Why the new face of opioid addiction calls for a new approach to treatment
Confronting America's opioid epidemic
The epidemic of opioid addiction currently raging in the United States had a precursor in the 1960s and '70s, but with significant differences. The majority of victims back then were African-American, mostly in cities; today they are white, and typically small-town or rural. The culprit then was heroin, a street drug that has been illegal since at least the 1920s, while for the last couple of decades — starting in 1995, when the FDA approved the original, easily crushed and inhaled version of OxyContin — it has been prescription painkillers, a different but no less dangerous form of opioids.
And those differences, in turn, require a different approach to treatment, a realization that has been slow to take hold across the country.
A 2014 study on the changing demographics of opioid addicts by the JAMA Psychiatry Network found that while 80 percent of those who began using opioids in the 1960s got started with heroin, 75 percent of recent opioid users were initiated by prescription drugs.
In an article from 1986, the New York Times cited an estimate by the National Institute on Drug Abuse that said the U.S. saw the number of heroin addicts increase from 242,000 to 558,000 between 1969 and 1974.
Almost half of those people lived in New York City. By the mid-1970s, the same Times article noted, "the New York City Health Department was reporting more than 650 heroin-related deaths a year."
Because New York was at the epicenter of this crisis — which, in addition to causing a spate of fatal overdoses, also fueled the spread of infectious diseases — it was the birthplace of the solution.
In the mid-1960s, researchers at the Rockefeller Institute for Medical Research began developing a protocol for methadone maintenance therapy — the clinical treatment of heroin addicts with regular doses of methadone, a synthetic painkiller that could both ease the symptoms of heroin withdrawal and block the effects of other opiates in the brain.
Methadone clinics soon began popping up across the city and, eventually, the rest of the country. As part of its “war on drugs,” which mostly involved law enforcement efforts to keep heroin out of the country, in the early 1970s the Nixon administration also funded expanded access to methadone maintenance programs. Between 1971 and 1973, the number of patients receiving methadone treatment in the U.S. skyrocketed from 9,000 to 73,000.
As recently as 2011, more than 300,000 people were still receiving methadone through federally-regulated opioid treatment programs (OTPs). Yet experts argue that what may have worked for the city-centered heroin epidemic of the 1960s and '70s is not a practical solution for the widespread outbreak occurring today.
“When we had an epidemic that was disproportionately impacting urban communities, it was easier to pop in a methadone maintenance clinic,” said Andrew Kolodny, chief medical officer at Phoenix House and executive director of Physicians for Responsible Opioid Prescribing, or PROP.
Today’s opioid epidemic, however, “is disproportionately rural,” Kolodny said, arguing that methadone therapy “is probably not as helpful in an epidemic where people might have to travel an hour a day to a clinic.”
According to the Centers for Disease Control and Prevention, the Midwest has seen the biggest increase in the rate of heroin-related deaths between 2000 and 2013. Last month, the CDC released a series of maps and charts detailing national trends in drug poisoning deaths by age, race, county and state from 2002 to 2014, which showed the rates of fatal overdoses in rural communities now surpasses those in more urban parts of the country.
It’s these characteristics that make maintenance medications like Suboxone—the brand name for a prescription dissolvable tablet that combines buprenorphine and naloxone and can be picked up at the pharmacy — or Vivitrol, injected monthly at a doctor’s office, more conducive to dealing with the current crisis.
Not only are these drugs more convenient for the today's opioid addict than methadone, Kolodny said, they’re safer.
“Methadone as a drug is not as good as buprenorphine. It’s got more side effects, it’s more dangerous,” he said. While like other opioids, too much methadone can be fatal, it’s impossible to overdose on buprenorphine.
The growing use of maintenance medications that can be taken at home or in the privacy of a doctor’s office rather than at a public clinic is reflective of more than just the changing landscape of opioid addiction in the U.S. It is part of a larger, slower-moving shift toward treating addiction more like other chronic illnesses.
“Everybody out there knows if you have HIV, you see a specialist; if you have breast cancer, you have a specialist; if you break a bone; you go to an orthopedist,” said Stuart Gitlow, president of the American Society of Addiction Medicine and a psychiatrist who treats patients for opioid abuse and other kinds of addiction at his private practice in Rhode Island. “Most people think if you have an addictive disease, you have to go to a rehab center in a warm place and then you come back all better. And that’s all wrong.”
Gitlow noted that while the specialty of addiction medicine has been around for nearly 60 years, “the vast majority of people with addictive disease I think don’t know that.”
“It’s not like breast cancer, we don't have a pink ribbon,” Gitlow continued. “We don't have a march for alcoholics. We don’t have a raffle or Girl Scout cookies or anything that really raises public awareness that other diseases have.”
Kolodny suggested that, if the tragic spate of opioid-related deaths in the U.S. over the past few years had a silver lining, it’s perhaps that — for completely politically incorrect reasons — it has raised awareness about the realities of addiction and helped accelerate that greater shift.
“When you have an epidemic that’s affecting white people, it’s affecting the children of lawyers and doctors and judges and policemen and firemen and politicians,” said Kolodny. “I think that helps remove the stigma and helps increase awareness that this really is a disease, that it’s not a moral failing.”
Read more from this series:
—This is your brain on opioids
—How buprenorphine, or ‘bupe’, changed opioid-addiction treatment
—Abstinence vs. medication-assisted treatment: Traditional 12-step programs embrace a new model
—It's easier to get a prescription for drugs that cause opioid addiction than those proven to treat it
—The menace in the medicine cabinet: The opioid epidemic’s pharmaceutical roots
—The rise of Narcan, the life-saving opioid antidote that can stop an overdose in its tracks
—Facing an epidemic of overdoses, Obama rejects governors' proposal to limit painkiller prescriptions
