The War On Addicts
Addiction will never go away. It is as much a part of being human as unhappiness and death. People become addicts because they are unhappy with their lives. If a person is happy, they don’t become an addict. Over half of all Americans have tried illegal drugs, but only 10% develop problems. And that problem was there before they took their first drug. Drugs don’t cause addiction, unhappiness does.
In order to understand addiction, one must understand human suffering. Human beings are designed to suffer. Studies have shown that happy people accomplish much less in life than marginally unhappy people. Only people who suffer from a modicum of existential anguish become the overachievers that propel humanity forward. There is an evolutionary advantage to being unhappy. It is that constant discontent that drives us on. The whole reason that humanity has been so successful is that we are never satisfied. But unfortunately there is a flip side to that. Statistically everything exists on a bell shaped curve. On one end of the spectrum are those who are happy all the time, content to sit around and enjoy where they are and what they have. On the other extreme are those who are unhappy no matter how hard they try. But try as they may, most of what makes us happy is beyond our control. Research shows that 50% of our baseline happiness is due to our family of origin, both from genetics and environment. And about 10% comes from life events. That means we personally have control over only 40% of our overall happiness. And for those who can never reach that 50% mark, there are frequently only very limited options, like drugs or suicide.
There are a multitude of ways people try to increase their happiness quotient, with sex, drugs, and rock & roll topping the list. Anything that will release those endorphins in our brains. (Currently it seems that food is the big addiction in the U.S., but that is culturally acceptable, and not illegal.) For those of us who are born with bigger brains and cultural advantages, we have more options. Climbing the social ladder through education and work provides us with the accolades and feelings of accomplishment that helps provide happiness in our lives. Higher social standing also gives us a much broader array of options to increase our level of satisfaction, such as the ability to travel and to experience the finer things in life. But for the average or disadvantaged, that list becomes much shorter.
Sometimes the only way of alleviating the pain is through alcohol or drugs. If your family is screwed up, and you don’t have the intellectual or financial resources to fundamentally change your life, you’re stuck. Statistically 10% of all people of all cultures in all walks of life will have a problem with substance abuse at some point in their life. That’s just the way it is, everywhere in the world. A stable statistic, just like the incidence of schizophrenia. But what we do from there is what makes all the difference. Those with more resources do better. Why do you think that doctors as a group have the highest success rate in recovery? It’s because they have much greater access to the things that can augment happiness in a person’s life; family, financial stability, leisure time, and the ability to pursue their life’s passions. But even for a percentage of high functioning individuals, it’s not enough. One of my medical school classmates is in prison for the better part of his life. He just couldn’t quit.
Now for the question of treatment. Treatment only works if it tips the scales in favor of happiness. If you only take away the drug addict’s drug, they will just find another one. For example, when they reformulated Oxycontin so that it could not be abused, all the people who were abusing it didn’t just magically quit using, 40% of them just switched to heroin. Taking away the drugs never works. THE DRUGS ARE NOT THE PROBLEM. The reason that the U.S. has 2.2 times the addiction rate of any European country is that our approach to addiction increases the addict’s pain, in effect making their addiction worse. The shame, blame and punishment we inflict on addicts actually exacerbates their disease. And the three institutions that lead the dysfunctional charge are our legal system, religion, and our health care system. The U.S. has the highest incarceration rate of any country in the world (actually, of any country in history), and half of the people incarcerated are there for non-violent drug offences. There has never been a study that showed incarceration improved addiction outcomes, but there are plenty that show it makes it worse. But unfortunately once we get an idea in our heads, it’s hard to change course. The same is true of our health care system. Many of my patients are terrified to walk into my office for the first time, because of all of the abuse and judgment they have received at the hands of medical providers. The Buddhists have a saying, you can’t put anything in a cup that is already full. Most health care providers think they know a lot about addiction, even though they actually have received absolutely no training in addiction. During my entire medical school and residency training, I did not receive a single class on addiction, even though addiction is as prevalent as diabetes. But I did get plenty of dysfunctional opinions from the medical professionals I encountered during my training. And the overwhelming message was that drug addicts were bad people, worthless individuals to be treated with derision and scorn. But I must admit, as an ER doctor for over 20 years I did my fair share of stone throwing. But thankfully in my case, God was not content to allow me to wallow in my unbridled ignorance, He had me marry an addict. But that’s another story.
Now on to Suboxone, also known as buprenorphine. Suboxone is hated simply because addicts are hated, and it is a drug used to treat addiction. Suboxone works by making people happier. Plain and simple. And anything that can make you happy can be abused. But what is important to understand is that the average addict is severely depressed due to a totally dysfunctional endorphin system, and they were born that way. They didn’t become addicts because they took drugs, they take drugs because they are an addict! That’s like saying a person is diabetic because they took insulin. Even the term ‘addict’ is misleading. Some people believe a better term would be “endogenous opioid dysfunction syndrome”. But that’s a little hard to say. I have had many patients tell me that they were miserable every day of their life until they took their first pain pill. They tell me it was the first time in their life they felt "normal". You have to understand that if you live at a 2 on a happiness scale of 1-10, and a pill gets you to a 7, to you that is ‘high’, even if to the rest of us that is just normal. These people don’t take Suboxone to get high, they take it to function normally. Most of my new patients have been taking Suboxone off the street for an average of 6 months, just to function normally. They have jobs, they have families, they are just trying to survive. But these are the invisible 99%. These are the people who remain in the shadows for fear of recrimination. Like being Jewish in Nazi Germany.
The ones who come to the attention of the media and health care providers are the people with severe psychiatric disorders as well as addiction. These people have a crippling mental disorder, of which substance abuse is but a part. Again, like schizophrenics, who simply take illegal drugs to quiet the noise in their heads, people with other serious mental disorders are not primarily drug addicts, substance abuse is just part of that disease. But unfortunately, most health care providers are blind to these distinctions. Like education in addiction, few health care providers ever receive adequate training in mental health and psychiatry. And as they always said in my internal medicine training, you only see what you
But one of the most important things to understand about Suboxone is that it doesn’t kill people. The LD50 (or lethal dose) for buprenorphine (Suboxone) orally is >600mg/kg. That works out to be 42 grams for the average 70 kg person, or 5250 pills taken all at once. Last year around 22,000 people died from opiate overdoses, 1/3 of those from methadone. Twenty six died from Suboxone. In the whole U.S. That’s less than the number of people killed by lightning. Less than the 500 deaths every year from Tylenol.
The other significant, and extremely important characteristic of Suboxone, is that it has a "ceiling effect". That means that once you take three Suboxone a day, you don’t get any additional effect from more medication. People don’t escalate their doses like they do with other opioids. When new patients call for an appointment, we ask them what street drugs they are taking, and how much. When they are taking oxycodone, the response is usually “as many as I can get”. 100 to 200 mg a day is not unusual. But if they answer Suboxone, the quantity is usually 2 per day, but almost never more than three.
So in summary, since the AMA describes addiction as “a chronic relapsing illness, like diabetes”, we may never have a cure. But at this point Suboxone is the closest thing to a miracle we may ever have. Just ask any one of my patients. They will tell you it has literally saved their lives.
The truth is people will always take drugs. It’s how we’re built. And you can’t shame or incarcerate it out of people. But in spite of that truth, there are effective, scientifically validated treatments for addiction, but we have to get over our prejudices before we can effectively utilize them. The data are there. The science is there. Other more progressive countries have shown clear and unequivocal success in reducing the toll of addiction on individuals and society. We just need to follow suit. And changing our attitudes is the essential first step.
Dr. Vance Shaw, MD, FASAM
Board Certified by The American Board of Addiction Medicine