MY MOTHER HAD A SAYING: “Even if history doesn’t repeat itself, those who ignore its lessons will suffer.” That is, unfortunately, as relevant today as it was when she first uttered it.
Just as we thought we were seeing light at the end of the tunnel in containing a deadly, decades-long prescription-opioid epidemic, we find ourselves battling another opioid-overdose crisis, driven by fentanyl, a synthetic opioid 50 times more deadly than heroin. In the 12 months ending in March 2022, nearly 110,000 people died from drug overdoses, according to the Centers for Disease Control and Prevention. That is a 44% jump from the same period two years earlier. Los Angeles County has not been spared. The Los Angeles County Department of Public Health released a report at the end of November in which it laid out the stark realities of the crisis closer to home: Fentanyl, which often is added to other misused drugs, was involved in 55% of overdose deaths across the county in 2021 — 1,504, up from 109 in 2016. That is a staggering 1,280% increase over five years.
Why is this happening?
There are three necessary steps to recovery from substance use disorder: detoxification (getting off drugs), relapse prevention (staying off drugs) and rehabilitation (living a life without drugs). While detoxification can free patients from the immediate effects of drugs, it does nothing to contribute to their staying off drugs. But this country’s treatment system seems to be focused primarily on detox.
I analogize this to a wedding. A wedding is a big deal, but it ultimately has nothing to do with making a happy, lasting marriage. Our recovery system is targeted on the wedding. Detoxification may be good for a lot of things, but keeping someone off drugs is not one of them.
The best way to stay off potentially lethal drugs like fentanyl and oxycodone — and thus achieve a rewarding, responsible and sustainable life — is to be on a prescribed medication. We have three effective, FDA-approved medications to be used as part of a comprehensive treatment plan: buprenorphine, methadone and naltrexone.
The tools are there, but we fail to make the best use of them. At a national level, we act according to what we believe and not according to what we know, adopting treatment philosophies and policies that ignore the lessons of history. As a society, we are ambivalent about substance use disorder, understanding, perhaps, that people with addiction are sick and need help, yet harboring feelings that they have done it to themselves. We believe that patients with substance use disorder should not be given medications — certainly not ones that might make them feel good — so we don’t embrace medications that work.
Some years ago, the noted author and recovery expert Anne M. Fletcher surveyed the country’s opioid-treatment system and found that medications are rarely used, that research data were mostly ignored and that most “treatment” consists of AA-style 12-step programs. The bulk of the country’s efforts remain focused on detoxification, which also happens to be the most lucrative, and least effective, element of recovery; its most common outcome is relapse. Even when use of medication-assisted treatment is reluctantly tolerated, the aim is to get patients off these beneficial medications as soon as possible.
Expecting detoxification on its own to return patients to their old selves, before they became ill, ignores the fact that substance use has irreversible impacts on the body and brain. To think otherwise is like believing that contraceptives don’t just keep you from getting pregnant, they also make you a virgin again.
On a national scale, we refuse to see that emphasizing the supply side has not worked. We congratulate ourselves for having reduced opioid prescriptions by half while ignoring the continued rise of opioid-overdose deaths. We don’t want to go against the abstinence-treatment industry, and we let the regulatory agencies become symbiotic with the system they regulate.
We can do better, and the prescription for doing so is not difficult: Support the broad use of prescribed medications like buprenorphine, eliminate regulations that limit physicians in exercising their best judgment and provide the resources to help patients live a life without drugs.
It’s been said that Americans love reality shows because we believe that if we put something on TV, we don’t then have to face it in real life. But opioid use disorder is not a reality show, and if we want to fight it and reduce overdose deaths, we must have the courage to look in the mirror, resist our biases, acknowledge where we fall short and find the gumption to make real changes to finally end this crisis.