America’s epidemic of heroin and prescription-pain-reliever addiction has become a major issue in the 2016 elections. It’s worse than ever: Deaths from overdoses of opioids (the drug category that includes heroin and prescription analgesics such as Vicodin) reached an all-time high in 2014, rising 14 percent in a single year. But because drug policy has long been a political and cultural football, myths about opioid addiction abound. Here are some of the most dangerous — and how they do harm.
1. Most heroin addiction starts with a legitimate pain prescription.
People who misuse prescription pain relievers are 40 times more likely to become addicted to heroin than those who don’t, according to the Centers for Disease Control and Prevention. Research also shows that 75 percent of patients in heroin treatment started their opioid use with prescription medications, not heroin. That sounds like pain treatment is at the root of the problem, and the CDC is targeting doctors with new guidelines aimed at reining in prescriptions.
But overwhelmingly, prescription-drug misusers are not pain patients. According to the National Survey on Drug Use and Health, more than 75 percent of recreational opioid users in 2013-14 got pills from sources other than doctors, mainly friends and relatives. Even among this group, moving on to heroin is quite rare: Only 4 percent do so within five years; just 0.2 percent of U.S. adults are current heroin users.
The proportion of patients who become newly addicted to opioid medications during pain treatment is also low. A 2010 Cochrane review — considered the gold standard for basing medical practice on evidence — found an addiction rate of less than 1 percent. A study of more than 135,000 emergency-room visits for opioid overdose found that just 13 percent of patients had a chronic pain diagnosis.
Further, a 2015 study showed that only 6 percent of those who received an initial prescription for opioids took the drugs for more than four months; the authors didn’t determine how many of those ongoing prescriptions were medically appropriate and what proportion were linked to addiction.
The real risk factor for opioid addiction is youth. Like 90 percent of all addictions, the vast majority of prescription-drug problems start with experimentation in adolescence or early adulthood, typically after or alongside binge drinking, marijuana smoking and cocaine use. Having a prior or current addiction to another drug is the best predictor of developing problems with prescription drugs — not pain care.
2. The best treatment for heroin addiction is inpatient rehab.
When the media covers addiction among the rich and famous, they almost always include an inpatient stay at a plush rehab center. Dr. Drew Pinsky’s “Celebrity Rehab” is typical of such programs. Like many who run inpatient programs, Pinsky rejects the ongoing use of anti-addiction medication (though Hazelden, the original model for the 28-day rehab center, began offering it to some patients in 2012 after experiencing record high death rates). Similarly, most drug courts and many state Medicaid programs also deny continuing access to the two best-studied maintenance medications, methadone and buprenorphine (Suboxone).
The position that residential treatment centers and their abstinence-only philosophies are superior to medication ignores overwhelming data and keeps families from seeking the best care. Let’s start with Dr. Drew’s patients: Nearly 13 percent who appeared on “Celebrity Rehab” died not long afterward; most had been addicted to opioids. While that may be an especially poor showing, research on more than 150,000 patients receiving treatment for opioid addiction in Britain found that people in abstinence-only care had double the death rate of those who received ongoing maintenance treatment. And other studies find that maintenance medication cuts death rates by 70 percent or more. Since untreated heroin addiction carries a mortality rate of 2 to 3 percent per year, the benefit is substantial.
This is why the World Health Organization, the National Institute on Drug Abuse, the Institute of Medicine and the White House drug czar’s office all agree that maintenance treatment — indefinite, possibly lifelong medication use — is superior to abstinence rehab for opioid addiction. While some argue that total abstinence is a moral imperative, dead people can’t recover. Sadly, only a small proportion of people with opioid addiction are currently in medication-assisted treatment — largely because of limits placed on it by misguided ideology, government policies and insurers.
3. Recovery from heroin addiction is rare.
The prognosis for heroin addiction seems grim because of the high mortality rate and because rehabs typically report relapse rates of 60 percent or greater. However, the odds of recovery are better than they appear.
Early evidence for this idea came from studies of Vietnam veterans, who, as young men, should have had particularly high addiction and relapse risk. Heroin and opium were cheap and easily available to American servicemen overseas; nearly half tried these drugs, and half of these soldiers became addicted. But upon returning home, just 12 percent of those who had been addicted relapsed within three years, and only 2 percent were still addicted at the end of the study — nowhere near 60 percent. Fewer than half got any treatment, and it didn’t make a difference in terms of who recovered.
This phenomenon, known as “natural recovery” or “maturing out” of addiction, is common with other drugs, too. Large population surveys show that most people who are addicted to alcohol or cocaine quit without treatment. The same type of study shows that around 60 percent of people who met the criteria for prescription opioid addiction at one time no longer do so — and one third of them never received any treatment. This research also finds that the average prescription opioid addiction lasts eight years; for heroin, the average is a decade. For alcohol, the average addiction lasts 15 years.
So why do heroin addicts appear so hopeless in the public imagination? Because people who quit on their own don’t show up for treatment — and so, while they are included in large epidemiological studies, they aren’t included in treatment research. This means that rehabs see only the worst cases, leading to an unduly pessimistic picture of recovery. Although opioid addiction certainly can be deadly, it doesn’t have to be — and those who struggle with it should absolutely seek help. Still, more research is needed to understand what people who recover without help can teach those who need it.
4. Tough love is the only thing that works.
The idea that people with addiction must “hit bottom” — or experience the worst possible consequences — before they can get better is prevalent among parents and policymakers. One drug court official told a researcher that “force is the best medicine” for treating addiction, and the 12-step program Al-Anon warns against “enabling” addiction by doing things like helping people avoid jail.
But research shows that the opposite is true. Like any other human beings, people with addiction respond best to being treated with dignity and respect. Programs that nonjudgmentally distribute clean needles, provide overdose-reversal drugs or offer safe spaces for injection do not prolong addiction; a Canadian study found that 57 percent of people who came to a safe injection facility to shoot up ultimately entered treatment . An approach for helping addicted family members that uses kindness, rather than confrontation or detachment, was found in another study to be twice as effective as a traditional confrontational “intervention” — and no studies show that harsh treatment or incarceration is superior to empathetic care.
Similarly, there’s no evidence that naloxone programs, which provide users and their families with the overdose-reversal drug, prolong addiction. But they do prolong life: The overdose death rate was cut by nearly 50 percent in communities that fully implemented these programs.
5. Whites have recently become the majority of people with heroin addiction.
In an article headlined “In Heroin Crisis, White Families Seek Gentler War on Drugs,” the New York Times recently claimed that “today’s heroin crisis is different,” because it is not “based in poor, predominantly black urban areas” and because use “has skyrocketed among whites.” NPR, the Atlantic and other major media outlets have run similar stories, often citing a study, published in JAMA Psychiatry, which found that 90 percent of new heroin users in the past decade were white.
What most of them omit is that the same study showed that whites have made up more than half of all heroin addicts since the early 1970s and hit 80 percent before 2000. In 1981, Newsweek panicked about a new wave of “middle-class junkies,” and in 2003, a Times headline read “Heroin’s New Generation: Young, White and Middle Class.” White heroin users are nothing new.
The reason for the misperception is political: Politicians from the first “drug czar,” Harry Anslinger, in the 1930s to Ronald Reagan in the 1980s have portrayed heroin and other illegal drugs as a black or “foreign” problem in order to justify tough policies. In the early 1900s, when heroin was sold over the counter without warning labels, the typical user was a white middle-class woman, and she was seen as a victim of unscrupulous manufacturers, not a criminal. After heroin became illegal and was framed as a problem of the poor and minorities, law enforcement began to predominate. Only now are policymakers beginning to recognize the failure of criminalization.