This blog post was written by a woman who was once addicted to opioids but gave them up for good seven years ago. She and I were discussing the current opioid crisis when I asked what she would say to the parents of someone struggling with such an addiction. What follows is her answer.
When Dr. Bevan-Lee asked me what I would say to the parents of a person addicted to opioids, I was stymied at first. I'm not a parent, so I can't guess which questions you'd most like to ask of someone like me. My own parents never had any questions beyond "Why can't you just exercise a little will power?" so imagining what they might want to know was a dead end. Finally, I realized that all I had to do was think about who would read comments by a former opioid addict on a therapist's blog: people who are open-minded, psychologically literate, and searching for answers beyond what they can find in the mainstream media.
The first thing to say is that I don't have the solution to your child's addiction because there is no universal solution. I know how I dealt with mine, and I have learned, mostly by keeping up with research, why some of the things I did were helpful, but addiction is a complex problem for which there is no solution that works for everyone, even everyone who wants healing and works at it. So my first bit of advice is to be skeptical of people who claim to have the answer, no matter how authoritative they appear.
That said, there are answers, plural, one or more of which may help your child. And some opioid-addicted people do stop on their own, though we don't yet know why one person "outgrows" an addiction while another doesn't--very likely some combination of physical, psychological, and environmental factors.[1] For those who don't, I'll talk about methods I find useful and some I don't and mention pitfalls to watch out for. Full disclosure: I have strong opinions about the help available to people with addiction, especially young people, because I don't want to see them--or their families--hurt any more than they're hurting already.
First things first: for anything I say to be relevant, your child has to survive. If you read news, you know that opioid overdose deaths have been steadily increasing since 2000, reaching 47,600 in 2017. The media blame this increase on hyper-potent fentanyl, a gross oversimplification.[2] Nevertheless, it's true that, if your child is using street drugs, the potency will vary--possibly enough to cause an overdose, especially in combination with other factors (see the next three paragraphs). Protection against unexpectedly potent fentanyl requires common-sense precautions such as taking a reduced initial dose of any new batch of non-pharmaceutical drugs and making sure there's someone around who can help in case of an overdose.
The media's focus on hyper-potent fentanyl ignores other common causes of overdose. The first is interaction with other drugs, especially alcohol but also benzodiazepines, antihistamines, acetaminophen, and antidepressants. For fifty years, scientists and activists have begged the media to report that most overdose deaths actually result from drug combinations, but American headlines always scream "heroin overdose" or "prescription drug overdose," so the public remains unaware of the danger in mixing opioids. If you take nothing else from my remarks, take the information that between two-thirds and three-fourths of deaths attributed to opioids alone are actually caused by the interaction of opioids with other drugs. A safe dose of an opioid plus a safe dose of another drug, especially a depressant such as alcohol or benzodiazepine, can equal death, and very few people realize it.
Here's a typical scenario. A young man, dependent on heroin but fresh out, waits for a friend with some to share. He's experiencing withdrawal symptoms, but the friend isn't due for several hours, so the young man looks in the medicine cabinet for something to take the edge off. He finds some valium for the anxiety and tylenol for the muscle pain, but neither helps much, so he has a beer as well. The beer doesn't help much either, but he keeps drinking because it's better than nothing and finishes a six-pack by the time his friend arrives. Eager to feel better, he quickly injects his usual dose of heroin, only now it's an overdose because of the other drugs he has taken.
Another common cause of overdose is reduced tolerance after a voluntary or involuntary break from opioid use. In a typical scenario, a young woman struggles to stay abstinent after a month in rehab. Though physically detoxified, she still feels lousy, and she knows she faces many more months of "post-acute withdrawal syndrome (PAWS)," including dramatic mood swings. Meanwhile, every day she doesn't use opioids, her tolerance to them drops lower--not back to baseline, but far lower than it was before she went to treatment. On one particularly difficult night, she decides she can't take the misery of PAWS any more. She doesn't want to return to active addiction; she just wants a few hours' relief--in secret, so no one knows. She calls her old dealer and buys her old dose, only now, with her tolerance so low, it's an overdose.
So what do you do with this kind of information? If you're able to calmly and candidly discuss your child's drug use (a rare but healthy state of affairs), you could share it in the hope that it might someday prevent a tragedy. If you can't share the information, you can still use it to recognize and reduce risk--by keeping alcohol and benzodiazepines away from a child who is currently using opioids, for example. Regardless of how well you and your child communicate, you could also prepare to help directly by learning how to recognize an overdose and reverse it with naloxone. Despite what some claim, helping a child avoid or survive an overdose is not "condoning" opioid use; nor does it encourage greater risk-taking by reducing drug fatalities.[3] Instead, it's being realistic about a complex and challenging situation. It's recognizing that recovery from drug addiction can be a gradual process marked by stages and occasional setbacks, and that moral absolutes, zero tolerance policies, and other forms of black-and-white thinking are not helpful to most addicted people.
So what is helpful? Number one, in my book, is understanding--and by "understanding," I don't mean overlooking or indulging or enabling; I mean making an honest effort to comprehend what's going on with your child. Given the way the media portray opioid addiction, it's natural to react with panic or moral outrage when you discover your child struggling with the problem. It's not natural to calm down and try to view your child as someone who is using opioids to cope with problems, though that is likely the case, according to research. Self-medication for an undiagnosed mental illness is extremely common among addicted people,[4] as is a history of adverse childhood experiences (ACEs) such as abuse, neglect, loss of a parent, homelessness, and medical trauma; in fact, about two-thirds of people with opioid addiction report a history of ACEs.[5]
Understanding, at its most fundamental, means seeing your child, not as a negative stereotype, but as a complex human being who has developed maladaptive (but not necessarily irrational) behavior in response to known or unknown pressures.[6] For parents who want to go further, understanding might mean working patiently with children to figure out (1) why they use drugs; (2) what healthier strategies they might use to achieve the same ends; (3) how to transition from drug use to these healthier ways of coping; and (4) how to minimize the harm drugs may do in the meantime.[7]
What's not helpful? Criminalizing addiction definitely tops the list, but that's another conversation, so I'll pick something more likely to be advocated to you: "tough love." There's a myth in the recovery industry that no one gets better without "hitting bottom," or reaching the greatest suffering and/or depravity they can endure. Because this nadir may take decades to reach (and reportedly lies lower than death in especially "low-bottom" individuals), the industry came up with the technique called "raising the bottom," or deliberately making life as miserable as possible for a person with addiction. Housing, employment, significant relationships, anything a person needs to survive may be withdrawn to create suffering, which the person will regard as the intolerable price of continuing to use drugs. The classic form of "raising the bottom" is the intervention beloved of reality television in which friends, family, and colleagues threaten to withdraw material and social support so that the person with addiction must choose between immediate inpatient treatment and homelessness, unemployment, isolation, and other ills. Most choose rehab, of course.
If it gets people into rehab, what's wrong with "raising the bottom" (aside from the fact that it's based on a myth)? First, one common belief about addiction actually is true: people have to want to get better. What makes people want to get better varies but tends to be positive or hopeful in some way, or recovery doesn't take. Raising the bottom, instead of cultivating hope, operates via fear and coercion, no matter how much the people in charge insist, "We're doing this because we love you." Fear feeds the physiological dynamic that sustains the addiction (see Donna's essay on addiction and trauma), and coercion bulldozes whatever fragile desire for recovery the addicted person has by making it irrelevant. In addition, all the fear and misery that the addicted person is supposed to associate with continued drug use may instead cling to the people dispensing the "tough love," eroding the social support vital to healing.
I know it's sometimes necessary to be tough on an addicted person, to create and defend boundaries in order to protect yourself, other family members, and the resources on which you all depend. I'm not saying you shouldn't hold addicted people accountable for causing harm, and I'm not insisting you shield them from the natural consequences of their actions. I'm talking about deliberately making their lives worse as a strategy to precipitate recovery or because you believe, consciously or unconsciously, that they deserve punishment for having an addiction.
A few minutes ago, I said it was a myth that an addicted person has to "hit bottom" before getting clean.[8] What is more true, in my experience, is that our feelings about our habits fluctuate constantly regardless of how "low" we have "sunk" in some master life narrative. I generally alternated between loathing of mine, resignation to it, and gratitude for the relief it provided. During the years I was addicted, there was never a period when I didn't regularly experience the urge to quit, but it's hard to just quit at those moments because withdrawal is, not just painful, but incapacitating and impossible to hide. So I'd put off quitting until I could find four or five days to do it in, by which time the momentum to quit had often faded. Or I'd realize I couldn't find time for a detox and so begin a long taper that would go well for a while until the problems I was medicating with opioids flared up, and I decided my habit was the lesser of the two evils. Once, many years ago, a kind friend took me to a county hospital that treated addiction after I called her and said I could not stand my habit another day. The hospital didn't have many beds for women, so I was put on a waiting list to be called when one opened up. Three weeks later, I got the call just as a party was beginning at my house. High, drunk, and happy, I said, "No thanks, no problem here!" and that was the end of the matter.
The key to getting people into drug treatment is treatment on demand, not "raising the bottom." In response to the opioid crisis, a handful of urban ERs and "opioid urgent care clinics" have begun offering treatment on demand,[9] so let's hope that these become the rule, rather than the exception.
I've been talking about treatment as though it's a single thing, when, in fact, treatment options are multiplying in response to the opioid crisis. Until very recently there were two fundamental approaches: Medication-Assisted Treatment (MAT) and treatment based on the twelve steps of Alcoholics Anonymous (12-Step). MAT combines behavioral therapy with long-acting, non-euphoric opioids such as methadone and buprenorphine,[10] which may serve as a bridge to abstinence or be continued for many years, even a lifetime. Chronic opioid use changes the brain in ways not easily mended, and these neurobiological changes make relapse likely, particularly after long addiction. MAT helps the brain to heal while encouraging the renewal (or establishment) of healthy routines and responsibilities, including work and school. Though MAT, especially with buprenorphine, is not as widely available in the US as it should be (and is rarely covered by health insurance),[11] that is changing as the current crisis worsens and attracts more media attention. The treatment-on-demand programs I mentioned in the last paragraph all involve MAT.[12]
When most Americans think of "rehab," however, they think of inpatient treatment based on the principles of Alcoholics Anonymous. In such programs, patients begin with a medical detox (or come from a separate detox facility) then progress to learning AA's fundamentals in lectures and therapy groups. In addition, they attend AA and NA (Narcotics Anonymous) meetings and complete the first five of the twelve steps,[13] which prepares them to participate in local AA or NA groups after they leave rehab. The 12-Step model is not based on science but nonetheless helps up to ten percent of people struggling with addiction (though data are so scarce that any estimate must be tentative). The model's principal strength is that it offers a simple path forward and help on that path, both metaphysical help and a world-wide social support system in the form of AA and NA meetings. Its principal weakness overlaps with its principal strength: that it understands addiction as a private moral problem that only a "higher power" can remedy, rather than a medical or psychological issue. That said, a child with strong (but not necessarily developed) spiritual impulses might do well in twelve-step-based treatment, as might a child who prefers a well-marked path to follow and like-minded companions on that path.
It used to be that 12-Step programs and MAT were adversarial, with most of the hostility coming from the 12-steppers, who insisted that only total abstinence from all drugs is recovery, and that MAT simply "trades one addiction for another." Some still cling to this notion despite widespread support for MAT among addiction researchers and other experts, including those at the National Institute on Drug Abuse (NIDA) and the World Health Organization (WHO). Lately, however, major players in the 12-Step treatment industry such as Hazelden Betty Ford have begun adding limited MAT to their AA-based core,[14] so perhaps the hostility is easing. As I said earlier, the more therapeutic options that become available, the greater the chance that people can find--or forge--a path out of addiction.
My own path was circuitous. When I stopped using opioids, buprenorphine was not an option for me, so I quit on my own, not for the first time. It was physically and psychologically brutal, and I soon began alternating miserable abstinence with binge drinking, which quickly became more dangerous than my opioid habit. At that point, no longer physically dependent on opioids but still craving them, I underwent inpatient treatment at a 12-Step facility that used a "confrontational" (their word) approach to convince me I was a defective, powerless addict only God could save. Because I arrived already convinced I was a defective, powerless addict, I would have fared better in a compassionate, rather than confrontational, program. If I had drug treatment to do over again, I'd skip rehab (and drinking, obviously) and instead take buprenorphine for a couple of years while I (1) began a serious meditation practice, and (2) worked on the unprocessed trauma that made life with an addiction, with all its difficulties, preferable to life without one.
For me, mindfulness and trauma work are the key to recovery, but I had to pursue them seriously--and simultaneously--to derive their benefit. I'm heartened to see trauma-sensitive addiction treatment becoming more available and mindfulness being integrated into traditional addiction treatment, as well as being offered in stand-alone aftercare workshops, such as Mindfulness-Based Relapse Prevention, which I've taken and think is excellent. I cheer the development of genuinely groundbreaking programs such as Samadhi in New York, and I condemn other facilities' preservation of outmoded, ineffective treatment methods just because they are profitable. I sometimes feel physically sick when I see addicted people returning a dozen or more times to a treatment facility that doesn't help them, covered in shame for "not getting it." Recovery from addiction is hard, yes, and often requires multiple attempts, but repeated failure can also signal a bad match between patient and provider.
That's the main thing I want to get across: different people need different things to get better. One-size-fits-all recovery is good for the hedge funds and private equity firms that have lately discovered the money to be made in addiction treatment, but it is not good for human beings struggling with addiction. If you can, try to set aside the stereotypes of "the addict" that all of us have absorbed, mostly without realizing it,[15] and see your child as a unique individual who is suffering. I know you're suffering, too, and I truly wish I could be more reassuring, but all I have are the facts as I see them and some hope that they might help you help your child. I will say, however, that, with a parent who would search out and read an essay like this one, your child has the kind of support that truly does make a difference. And that's huge, it really is.
Originally published on the blog of Dr. Donna Bevan-Lee.
[1] The notion that some people "outgrow" or walk away from heavy drug use is controversial, like almost every claim about addiction and recovery. Research data (e.g. studies of heroin-addicted Vietnam veterans) show that many do, yet experts disagree about how (and whether) to interpret those data.
[2] Reporting that fentanyl is anywhere from "forty times as strong" to "2,000 times as strong" as heroin, the media further emphasize fentanyl's strength with fabricated stories about people keeling over dead after touching trace amounts. While the drug's potency and provenance are issues for law enforcement, heroin users don't suddenly find that the white powder in their regular $25 bag is dozens or hundreds of times stronger than usual. Nor does the potency of fentanyl create more addicts, except (perhaps) insofar as it enhances distribution. But it's easier to blame demon fentanyl from China (or the Sackler family) than to ask why so many of our citizens are now addicted to narcotics--or how our own drug policies may be contributing to the rising death toll. That said, the more potent a drug, the smaller the margin of error when diluting it for sale, so the presence of fentanyl in the drug supply does call for sensible precautions.
[3] These criticisms are losing credibility, noted The New York Times in 2016, yet just last year two professors at major universities revived the argument with a paper titled "The Moral Hazard of Lifesaving Innovation: Naloxone Access, Opioid Abuse, and Crime." It wasn't much of a revival, though; the authors' main point was that there's more addiction because fewer addicts are dying. Duh.
[4] People may use opioids to medicate depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, personality disorders, and even schizophrenia while the people around them attribute their symptoms to drug use alone.
[5] This figure has been repeatedly confirmed by research. See also Donna's essay, "Childhood Trauma and Addiction."
[6] When I say that drug addiction is "not necessarily irrational," I'm referring to the fact that drugs of addiction actually work quite well to calm a brain overstimulated by chronic trauma. For more information, see Donna's essay, "Childhood Trauma and Addiction."
[7] See the web site of the Harm Reduction Coalition for valuable information.
[8] Maia Szalavitz explains the history of this myth in her excellent book, The Unbroken Brain: A Revolutionary New Way of Understanding Addiction. For a quick summary, see this article in The Cut.
[9] Cities with pilot programs include Boston, Denver, and Oakland.
[10] Methadone, used to treat heroin addiction since the 1950s, is familiar to most people. Buprenorphine has been available since the 1980s, but its use has been restricted by limits on prescribers, though those limits are gradually being eased in response to the opioid crisis. In the US, buprenorphine is marketed as Subutexâ and (in combination with naloxone) Suboxoneâ, the latter more commonly prescribed for long-term MAT. The past couple of years have seen the introduction of new formulations that don't require daily dosing: Sublocadeâ and Probuphineâ.
[11] For those who cannot pay for MAT and don't qualify for state assistance, the herb kratom may provide a natural alternative. While most articles on using kratom to treat opioid addiction exaggerate the benefits or the risks of the herb, this article from Web MD offers a sensible overview. Its concern about quality control is legitimate, but risk can be minimized by purchasing online from a vendor that adheres to the standards of the American Kratom Association. Using kratom may require more supervision than other forms of MAT because there is no prescriber to monitor dosage, so caution is advised.
[12] A 2017 article in Substance Use and Misuse points out, quite rightly, that the medication alone in MAT is valuable, even if the person with addiction does not undergo additional therapy.
[13] The steps are: (1) admitting that we're powerless over addiction, that our lives have become unmanageable; (2) coming to believe a power greater than ourselves could restore us to sanity; (3) deciding to turn our will and our lives over to God as we understand God; (4) making a searching and fearless moral inventory of ourselves; (5) admitting to God, to ourselves, and to another human being the exact nature of our wrongs.
[14] Hazelden Betty Ford uses the newer medication, buprenorphine, combined with naloxone for detox, possibly followed by extended-release naltrexone to "block cravings." They do not use methadone, and it's clear from their web site that they do not support long- or even medium-term buprenorphine use.
[15] For an essay about where the stereotype comes from and how it affects people with addiction, see "All Addicts Lie" by the Sober Heretic.
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