Drug overdoses are reaching unprecedented rates. They now kill more people than motor vehicle crashes, according to the Centers for Disease Control. Abuse of opioid drugs, particularly prescription painkillers and heroin, has surged in people of all demographics. In 2010, prescription opioids were the primary cause (60%) of overdose deaths in the United States (where the drug was identified), compared to causing 30% of overdoses in 1999.
Federal and state agencies are working to educate prescribers to keep unused prescription painkillers from being abused. But those already addicted need more help staying off drugs and having productive lives, especially those who become incarcerated, experts said at a Capitol Hill briefing organized by AAAS and the Dana Foundation. While new medications have been developed, outdated regulations and the stigma associated with addiction medications can make addicts reluctant to use them. More people need access to treatment programs that offer a combination of psychotherapy and anti-addiction medications, the panelists said.
Charles O'Brien (above) and Chaka Fattah | Kathleen O'Neil
While many people recognize addiction is a mental illness, they fail to recognize that a drug addiction is a chronic disease, said Charles O'Brien, the vice-chair of psychiatry and founding director of the Center for Studies in Addiction at the University of Pennsylvania. Non-medication therapy programs may help addicts while they are participating, he said, but afterwards, cravings remain because the addicts' brains haven't returned to normal, he said.
O'Brien spoke at a 9 July lunch briefing for policy-makers, one of a continuing series on brain research. It was hosted on the Hill by U.S. Rep. Chaka Fattah (D-Pa). Joshua Lee, associate professor of population health and medicine at New York University Langone Medical Center, also participated in the briefing. He is an addiction medicine specialist who treats patients incarcerated in New York City jails as well as in community practice at Bellevue Hospital Center.
Lee cited a study of Washington State incarcerated addicts that found they have much higher chance of dying of drug overdose, trauma, violent death, or even suicide in the two weeks after leaving jail than the rest of the population. "Incarceration is not a treatment," Lee said. "You can't think that just because someone's been in jail for 30 days that they will be different when they get out." After people spend weeks wishing they could get high, he said, they end up bingeing on drugs and alcohol, with sometimes fatal results.
Some addicts enter drug treatment programs after being referred by a court following an arrest for possessing drugs or for committing a crime to support their addictions. In the Philadelphia prison system, for example, 18% of parolees have a history of opiate addiction, O'Brien said. However, many jails and prisons do not refer addicts to treatment clinics. "We need to take a new approach. Why don't we offer people medication instead of prison?" O'Brien asked.
Not only does the criminal justice system often fail to facilitate treatment, Lee said, many facilities do not let addicts stay on anti-addiction medications, such as methadone, while they are in jail. The same systems don't deny prisoners medications for other medical conditions, however, but the attitude persists that addiction is a moral failure, rather than a disease. "It's not surprising that you don't get good outcomes by treating addiction as a criminal issue," Lee said.
Studies have found that the most effective treatments are a combination of psychotherapy and medication, O'Brien said. Many addicts have other mental illnesses that also need treatment, usually a similar combination of medication and psychotherapy. However, the stigma associated with methadone and newer drugs has made medication-assisted therapy less popular than counseling-only programs with addicts and treatment providers in general, he said.
Joshua Lee | Kathleen O'Neil
Methadone is an inexpensive opioid medication that targets the same receptors in the brain as opioid drugs, but is much longer-lasting than heroin or morphine. It can be used to wean addicts off their drug of choice, and then is either discontinued or continued at a lower, maintenance dose. Since it can be abused or toxic if taken in high doses, legal limits have been placed on its use, including requiring new users to report each day to a methadone clinic, and take the medication on site.
Newer medications are also available, including a synthetic opioid, buprenorphine, that targets the same brain receptors but is safer than methadone. There is also naltrexone, a medication that blocks opioid brain receptors, so that if patients relapse and try to get high, they will not feel any heroin or other opioid effects.
Extended-release naltrexone can be given as a long-acting injection that is effective for 30 days, lessening the need for repeat visits to a clinic or daily adherence to an oral medication. It prevents an addict who uses drugs from feeling high. "This is ideal for people leaving jail," Lee said. "It gives you the space to clear your mind and probably makes it less likely that someone will overdose."
While these are all good medications that could be used to help more substance abusers, more medications need to be developed, O'Brien said. Drug companies have in the past been relatively uninterested in developing new addiction medications, since they don't see a good pay-off from them, he said. The Affordable Care Act may help change that, since it requires all qualifying insurance plans cover substance abuse treatment, ensuring a market will be there.