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Experience argues against embrace of medication-assisted treatment

August 15, 2013
by Dan Cain
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Mark Twain is credited with saying, “There are lies, damned lies, and statistics.” Researchers are limited to measuring quantity and have a very difficult time even considering quality. Very few of them have treated, or would even recognize, addictive behavior. Physicians, who are required to have absolutely zero training in addiction, are collectively in the same category. Without understanding the mind of an addict, they are operating virtually in the dark.

First, what people are actually addicted to is changing the way they feel. And drugs do that. The fact that some of them result in what we call tissue tolerance is a byproduct. While methadone and Suboxone restrict the ability to get high on narcotics, they do nothing to inhibit use of benzodiazepines, methamphetamine, cocaine, marijuana, alcohol or any other mood-altering substance. In prison, inmates have eaten tablespoons of nutmeg to get high. Those who do not examine and change the things they don’t like about themselves or their lives simply will use other drugs in tandem with methadone.

Methadone should never be employed as a one-size-fits-all approach. It should be used sparingly and with caution, limited to those who have tried abstinence and failed. And more often than not, it should be a conduit to abstinence and accompanied by therapy.

Second, addiction is hard, but recovery is harder. When faced with a choice, who among us will not take the easiest route? Taking a pill is certainly easier than self-examination and change. We are conditioned to look to pharmaceuticals to address issues (from obesity to high cholesterol) that are much more effectively addressed by lifestyle change. Addicts are no different; if anything, they’re even more likely to choose what appears to be the easy way, even if it yields less positive results.

Addiction itself is nothing if not immediate gratification and pain avoidance. The world is full of snake oil salesmen who are selling the same thing as the solution. Shielding someone from the consequences of their actions used to be referred to as “enabling.” Now it falls under “harm reduction.”

Third, addicts are preprogrammed to please their caregivers. If you argue for their limitations, they will never let you down. If you argue for their abilities, some will let you down, but those who don’t will be the better for it.

Fourth, many opiate addicts cross thresholds that never can be re-created in the same way. Most people have never used illegal drugs or engaged in ancillary behavior that includes being dishonest, stealing, selling sex, or putting a gun in someone’s face. For those who have, the inhibitions of childhood are gone. Any treatment that does not focus on creating new prosocial attitudes and behavior is just a Band-Aid.

Fifth, practicing addicts, in order to continue practicing, need to view themselves as different from how the world views them. A petty thief might see himself as Captain Jack Sparrow, and Sparrow doesn’t need to change—he’s just misunderstood. Breaking through denial requires accountability to the real world, not the world they create to live with themselves.

Finally, as hard as it is for people to believe, addicts get status out of being addicts. There is a level of belonging and camaraderie that results in people encapsulating themselves with people who support their addiction, and also makes them afraid that “normal” people will not accept them. Those in recovery who experience loneliness have a built-in family that will welcome them back with open arms: those who are still using. Unless a program promotes and fosters positive fellowship, it likely will fail.

Methadone and Suboxone have their place. And those who are using either one should never be automatically excluded from the recovery community. But neither are these medications the answer, and those who suggest that they are should be viewed with suspicion, particularly if they reject input from those who have been there and emerged to the other side.

Since I run a program that has abstinence as its goal, this may be written off as self-serving. It is self-serving. Nearly all of my closest friends are ex-addicts in long-term, abstinence-based recovery. I don’t want to stand by and see the pool shrink.


Dan Cain is President of RS EDEN, a Minneapolis-based agency that operates chemical dependency treatment programs, correctional halfway houses and a drug testing lab among its services. He is a 2007 recipient of the Hazelden C.A.R.E award for sustained impact on the problems of addiction. His e-mail address is dcain@rseden.org.




Perhaps that within the environs of all this pharmaceutical advertising we see, it's time to bring back some of the good old "cures" - how about the Keeley Cure - or the Bi-Chloride of Gold Cure - or even the Irish Milk Cure. The advertising positioning line - - "The Easier Softer Way!"
Excellent article - I am so with you.

Couldn't agree more. We all want the easy way, but things that are worth having are rarely easy. It is the struggle, the confidence, the comaraderie of others that helps me to keep going. I've always wondered whether it is worhtwhile to replace heroin with Methodone, or Suboxene. Trading one drug that is illegal for one that is legal? Never have been able to figure that one out.

"Methadone and Suboxone [Actually buprenorphine/naloxone: Suboxone is just one brand.] have their place. And those who are using either one should never be automatically excluded from the recovery community."

That's the bottom line. Abstinence is preferable, but for opiate addicts it's not worth risking death. It's wrong to hold up methadone as equivalent to buprenorphine. Methadone is much more dangerous and does nothing to block the effects of other opiates. Neither blocks any of the other types of addictive drugs. No, we don't have a magic pill Dan.

You mislead with your claims about methadone overdose. Most deaths due in methadone prescribed for pain result from docs prescribing too high a dose. This has nothing to do with addiction. When addicts overdose it is more likely intentional, an attempt to get high, or results from combing with alcohol or other drugs.

The current epidemic of opiate addiction almost certainly resulted from people who had no business doing so telling doctors they should prescribe more for pain. But the real culprit is the failed war on drugs which created huge economic incentives. If all these drugs (even heroin, but especially buprenorphine) were available more like alcohol and tobacco (the real killers) there would be less damage all around.