Surviving the Overdose Crisis

Arguments against medication-assisted treatment impede addiction recovery.

Posted Jul 03, 2018

JAMA Network Open
"Death data were obtained from the Centers for Disease Control and Prevention WONDER online database. This analysis was performed at four 5-year time intervals between 2001 and 2016."
Source: JAMA Network Open

I live in what is called a sober residence with a group of other recovering drug addicts and alcoholics on the southeastern coast of Florida. In our twenties and early thirties, we are the leftover millennials who traveled here by way of the northeast or the midwest to treat some malady of the mind or another: addiction, depression, burnout, despair—qualms of the human spirit. 

As much as it is cyclical, addiction is a disorder of ambivalence; someone is always relapsing as someone else is returning from a binge, while yet another straddles the fence between wanting to embrace recovery and wanting also to indulge habit. The good, the ugly, the passions and the repentances, all are simultaneously, and alternately, true.

Long before the Twelve Steps taught us to sit in circles of peer groups with strangers, confessing our crimes and sins, Saint Augustine wrote of similar warring appetites in his memoir Confessions, circa 397 AD: "God, grant me chastity and sobriety, but not yet.”

And for people like me, who quarrel daily with our worst inclinations, it is just that way: A healthy, progressive arc—or even a dark and dismal one—may split, at any moment, by degrees of idiosyncrasy and nuance so variable as to confound expectations altogether. 

While we learn self-protectively to forgo expectations in such matters, of predictions about ours or another’s recovery, it’s imperative that we strive to defy our darknesses—to grapple with them actively to become more substantial than our limits. The passivity of surrendering to powerlessness, a major motif of Twelve Step and still the working ethos of many accredited treatment centers, only works to cosign the overdose rate, and opioid-related tragedies are everywhere leveling the towns and counties of the United States. 

1.68 million years of human life were lost to opioid overdoses in 2016, according to a report from the JAMA Network Open, “On the Burden of Opioid-Related Mortality in the United States.”

The authors of the study cited that “adults aged 24 to 35 years” bore the greatest loss, noting as well that opioid-related death had risen by 292% between 2001 and 2016. 

Of course, there are ways to mitigate such emergencies, volumes of research now to prove the efficacy of Medication-Assisted Treatment (MAT) with drugs like buprenorphine, methadone, and naltrexone—which ameliorate cravings and effectively reduce the primary concerns of relapse, namely, that of overdose. They do so by blocking the brain’s opioid receptor sites so that other opioids, like oxycodone, or opiates, like heroin and morphine, cannot penetrate; taken daily, consistently, appropriately, these drugs produce no euphoria.

In fact, a report funded by the National Institutes of Health, and published in the Annals of Internal Medicine on June 19, found that using either methadone, an opioid agonist, or the partial-agonist buprenorphine to treat addicts following a non-fatal overdose of opioids markedly reduced rates of mortality thereafter in a group of 17,568 Massachusetts adults surveyed between 2012 and 2014.

Whereas no correlations between “naltrexone and all-cause mortality or opioid-related mortality were identified,” the authors of the study confirmed that overdose deaths decreased by 59 percent for methadone patients and 38 percent for patients receiving buprenorphine.

The idea of MAT incurs consternation quite often from vigilante Twelve-Steppers, who argue against it to insist that someone abiding a maintenance-based recovery program is cheating, essentially, and that buprenorphine and methadone—and, in some circles, mood stabilizers—are merely chemical crutches, simple replacements of one drug for another. Which is true, even somewhat exactly the case, but MAT substitutes are not nearly as potent as heroin or fentanyl, or even oxycodone, and are far safer; moreover, the effects of buprenorphine cap at a ceiling dose of 32 milligrams, meaning that doses of the drug in excess of that yield no additional benefit.

Let's us face it, shall we? As the National Institute on Drug Abuse has recorded, 91 percent of all recovering addicts relapse at one point or another, 59 percent of whom relapse within the first week of leaving treatment, 80 percent of whom relapse within the first month. In the grim overcast of so many deaths by overdose, from drugs more potent now than ever in human history, human life calls out for practical, evidence-based solutions, rather than moral conditioning—because successful recovery from a substance use disorder is not a matter simply of swapping one unsavory shade of character for an easier, prettier one. Life, actually, is at stake here.

I live with the stakes myself, the risks, as I no longer take buprenorphine, or any opioid blocker, for that matter, and I have likely internalized a lot of the stigma that addicts inherit when they ask for help. 

I have not used heroin in over nine months, my cravings have fallen away, I am no longer who I was on the night that I flew into Florida, several transitions ago, for rehab in early 2017. But even now, as my world turns around a series of waiting rooms and pharmacy queues, and I fill multiple prescriptions for antidepressants and mood stabilizers, I know that I am still walking among shades of stigma.

I remember the first memorial service that I attended here in South Florida for a friend of mine who relapsed and died after taking a dose of heroin too potent for what his body could have endured after nearly a year of abstinence. 

He had been building back his life, bit by bit—and still. My heart broke that morning, though I did not know Zach long—about three months–we saw each other every day. And I do remember the particularity of that heartbreak, which dimmed to a more general sadness later that evening for the plight of junkies everywhere and for the extent to which luck figures into it.

Now, when I hear that someone I know has died of an overdose, I am the opposite of shocked; I am rather more sadly reminded of how near to the perilous limit we are who live with substance use disorders, even in remission. 

References

Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of Opioid-Related Mortality in the United States. JAMA Network Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.021

Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med. [Epub ahead of print 19 June 2018] doi: 10.7326/M17-3107