his relationship with Ryan that ultimately propelled him toward treatment with a medication.
The third level, community, includes local resources and institutions, such as the availability of treatment providers in the city. Obviously, even if one is highly motivated to begin treatment and lives in a supportive household, the lack of any local treatment provider will prove a huge deterrent to compliance. Not finding a provider can be very discouraging, undermining motivation for treatment.
Finally, the fourth level is the societal or policy level, which includes such factors as laws and the broader culture. Laws impact the availability of community resources, including methadone clinics and buprenorphine treatment providers. Likewise, culture affects whether a person seeks treatment and then whether he or she sticks with treatment. For example, the antimedication attitudes associated with the twelve-step support movement may deter people from sticking with buprenorphine or methadone treatment as they experience pressure from group members to quit. Finally, laws and culture interact. Laws are informed by cultural assumptions about drug users, including that they are dangerous and should be locked up rather than treated. Cultural assumptions are likewise informed by laws, especially criminal laws that make it seem like drug users are immoral simply because they are doing something illegal.
My work is also informed by the theory of reasoned action and planned behavior.32 This theory is particularly applicable to the first level of the socio-ecological model: the individual level. The theory has been validated in the substance use disorder treatment context and assumes that people’s intention to seek treatment or stick with treatment is predicted by three constructs:
1. A person’s beliefs about the treatment, such as whether the treatment will help solve a problem;
2. Perceptions of social norms surrounding the treatment, such as whether others view the treatment positively; and
3. Feelings of self-efficacy, such as whether one can really do the treatment (e.g., whether one has the financial means or the necessary transportation).
The theory likewise applies to health care providers. For example, if physicians think buprenorphine is dangerous, feel social pressure from colleagues against prescribing buprenorphine, and worry that they lack adequate training, they are unlikely to prescribe buprenorphine to patients.
These theoretical frameworks are important because they help explain why the mere existence of an effective treatment, even one that lowers the risk of death from overdose by approximately 50 percent, is rarely prescribed or used.14 Clearly, it is insufficient for a lifesaving drug to merely exist in the market; it may still never be accessed. Treatment occurs not in a vacuum but in a complex legal and cultural context with multiple levels of potential barriers and facilitators to retention and compliance. The job of health service researchers such as myself is to tease out health service barriers and facilitators so that micro and macro level policies can be created to address them.
In my research I rely heavily on interviews with a variety of people who have an effect on, provide, or use health services for addiction, including current drug users, people in recovery, their family members, activists, criminal justice professionals, policy makers, and health care providers. In-depth interviews, especially unstructured or semistructured interviews, allow me to explore a wide range of experiences without established preconceptions. Even though I approach interviews with questions in hand, often new topics emerge that I had not anticipated as I prepared for the interview. In a poorly understood research area involving vulnerable social groups, such openness in methodology is an asset. My interviews have led me to venture into new areas of research that I had previously not considered.
After my interviews are professionally transcribed, I analyze them for themes in collaboration with other researchers. I typically use an approach called “thematic analysis,” wherein we apply “codes” to topics that seem to repeatedly appear across interviews. These codes are basically like different-colored highlighters but are applied in a software package called Dedoose. My research team members and I independently code topics in each transcript and then compare our results, discussing and negotiating any differences. Since qualitative research can be subjective, this process, called “consensus coding,” helps ensure that I am not seeing something in the data that is not there. For example, I might read a quotation in an interview transcript that I think means the interviewee distrusts his physician, so I code it as “physician distrust”; but my colleague may not see physician distrust in this quotation at all. After comparing our codes, we negotiate and come to an agreement about the final application of the code.
After completing the consensus coding process, the research team then views all transcript excerpts associated with a certain code. For instance, we might pull all excerpts coded as “physician distrust” from all interviews. After reading and rereading these excerpts, we identify patterns within and across codes. We might, for example, find that interviewees who feel stigmatized by their physicians are the ones who distrust their physicians’ motivations. In the end, we call this observation a “theme.”
The purpose of qualitative research, such as interview data collection and analysis, is not to identify frequencies (e.g., 50 percent of drug users have tried buprenorphine treatment), because the sampling is not representative. Often when I interview people who use drugs, the sampling is not even random but rather “snowball,” meaning that I start with a group of drug users or people in recovery who then connect me to their friends, who connect me to their friends, and so forth. It is a well-respected method for reaching stigmatized populations who often prefer to remain secret.
Instead, the purpose of qualitative research is largely exploratory, to identify themes in the population sampled. These themes can later inform quantitative methods, such as surveys, which can provide a representative, random sample of opinions and experiences. But the first exploratory step is very important, because without it we might not even know what questions to ask in a survey. After all, a survey, unlike a semistructured or unstructured interview, is primarily composed of close-ended questions wherein the researcher guesses and provides potential survey answers ahead of time. The other benefit of qualitative research is that the data is “rich,” illuminating the context and relationships between different actors, cultures, and policies. Qualitative data allows one to paint a picture in a way that many quantitative methods rarely permit, given their topic and answer-choice restrictions.
Rich qualitative data complements quantitative data, suggesting potential reasons why a phenomenon is occurring. For example, quantitative analysis of deidentified electronic health records demonstrates that medication-assisted treatment retention rates are frustratingly low. But why are people dropping out of treatment? By interviewing these people and hearing their stories, we can learn about the barriers they face as well as hear their perspectives on what might lead them to stick with treatment. Such data is not available in the electronic health record but can help policy makers create tailored policies that directly address the problem. I hope that my research helps you, the reader, better understand the results from quantitative studies in a rich context of individual, interpersonal, community, and societal layers impacting health services.
All interviewee names, including those of the judges and health care providers in chapters 5 and 6, have been changed. Certain details of their stories, too, such as specific locations, dates, and professions, have sometimes been changed to protect their confidentiality. For interviewees in recovery, sometimes I have combined two stories into one story to further ensure confidentiality and to ease readability. For example, I may combine John Doe’s story of how he started misusing opioids with Jane Doe’s opioid addiction treatment experience. Additionally, based on my experience of visiting treatment centers and support group meetings, I provide sensory details to assist you in having a fuller picture. For example, I may not have attended John’s specific AA meeting, but I have seen enough of them to know it was likely in a church basement with people seated in a circle, the smell of inexpensive coffee filling the room, and AA brochures and books distributed on empty chairs. Otherwise, all the stories you will read are true and the quotes are taken verbatim from interviews.
Interviews were conducted between 2015 and 2019, with the majority of participants coming from Indiana or Florida due to my physical presence in these two states, though in total interviewees came from thirteen states. Of the 120-plus interviews I have conducted, about sixty have been with individuals recovering from a substance use disorder. Approximately four dozen of these interviewees were recovering from opioid addiction. Among those interviewees, approximately 90 percent had experience with MAT, 90 percent had experience with twelve-step support groups, and two-thirds had experience with residential rehabilitation. Approximately half were male and half were female, with the vast majority of both groups being white, non-Hispanic. Their ages ranged from young adult to upper sixties.
Finally, a few comments on terminology. The Diagnostic and Statistical Manual of Mental Disorders, essentially the bible of mental health treatment, recently changed and no longer uses the term opioid addiction, preferring opioid use disorder instead. I have purposely chosen to continue using opioid addiction in this book because it is essentially a severe form of opioid use disorder, and the focus of this book is on people with moderate to severe opioid use disorder, not on people who occasionally misuse opioids. It is also a lot easier to write “opioid addiction” than “moderate or severe opioid use disorder.”
I have also struggled with whether to use the phrase “medication-assisted treatment” or the more modern terms “pharmacotherapy” or “medications for opioid use disorder” instead. Ultimately, I have chosen “medication-assisted treatment” because it remains the dominant term used to refer to FDA-approved medications for treating opioid addiction, such as methadone, buprenorphine, and naltrexone. With that said, “medication-assisted treatment” is an imperfect term because it incorrectly implies that medication is not enough of a treatment—that it just “assists” treatment—though for many people it is the only tool needed for recovery. Technically speaking, MAT refers to the combination of medications and psychosocial support, such as counseling, but in this book I use it to refer to buprenorphine, methadone, or extended-release naltrexone treatment with or without psychosocial support.
* All interviewee names, including names of health care providers and judges in chapters 5 and 6, have been changed. Additionally, certain details of their stories, such as specific locations, dates, and professions, have been changed to protect their confidentiality. See the last section of this chapter for more information about my methodology.