Understanding Addiction

…by Percy Menzies…

I met Percy, a treatment provider and policy person, in Minnesota about six months ago. We have had some spirited discussions since then. In his view, the culprit in the opiate crisis is access — drug availability — a position that’s put him in direct opposition to Johann Hari and others who favour decriminalization/legalization. He is also a champion of naltrexone…an evidence-based treatment we don’t hear much about. Here’s what he’s got to say:

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Access to drugs is by far the strongest factor contributing to the spread of addiction. The unprecedented quantity of heroin being produced by Afghanistan, Burma and Mexico is causing a sharp increase in heroin addiction and deaths in bordering countries including the US. Addiction rates are rising in Europe, Asia, Africa and many other countries. The access is almost certain to grow as more opium poppies are grown in these countries. The heroin problem in the US is compounded by the huge increase in the use of prescription opioids to treat chronic pain. Indeed, the US consumes in excess of 80% of the world’s legal opioids! We have not seen a problem this big since the days when morphine was an unregulated drug and used indiscriminately.

How do we grapple with this growing problem? A little history before we attempt to answer the question. The treatment of opioid addiction is overwhelmingly dominated by opioid substitution treatment (OST) based on a hypothesis that opioid use causes permanent changes to the opiate receptors necessitating prolonged opioid use as a form of harm reduction. Using an opioid to treat an opioid addiction is tricky and works best when access is controlled. It started when President Nixon in the 1970’s reversed the long-standing policy against maintenance treatment with opioids and authorized the opening of methadone clinics. Heroin addicted patients were required to go to the clinic each morning to ingest a carefully controlled dose. This highly restrictive and controversial program was planned as a temporary measure and served a dual purpose. It protected society from the criminal activity of drug addicts and at the same time provided heroin addicts treatment.

If opiate substitution treatment is the only way to go, could we develop or look at existing opioids that could be administered in a less restrictive environment? Buprenorphine, a powerful, but safer opioid, developed in the 1970’s as an injectable drug for the treatment of acute pain, emerged as the best candidate. The oral formulation as a sublingual tablet was found to be highly effective in curbing the cravings for opioids. Although abuse was an ongoing problem, buprenorphine emerged as a safe, effective medication that could be prescribed by a physician. Researchers believed that adding the opioid antagonist naloxone (better known by the trade name Narcan) would deter patients from injecting the sublingual tablet.

The introduction of buprenorphine in 2002, better known by the trade names Subutex and Suboxone took a rather convoluted path. The approval occurred when the nation was in the throes of a man-made epidemic of prescription opioid use. To prevent buprenorphine turning into “pill mills,” physicians were required to obtain a DEA-waiver and there were limits on how many patients could be treated at any one time – 30 the first year and 100 thereafter. Too few physicians bothered to get the exemptions, and although the sales of buprenorphine soared to in excess of $2 billion per year, we have not seen a drop in reduction of heroin use or overdoses. Why? Too few physicians with the required exemption and too few treatment slots for buprenorphine, the experts told us. After much debate and lobbying, the compromise is to increase the access by allowing physicians to treat up to 200 patients at a time.

We are facing an unprecedented epidemic. Why not remove all restrictions on the use of methadone and buprenorphine and throw open the floodgates for OST? Why not treat addictions as we have treated chronic pain in the past? Will this solve the problem? Not by any stretch of the imagination. It will only exacerbate the existing problem as the pool of opioids will greatly increase along with abuse and diversion. We have to offer patients treatment options including non-opioids.

Marc Lewis in his very thoughtful post on visiting a harm reduction facility in Belgium observed: “Methadone provides a solution to heroin epidemic, but not a great solution. Something is still seriously wrong here, and this form of treatment, connection and care can make it livable. But only just.” Marc’s observation that many patients in the clinic he visited balanced their methadone dose with heroin obtained on the street also applies to buprenorphine. As long as there is access to heroin, treatment options centered on buprenorphine or any other opioid are going to be problematic.

My clinics have treated thousands of patients addicted to prescription opioids and heroin by offering them clear treatment options. We refer them to methadone clinics when appropriate; offer buprenorphine as a detox and maintenance medication when necessary; and when they want to be completely abstinent from all opioids, we start them on naltrexone. A monthly injection of naltrexone (called Vivitrol) is a highly favorable alternative to continuous opioid addiction, especially when street drugs are mixed with OST. Our patients can always go back on buprenorphine or methadone if they change their minds. For many patients it is refreshing to know that they don’t have an incurable disease, and a spectrum of treatments options gives them a fighting chance to feel empowered and to quit using drugs. Even if only 15-20% of patients are likely to benefit from naltrexone/Vivitrol, is it not ethical to offer it as a treatment option? Especially for patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.

Access is the major culprit in the spread of addiction and a major contributor to relapse. Increasing access to opioids as part of treatment may help some people, but it is only going to worsen the big picture.

Percy Menzies holds a Master’s degree in pharmacy from India and is the president of Assisted Recovery Centers of America, a clinic based in St Louis, Missouri, that treats in excess of 400 heroin addicts a month through evidence-based treatments.

…by Shaun Shelly…

Percy Menzies’ post has stirred up a lot of controversy! Here, Shaun’s extensive rebuttal gathers some of these arguments, plus many of his own, and launches them in torpedo-like fashion. Shaun’s command of the research landscape is awesome, but let’s take care to keep a balanced perspective.

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In the previous post on this site Percy Menzies makes what appears to be a persuasive argument for naltrexone as a favourable intervention when addressing heroin use disorders. Where Dr. Menzies and I agree is that people who have a heroin use disorder should have a wide range of options for treatment, all the way from non-pharmaceutical to antagonist to agonist. Having said this, I have some major problems with his argument, and I believe that the promotion of naltrexone as a valid response to the heroin epidemic, compared to agonist and partial agonist therapies, is flawed.

The first thing we need to know is that opioid substitution therapy (OST) works. It is the gold standard recommended by the World Health Organisation, and for the last 50 years methadone has been proven to reduce mortality, reduce crime, improve health, improve retention in treatment and allow people the space to resolve many of the issues that have made drug use so meaningful to them. It also reduces the spread of HIV. Through robust head-to-head clinical trials, buprenorphine has also been shown to be effective, in some cases more so, in some cases less, but it is effective and has a better safety profile.

Dr. Menzies suggests that the treatment of heroin use disorders is “overwhelmingly dominated” by OST. This is simply not true. According to a 2015 SAMHSA report, only 22% of people between the ages of 22 and 34 accessing treatment for heroin use disorders received OST. Even judges playing doctor are ordering people to stop OST. Further, Dr. Menzies argues that if OST was made more available it would “exacerbate the existing problem, as the pool of opioids will greatly increase along with abuse and diversion.” The data simply do not support this: In Switzerland, where 92% of people in heroin use treatment are receiving agonist therapies, the number of people with a heroin use disorder is dropping by 4% per year and no one has died from a heroin overdose since the programme was started in the early 90s. Similarly in France, where buprenorphine is the norm, 70% of heroin users have access to OST and there has been an 80% reduction in heroin-related deaths and a 75% drop in HIV prevalence among injecting drug users. 20% of French physicians prescribe buprenorphine compared to 3% in the US.

As far as diversion is concerned, diversion is a function not of greater availability but of lack of availability. The diversion of methadone and buprenorphine occurs because they have a street value — because people cannot access these medications or because the services that offer them are not attractive to them. This is basic economics, and it has been proven throughout history. Increased access through appropriate services will reduce diversion!

The most concerning aspect of Dr. Menzies argument is his promotion of naltrexone in lieu of OST. Naltrexone has been available since 1984 in the oral form for treating opioid dependence and XR-NTX, the extended release injectable version, since 2010. Naltrexone is an opioid antagonist. In other words it has affinity with the opioid receptor but has no intrinsic value and therefore no efficacy. Theoretically this blockage causes the dissipation of Pavlovian learning over time. But for this to occur, the naltrexone needs to be taken over time, and retention and compliance are listed as a major problem in all the studies. The 28-day injection (XR-NTX) was developed, and this has improved compliance, but in many studies patients do not complete the course — in a phase four trial only 36% of participants completed the treatment. Dr. Menzies and his organisation, Assisted Recovery Centers of America (ARCA), also describe naltrexone as an anti-craving medication on their website. But what does the data say?

A Cochrane and other reviews have shown that naltrexone performs no better than placebo in reducing heroin use. Craving has only been shown to be reduced with the XR-NTX formulation, but studies suggest this is linked to period of abstinence independent of the drug. Further, due to the antagonist nature and subsequent upregulation of opioid receptors, once naltrexone is stopped it significantly increases the risk of overdose. Some studies have suggested that this risk can be 7 times higher than with methadone.

Further, the studies that were used to secure FDA approval for XR-NTX in the treatment of heroin use disorders were done in Russia, where OST is outlawed. It is a basic principle of clinical trial ethics that if there is an existing treatment option, placebo controlled trials are not ethical. There have been no head-to-head trials in the US for naltrexone vs. OST. A Malaysian trial ended prematurely because the difference between buprenorphine and naltrexone was so great that it would not have been ethical to continue!

Dr. Menzies is suggesting that we use a medication that has: not been through head-to-head clinical trials with a known effective treatment (OST); that performs no better than placebo unless autonomy is taken away and it is given in a 28-day formulation; and that has been shown to significantly increase the risk of mortality on termination. He further suggests that it may be especially useful for “patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.” This despite the recommendations of the World Health Organisation and the UK National Institute for Health and Care Excellence (NICE) guidelines recommending that only employed, fully informed, short-term users who want total abstinence and are well informed of the consequences of naltrexone would benefit. Studies looking at retention and efficacy have shown that people who are homeless, injectors, or have co-occurring disorders are not suited to naltrexone. At US$1000 a shot, I wonder how long the “not well-to-do” will be compliant.

In the interests of autonomy, disclosure and choice, naltrexone should be on the menu, as Dr. Menzies suggests. But based on the evidence, Dr. Menzies’ post promoting naltrexone as the most promising response to the heroin epidemic appears to be less of a reasoned argument and more of a biased stance that capitalises on the fear and stigma so many have towards opioids and those who use them.

For a more complete argument against the use of naltrexone, complete with references, please see my piece in The Influence.

I had read about a third of Johann Hari’s powerful book, Chasing the Scream: The First and Last Days of the War on Drugs, in quick snatches during my weeks of travel. I’d seen his TED talk and read reviews in the press. He’s the guy who traveled the world uncovering the damage done by the War on Drugs. He’s the poster child of decriminalization – and perhaps legalization. I liked his book a lot, and I kept looking forward to spending more time with it.

Hari is a journalist by profession, and he writes in stirring detail about the victims of the draconian punishments handed down by court systems all over the world, intended to stamp out the scourge of addiction. He writes about the mayhem and murder that keep sprouting up in the footprints of drug prohibition – resulting not from drugs but from the clashes of criminal gangs. And he writes about the feelings and beliefs of those who’ve supported, enforced, and legitimized anti-drug policies for compelling personal reasons.

Now I was about to meet him: He was designated as the chair of my final talk in Australia, to be held in the magnificent Sydney Opera House. Who was this guy? What was he like?

I had a foretaste a couple of days before my talk. We were interviewed together on a popular Sydney radio station. He was rather manic, or so it seemed in the flat silence of the studio. His answers went on too long. Isn’t it my turn now? I thought, maybe success has gone to his head. We’d agreed to go out for a drink after my lecture, but maybe that wouldn’t be such fun after all.

Then I met him again onstage. He was a delight. He introduced me with real generosity and warmth. His clever, sometimes pyrotechnic wit and sparkly knowledge of the addiction field created the perfect backdrop for my talk, and we got into an easy banter in response to comments from the audience. I started to like him a lot.

We left the Opera House and found an outdoor café – one of dozens lining the harbor in a royal road of good cheer. And I noticed a couple of times without really noticing it that he had his voice recorder on the whole time and he kept asking me questions. The guy was interviewing me! I guess I was flattered – I really didn’t mind – but by the time we parted I realized I had done all the talking. I regret that now…

Before meeting Johann, I’d gotten into an email discussion with a guy name Percy Menzies, a thoughtful and passionate man who worked for a major pharmaceutical company, a division of DuPont, for many years, training doctors in the use of medications derived from opium. This company had produced a number of well-known medicines, most important among them being Naloxone and Naltrexone, opioid antagonists which suppress the effects of heroin, making it almost impossible to OD. Now he runs several clinics combining drug therapy with counseling to help addicts withdraw, stay clean, and reconnect with their community.

Well Menzies has what can only be called a simmering contempt for Hari. Like other “pro-choice” advocates, Hari reminds us that heroin-addicted American GIs mostly quit the habit once they got back from Vietnam. Just as in Rat Park, environment mattered hugely, so addiction could be seen as a response to trauma and disconnection rather than a characteristic of drugs themselves.

But Menzies makes the following counterargument:

Yes, they came home to a “park” mostly free from fatal threats and populated by loved ones. Environment mattered.

But what mattered most was supply. In their day-to-day lives, most returning soldiers were in no position to continue scoring dope, especially not at the potency they had enjoyed in Southeast Asia. The 1980s Soviet experience in Afghanistan is particularly revealing: many soldiers found themselves addicted to the region’s pure heroin. But unlike their American counterparts, demobilized Soviet troops continued using heroin back home as it was readily available. Today Russia has one of the worst heroin problems in the world.

Menzies goes on to another potent example of why access matters so much:

Hari ignores all historical evidence that identifies access and price as the two most significant factors contributing to the spread of addiction. We as a society have known this for the longest time, yet people like Hari ignore these facts.

In his intellectual arrogance, Hari fails to consider the larger consequences of drug legalization. Returning again to Afghanistan, before the early 1980s that country had virtually no heroin addicts. Local drugs of choice were hashish and smoking opium. This was because most of the opium grown in Afghanistan was smuggled into other countries for processing into heroin. But a combination of international trafficking disruption and supplier economic savvy relocated processing to the countries where opium originates. Cheap, potent heroin was now available to Afghans for the first time ever. As a result, today Afghanistan has more than 1.5 million heroin addicts.

Now what are we to make of this? I am very taken with Hari’s investigation of the War on Drugs. I’ve plunged back into his book, and I’m now savoring every chapter. I am taken with his intelligence, compassion, his courage, and his mesmerizing ability to write about suffering without muting the pain or descending into sentimentality. And his argument about the damage done by drug prohibition is indisputable.

In fact, Menzies agrees that criminalizing drug use and locking up addicts is inhumane, ineffective, and wrong-headed. He says:

If we…tackle the drug addiction [problem], we have to begin with decriminalization and start dismantling the ‘treatment industrial complex’. These entrenched silos of residential treatment programs, jails prisons, methadone clinics, buprenorphine clinics have to be inter-linked. Indeed, the present treatment sets the patient up for failure and sometimes overdose deaths.

This is someone whose views resonate with my own.

Where Menzies and Hari differ is on the issue of legalization. If we decriminalize drug use, then do we make drugs legal? That is essentially what happened in Portugal, and Hari sees that small revolution as a huge step forward. But will cocaine and heroin be sold in stores in my town? Do I want my kids to be able to meander down to the local smartshop (we have these here in the Netherlands — very progressive) and buy a gram of methamphetamine?

Let me know what you think. And I’ll think about it some more myself.

…by April Wilson Smith…

I used to hate the word “recovery.” To me, it was a mark of shame, stating that I was permanently damaged and different from “normies,” as they call people without substance use problems in AA. Recovery signified a lifetime of isolation, avoiding social events and going to dull nightly meetings where people wallowed in the past. It also implied that I had a disease, which I never believed.

So I refused to use the word. If it happened to come up that I had had a problem with alcohol, I’d simply say, “That’s no longer an issue for me.” I wanted to erase the period of time when I had struggled to get over my alcohol problem, and make life a well-paved road without the giant bump of my alcohol crash and stint in rehab.

Then I started to work in harm reduction. I founded a SMART Recovery meeting, and went on to become an officer in the Harm Reduction, Abstinence and Moderation Support (HAMS) group. I met people who were at all stages of the struggle, from still using to fresh out of rehab to 18 years without a problem. I met people who were deeply in pain.

As I witnessed their pain, I began to reconnect with my own. It had been too difficult, at first, to remember the pain of passing out in the street or finding out the next day what I had said or done the night before. I didn’t want to remember the horror of withdrawing from alcohol more times than I can count, sometimes throwing up blood for days on end and nailed to the bed in a panic attack. I didn’t even want to remember those early days of abstinence when my senses first came back and I could smell the flowers in summer and taste blueberries and coffee as though for the first time.

After almost two years and working with countless people with substance use problems, I could feel my own pain again. And I realized something: to deny that there is a period of time when the pain is acute, and when healing has to be a priority, is to deny an essential reality of people’s lives. Of my own life. That’s when I started to use the word “recovery” again. But I do not believe that “recovery” is a permanent state. With proper self-care, support, and meaning in life, one can heal.

My path to healing was a jagged one. When I left a traditional Twelve Step rehab, I was grateful to be out of addictive crisis, but I was even farther away from finding my true self than I had been. In rehab, we were taught to identify as “addict” and “alcoholic,” and told that all our problems were due to our “disease.” We did little to address the issues that drove our addiction. Instead, we were taught that the answer to all problems was to attend Twelve Step meetings and work the Steps.

I got home and dutifully did my 90 meetings in 90 days as instructed, but it didn’t feel right. Gradually, I discovered writers who saw addiction differently. First Marc, then onto Carl Hart, Johann Hari, and eventually Stanton Peele and Kenneth Anderson. I saw a new way of looking at addiction, not as a symptom of a disease or indication that I was damaged for life, but as a behavior over which I could have control. As I read more, I gradually began to discover my own voice, and started to write. Reclaiming my own identity, not as an “alcoholic” but as a writer, activist and scholar was my way out, not only of addiction but of the narrow, confined life that rehab and AA had defined for me as “recovery.” And I found that my own painful experiences gave me a perspective that could help others. Today, having recovered means living a life that I don’t have to medicate away.

Two years after my 28 day stay in rehab, I find myself writing about substance use and mental health full time, and I’m doing my PhD on harm reduction. I hope that my work can help people who are going through that difficult period of healing. By using the word “recovery,” I honor their pain, and I honor my own. I also honor our triumph over the pain.

My substance problem is not who I am, but it is an essential part of my life experience. It has given me insight into things I never would have known about, and a kind of empathy I never had before I woke up on the concrete.

I am grateful for recovery. I am also grateful for the ability to move on.

The word “substance” may have a double-meaning when it comes to addiction. The basic meaning is obvious: the substance is a chemical that we want badly and pursue relentlessly. But the second meaning of “substance” is suggested by a well-documented phenomenon: the parallel between substance addictions and behavioural addictions.

The feelings, actions, and brain changes seen with compulsive gambling, sex addiction, porn addiction, and many eating disorders (e.g., binge-eating disorder) look very similar to those seen in substance addictions. The feelings and behaviours include craving, gorging, risk-taking, reduced inhibition and compulsive repetition. The brain changes include sensitization of the dopamine system and reduced interaction between the prefrontal cortex and certain subcortical regions (in specific contexts). Because attractive drugs and attractive activities are craved and pursued in similar ways, it might not be too far-fetched to give “substance” a second meaning. The substance common to drug addictions and behavioral addictions may be the feeling of wholeness, once lost, now regained.

A substance is what fills up a space. The lack of substance equals, well, nothingness. When people talk about their addiction they often talk about a sense of profound emptiness, a psychological void, that gets filled by a something they can only get from what they’re addicted to. To replace a sense of nothingness with a sense of somethingness (what else to call it!) is more powerful than words like “pleasure,” “relief,” or “satisfaction” can possibly convey.

At first glance it seems that chemicals provide pleasure directly while certain behaviours provide pleasure through taking action, and that’s the whole story. But in real life, you need to take action to get those nice chemicals, to put them into your body, and that’s what the dopamine system is triggered by: not just reward but reward-seeking. Hundreds of studies have shown that dopamine release in the “craving centre” (the ventral striatum or nucleus accumbens) corresponds with effortful action, not with pleasure per se.

So whether we think we’re addicted to chemicals or to actions (behaviours) doesn’t much matter to the brain. Actions (like gambling) release dopamine because they are pathways to a monetary reward. Actions like shooting heroin release dopamine because they are pathways to a chemical reward. In both cases, the hook is a feeling state that springs from an action more than an outcome. To put it another way, it’s not really the heroin that you get addicted to. Heroin will bequeath satisfaction or pleasure. But what you get addicted to is the feeling of acquiring this special something: anticipating it, going after it, and getting it.

One of my favourite models of addiction (and one highly regarded in the field) is Robinson & Berridge’s theory of “incentive sensitization.” This phrase means that dopamine release in the brain (e.g., in the striatum) gets triggered, more and more predictably, by cues connected with the thing you’re addicted to. These authors specify that dopamine uptake signals wanting, not liking, a drug or other reward, and this has been a major contribution to our understanding of addiction. But to bring this understanding home, we have to clarify what incentive we’re talking about. Does “incentive” just mean urge, attraction, or motive? Just “wanting”? No, the incentive that powers addiction — what the brain gets sensitized to — is the availability of something you not only want but feel you need.

Berridge has compared this urge to the desperation of a starving animal seeking food. So it may be useful to view substance and behavioural addictions as fulfilling biological needs, or at least their psychological expression. Whether we take pills, snort powder, smoke, or inject, we are putting something into our bodies. This “inputting” is a behavioural prototype. It’s primal. It’s how we eat. In the case of binge eating, the target of the behaviour makes obvious biological sense. But perhaps all behavioural addictions relate to biological needs: e.g., winning against competitors (gambling), sexual needs (obviously sex and porn addiction), even social inclusion (internet addiction) and resource acquisition (compulsive shopping). In my book, The Biology of Desire, I make the case that addiction serves symbolic goals. For example, the warm feeling you get from opiates symbolizes the warmth that comes from being hugged or cuddled (no small matter for us mammals).

This may all sound a bit abstract. But the feeling of emptiness we (addicts) feel when we don’t have, or can’t do, or can’t get the thing we’re addicted to is very concrete, and very palpable. It’s the feeling of an empty day that can’t be filled. It’s the total eclipse of purpose, when there’s no point in doing anything. This is what I mean by the absence of substance.

Many see addiction as an attempt to repair a rupture in attachment (as in child-to-parent attachment) or care (by a parent, lover or even oneself). Certainly these are biologically-grounded needs. Gabor Maté’s study of addicts in downtown Vancouver, mostly aboriginal, mostly from foster homes, mostly abused or neglected in childhood, highlights the enormous holes in the lives of people with devastated attachment histories — holes filled by drug use. Bruce Alexander extends this idea of loss to groups cut off from their cultural roots and resources. What’s lost for these people isn’t just pleasure or relief; it isn’t just something they like or want. Rather, it’s something they feel they need. In the words of Johann Hari, it’s connection itself. People who have lost this “something” walk around with a sense of their own emptiness, and it hurts like nothing else. By filling that emptiness, a drug (or habitual behaviour) becomes the main source, maybe the only source, of the substance they have gone without.