Addiction to heroin and prescription opioid painkillers recently has increased, leading to a rising number of overdose deaths. As an addiction psychiatrist who has treated opioid addiction for more than 30 years, I applaud recent efforts to restrict inappropriate access to pain medication and to make naloxone (a medication that reverses the effect of the drugs, thus saving people from overdosing) available. However, there is a major gap that is not getting the attention it deserves: treatment.
Most reports note the need to make treatment available. The problem is that the treatment most often available (so-called "abstinence-based" treatment, usually based on the 12 Steps of Alcoholics Anonymous), does not work for opioid addiction. The message to addicts that relapses are their fault for not "following the program" is not only stigmatizing and cruel, it is a lie.
There is only one treatment proven effective for established heroin or other opioid addiction: indefinite maintenance on another opioid medication, such as methadone or buprenorphine. Dozens of studies have shown that opioid maintenance reduces drug use, crime, sickness and death and that it restores people as functioning and productive members of society. It is regarded as the first-line treatment for opioid addiction by the World Health Organization, the U.S. Centers for Disease Control, and the U.S. departments of Veterans Affairs, Defense, and Health and Human Services.
On the other hand, there is not one high-quality clinical trial demonstrating the effectiveness of detox followed by abstinence. Even stabilization on opioid medication for weeks, combined with better counseling than is available in most communities, followed by opioid taper, does not work.
Does this mean that no one ever recovers using an abstinence program? Of course not. There are always exceptions. But they do not refute dozens of high-quality research studies.
Why is maintenance necessary for opioid addiction but not for, say, alcohol addiction? It is because opioid addiction directly affects the brain's opioid system (i.e., endorphins) and suppresses natural brain opioid activity. The brain opioid system is our pleasure system. When the heroin is removed, the internal system does not return to normal; instead there is a "brain opioid deficiency."
This means that abstinent addicts are unable to experience pleasure or a sense of well-being. Their brains are screaming for opioids, so they are constantly obsessed by craving. Medications like buprenorphine return the brain opioid system to normal function, relieving the misery and craving.
Former addicts do not have any sense of intoxication; they just feel normal. They are freed to pursue life's normal pleasures (and miseries, of course).
