In the U.S., there were more than 72,000 deaths from drug overdose in 2017, two-thirds of which were linked to opioids. And while provisional data for 2018 suggest a modest slowing of fatalities, we are still grappling with a nationwide drug crisis that in addition to prescription and synthetic opioids now encompasses a resurgence of methamphetamine, heroin and cocaine use across the country. It is a dire public health problem with profound consequences for families, communities and the economy.
As we seek solutions, it is important we understand the true nature of how people become addicted—because regardless of what the drug of choice might be, the underlying psychology of addiction rarely changes.
Addiction is an unexpected trap. It often begins innocently enough—with prescription painkillers after a back operation, perhaps, or a line of coke snorted for fun at a party. External factors – poverty and social misery, personal hardships and peer pressure to conform – can influence the desire to experiment with powerful, mind-altering and physically harmful substances. Nobody is immune, as we have seen the opioid crisis ensnare young and old, rich and poor, urban and rural residents and people of all races and ethnicities.
Most who try drugs quickly recognize they might become addicted and decide to quit. Unfortunately, many others can’t or won’t. The euphoria of pain relief or getting high is too great, and the need for more becomes insatiable. Tolerance increases for the user and with it the craving for stronger doses. Eventually, the drugs take over and a downward spiral ensues, shattering their lives and destroying the bonds they share with those around—and with them society. Or worse yet, they end in overdose and death.
As a clinician with more than 50 years of experience treating substance abuse, I’ve seen this tragedy unfold countless times. What I know is that addiction is not a moral failing. It happens when the morphine molecule—the essential component of all opiates—or other drug initiates a chemical process that rewires the neural networks in the brain and renders the user a partial captive of the drug.
How then can we help? All too often the initial response to substance abuse is to rely on law enforcement to interdict supplies and arrest dealers. (President Trump once suggested convicted drug dealers be executed.) Stopping the flow of drugs is, of course, critical. But we must also address the needs of the substance abuser and the overall trajectory of addiction.
As a frontline measure, successful harm-reduction programs offer points of engagement. Needle-exchange sites can help reduce overdoses, especially if testing is available for fentanyl, the powerful synthetic opioid responsible for the spike in nationwide fatalities. Overdose antidotes such as naloxone are also essential: in Dayton, a city at the epicenter of Ohio’s opioid epidemic, overdose deaths declined nearly 50 percent in 2018 after each of their police officers was given a naloxone kit.
While such programs help keep substance abusers alive, the next and most crucial step is getting them into appropriate treatment. Treatment marks the start of a healing process, whether as an outpatient or as part of short- or long-term residential care for those most at risk of overdose. The goals are to get the patient totally sober and return the brain chemistry to normal. We also re-orient the user to a life without drugs and an understanding of their own emotional vulnerabilities.
Battling drug addiction is never easy. Most users resist treatment, exit too soon, and relapse frequently. The start of treatment is often accompanied by anxiety and depression. With the help of medications that reduce cravings, such as methadone and buprenorphine, combined with group therapy and counseling – an approach known as medication-assisted therapy – we can improve retention and results.
Unfortunately, less than 10 percent of the estimated 21.7 million individuals in need of substance abuse treatment – including 2 million opioid users – receive it. And it is this treatment gap that will likely lead to the millennium’s millionth overdose death by 2021.
In many ways, the opioid crisis represents the “perfect storm” of addiction. Pill-pushing pharmaceutical companies exploited the legitimate needs of patients seeking pain relief, claiming their highly habit-forming drugs are non-addictive, according to more than 1,500 lawsuits filed against opioid manufacturers. Compliant pharmacists often obliged. Meanwhile, doctors wrote excessive opioid prescriptions even for minor ailments such as a sprained ankle.
Prescription painkillers as well as illicit drugs such as heroin, meth, cocaine and many new cannabis products are powerful drugs that can easily draw users into a cycle of dependence and substance abuse. That’s why fighting addiction is an ongoing challenge faced by every new generation.
We have the tools and resources – through education, prevention, law enforcement, and most importantly treatment – and the awareness to help those with substance-abuse disorder. But in order to be successful we must commit to a coherent, compassionate and well-funded national anti-drug strategy on a scale equivalent to the enormity of the drug problem itself.
Mitchell S. Rosenthal, M.D., is the founder and former president of Phoenix House, the national drug treatment organization, and president of the Rosenthal Center for Addiction Studies.