Michael Stein is chair of health law, policy and management at the Boston University School of Public Health and author of “The Addict: One Patient, One Doctor, One Year.”
“I’m detoxing.” This is the sort of news that delights the families of patients who are addicted to heroin. The promise of a seven-day detox solution is seductive.
But detoxification is actually extremely dangerous. Nearly every addict who successfully completes a week-long detox program without further treatment relapses, and in a world with increasingly powerful synthetic drugs on the market, the risk of overdosing and dying during a relapse has become ever more threatening.
So when someone says, “I’m detoxing,” I ask, “And then what are you going to do?”
“Detoxing” refers to treatment designed to get patients off drugs that can kill them. But detox is also a place, usually a hospital-like setting where a drug user will stay for up to seven days, medically supervised, to get tapered off drugs.
Unfortunately, it is an extraordinarily rare person who uses opioids for months or years and quits it cold without a period of medication treatment — regardless of willpower, self-confidence or support from family and friends. Even with the best clinicians working with the best detoxification protocols, most patients delude themselves that detox alone is enough. The reality is that patients detox, relapse, detox and relapse again.
As fentanyl — a potent, synthetically born killer — infiltrates the drug supply, the epidemic of overdose deaths will only worsen. There were about 60,000 overdose deaths in 2016, and there will likely be more in 2017. Fetanyl now laces most heroin (and, increasingly, cocaine) bought on the street. Some 75 percent of fatal overdose victims in New England last year tested positive for fentanyl.
Detoxification programs need to change their mission and their magical promises. They should become short-term refuges where people can begin long-term treatment. They should become sites where medication is begun for all seeking to live without illicit drugs. They should offer seven cloistered days to deal with acute medical or psychological issues and to discuss treatment with any of the three well-known and effective medications for opioid users, which, if taken correctly, can reduce the risk of relapse and possibly save lives.
I often hear parents say, “But medication treatment is just replacing one drug with another.” This is painfully discouraging. Refusing medication treatment is essentially sentencing drug users to death. If the chance of relapse following detox is nearly guaranteed, and the chance of death by fentanyl during that relapse is high, and the evidence shows that medications protect against overdose death, then the only safe way to treat opioid users is through long-term medication.
As the White House and state leaders commit to strategies that combat opioid deaths, there must be a parallel revolution in our understanding of treatment. A detoxification program is not treatment but rather the site for the beginning of treatment. Making the best use of short-term inpatient programs is critical, but patients are best served when such programs put them on the long road of recovery with the help of a daily medication covered by all insurers and a caring prescriber.
Under the pressure of rising opioid deaths, the Centers for Disease Control and Prevention has produced guidelines suggesting that chronic pain should not be treated by opioids and that chronic opioid use puts people at risk of addiction without countervailing benefit. It’s time that the CDC, the Department of Health and Human Services and medical professional societies also declare that opioid use disorder should be treated with medication.
Detox programs, as they currently exist, must change. Every episode of illicit drug use is now even more perilous because of fentanyl. It would be a shame if someone who has taken a step to get better believes that detox alone will save them.