Practically-A-Book Review: Dying To Be Free

I am the last person with a right to complain about Internet articles being too long. But if I did have that right, I think I would exercise it on Dying To Be Free, the Huffington Post’s 20,000-word article on the current state of heroin addiction treatment. I feel like it could have been about a quarter the size without losing much.

It’s too bad that most people will probably shy away from reading it, because it gets a lot of stuff really right.

The article’s thesis is also its subtitle: “There’s a treatment for heroin addiction that actually works; why aren’t we using it?” To save you the obligatory introductory human interest story: that treatment is suboxone. Its active ingredient is the drug buprenorphine, which is kind of like a safer version of methadone. Suboxone is slow-acting, gentle, doesn’t really get people high, and is pretty safe as long as you don’t go mixing it with weird stuff. People on suboxone don’t experience opiate withdrawal and have greatly decreased cravings for heroin. I work at a hospital that’s an area leader in suboxone prescription, I’ve gotten to see it in action, and it’s literally a life-saver.

Conventional heroin treatment is abysmal. Rehab centers aren’t licensed or regulated and most have little interest in being evidence-based. Many are associated with churches or weird quasi-religious groups like Alcoholics Anonymous. They don’t necessarily have doctors or psychologists, and some actively mistrust them. All of this I knew. What I didn’t know until reading the article was that – well, it’s not just that some of them try to brainwash addicts. It’s more that some of them try to cargo cult brainwashing, do the sorts of things that sound like brainwashing to them, without really knowing how brainwashing works assuming it’s even a coherent goal to aspire to. Their concept of brainwashing is mostly just creating a really unpleasant environment, yelling at people a lot, enforcing intentionally over-strict rules, and in some cases even having struggle-session-type-things where everyone in the group sits in a circle, scream at the other patients, and tell them they’re terrible and disgusting. There’s a strong culture of accusing anyone who questions or balks at any of it of just being an addict, or “not really wanting to quit”.

I have no problem with “tough love” when it works, but in this case it doesn’t. Rehab programs make every effort to obfuscate their effectiveness statistics – I blogged about this before in Part II here – but the best guesses by outside observers is that for a lot of them about 80% to 90% of their graduates relapse within a couple of years. Even this paints too rosy a picture, because it excludes the people who gave up halfway through.

Suboxone treatment isn’t perfect, and relapse is still a big problem, but it’s a heck of a lot better than most rehabs. Suboxone gives people their dose of opiate and mostly removes the biological half of addiction. There’s still the psychological half of addiction – whatever it was that made people want to get high in the first place – but people have a much easier time dealing with that after the biological imperative to get a new dose is gone. Almost all clinical trials have found treatment with methadone or suboxone to be more effective than traditional rehab. Even Cochrane Review, which is notorious for never giving a straight answer to anything besides “more evidence is needed”, agrees that methadone and suboxone are effective treatments.

Some people stay on suboxone forever and do just fine – it has few side effects and doesn’t interfere with functioning. Other people stay on it until they reach a point in their lives when they feel ready to come off, then taper down slowly under medical supervision, often with good success. It’s a good medication, and the growing suspicion it might help treat depression is just icing on the cake.

There are two big roadblocks to wider use of suboxone, and both are enraging.

The first roadblock is the #@$%ing government. They are worried that suboxone, being an opiate, might be addictive, and so doctors might turn into drug pushers. So suboxone is possibly the most highly regulated drug in the United States. If I want to give out OxyContin like candy, I have no limits but the number of pages on my prescription pad. If I want to prescribe you Walter-White-level quantities of methamphetamine for weight loss, nothing is stopping me but common sense. But if I want to give even a single suboxone prescription to a single patient, I have to take a special course on suboxone prescribing, and even then I am limited to only being able to give it to thirty patients a year (eventually rising to one hundred patients when I get more experience with it). The (generally safe) treatment for addiction is more highly regulated than the (very dangerous) addictive drugs it is supposed to replace. Only 3% of doctors bother to jump through all the regulatory hoops, and their hundred-patient limits get saturated almost immediately. As per the laws of suppy and demand, this makes suboxone prescriptions very expensive, and guess what social class most heroin addicts come from? Also, heroin addicts often don’t have access to good transportation, which means that if the nearest suboxone provider is thirty miles from their house they’re out of luck. The List Of Reasons To End The Patient Limits On Buprenorphine expands upon and clarifies some of these points.

(in case you think maybe the government just honestly believes the drug is dangerous – nope. You’re allowed to prescribe without restriction for any reason except opiate addiction)

The second roadblock is the @#$%ing rehab industry. They hear that suboxone is an opiate, and their religious or quasi-religious fanaticism goes into high gear. “What these people need is Jesus and/or their Nondenominational Higher Power, not more drugs! You’re just pushing a new addiction on them! Once an addict, always an addict until they complete their spiritual struggle and come clean!” And so a lot of programs bar suboxone users from participating.

This doesn’t sound so bad given the quality of a lot of the programs. Problem is, a lot of these are closely integrated with the social services and legal system. So suppose somebody’s doing well on suboxone treatment, and gets in trouble for a drug offense. Could be that they relapsed on heroin one time, could be that they’re using something entirely different like cocaine. Judge says go to a treatment program or go to jail. Treatment program says they can’t use suboxone. So maybe they go in to deal with their cocaine problem, and by the time they come out they have a cocaine problem and a heroin problem.

And…okay, time for a personal story. One of my patients is a homeless man who used to have a heroin problem. He was put on suboxone and it went pretty well. He came back with an alcohol problem, and we wanted to deal with that and his homelessness at the same time. There are these organizations called three-quarters houses – think “halfway houses” after inflation – that take people with drug problems and give them an insurance-sponsored place to live. But the catch is you can’t be using drugs. And they consider suboxone to be a drug. So of about half a dozen three-quarters houses in the local area, none of them would accept this guy. I called up the one he wanted to go to, said that he really needed a place to stay, said that without this care he was in danger of relapsing into his alcoholism, begged them to accept. They said no drugs. I said I was a doctor, and he had my permission to be on suboxone. They said no drugs. I said that seriously, they were telling me that my DRUG ADDICTED patient who was ADDICTED TO DRUGS couldn’t go to their DRUG ADDICTION center because he was on a medication for treating DRUG ADDICTION? They said that was correct. I hung up in disgust.

So I agree with the pessimistic picture painted by the article. I think we’re ignoring our best treatment option for heroin addiction and I don’t see much sign that this is going to change in the future.

But the health care system not being very good at using medications effectively isn’t news. I also thought this article was interesting because it touches on some of the issues we discuss here a lot:

The value of ritual and community. A lot of the most intelligent conservatives I know base their conservativism on the idea that we can only get good outcomes in “tight communities” that are allowed to violate modern liberal social atomization to build stronger bonds. The Army, which essentially hazes people with boot camp, ritualizes every aspect of their life, then demands strict obedience and ideological conformity, is a good example. I do sometimes have a lot of respect for this position. But modern rehab programs seem like a really damning counterexample. If you read the article, you will see that this rehabs are trying their best to create a tightly-integrated religiously-inspired community of exactly that sort, and they have abilities to control their members and force their conformity – sometimes in ways that approach outright abuse – that most institutions can’t even dream of. But their effectiveness is abysmal. The entire thing is for nothing. I’m not sure whether this represents a basic failure in the idea of tight communities, or whether it just means that you can’t force them to exist ex nihilo over a couple of months. But I find it interesting.

My love-hate relationship with libertarianism. Also about the rehabs. They’re minimally regulated. There’s no credentialing process or anything. There are many different kinds, each privately led, and low entry costs to creating a new one. They can be very profitable – pretty much any rehab will cost thousands of dollars, and the big-name ones cost much more. This should be a perfect setup for a hundred different models blooming, experimenting, and then selecting for excellence as consumers drift towards the most effective centers. Instead, we get rampant abuse, charlatanry, and uselessness.

On the other hand, when the government rode in on a white horse to try to fix things, all they did was take the one effective treatment, regulate it practically out of existence, then ride right back out again. So I would be ashamed to be taking either the market’s or the state’s side here. At this point I think our best option is to ask the paraconsistent logic people to figure out something that’s neither government nor not-government, then put that in charge of everything.

Society is fixed, biology is mutable. People have tried everything to fix drug abuse. Being harsh and sending drug users to jail. Being nice and sending them to nice treatment centers that focus on rehabilitation. Old timey religion where fire-and-brimstone preachers talk about how Jesus wants them to stay off drugs. Flaky New Age religion where counselors tell you about how drug abuse is keeping you from your true self. Government programs. University programs. Private programs. Giving people money. Fining people money. Being unusually nice. Being unusually mean. More social support. Less social support. This school of therapy. That school of therapy. What works is just giving people a chemical to saturate the brain receptor directly. We know it works. The studies show it works. And we’re still collectively beating our heads against the wall of finding a social solution.