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Death by Detoxification

The "medication-free" approach cannot be justified as the only treatment of opioid addiction, where overwhelming evidence exists to support the greater success of a medication-assisted approach.
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Hardly a day passes when we do not hear reports from many different areas of the country about young people dying from overdoses of narcotics. The recent death of the actor Cory Monteith was a stark public reminder of this recurring tragedy. Many of these incidents are even more tragic since they happen not too long after discharge from a treatment program. These headlines are a wake-up call: What more can be done to save the lives of young people with drug addictions, especially those who come to us seeking help?

Monteith was taking heroin, but we know that taking opioid painkillers -- such as Vicodin or Oxycontin -- affect the brain similarly to heroin and could have resulted in the same tragic outcome. He died of an overdose, a leading cause of death in individuals who use heroin or misuse painkillers. Overdoses, which are most often unintentional, are too common among people who regularly use heroin or misuse painkillers. Drug overdose death rates in the U.S. have more than tripled since 1990. In the past decade, deaths from opioids have surpassed motor vehicles as a cause of death in some states.

When individuals seek to stop using opioids, they usually undergo "detoxification," a procedure whereby medications are used to relieve symptoms of opioid withdrawal, and abstinence is initiated. Patients are then discharged to either a residential or an outpatient rehabilitation program to receive intensive therapy and peer support for preventing relapse. Because most of these individuals will receive no medications to treat their addiction, this treatment approach is called "drug-free," which too often means "medication-free." It resonates with a longstanding tradition, the abstinence-based model practiced by the great majority of U.S. addiction treatment programs. We know it as the 12-step program, the Alcoholics Anonymous (AA) model of recovery. With this approach, using medication to support abstinence is considered unnecessary -- even antithetical -- to the goal of recovery, defined as the absence of all "substances." This "medication-free" abstinence model persists despite growing medical evidence that alternatives exist and may be more effective and reduce the risk of overdose death. Relapse rates in abstinence-oriented programs are extremely high, and relapse can be fatal.

Patients face a significantly elevated risk of dying during the first month after leaving "medication-free" treatment programs. Paradoxically, detoxified individuals are at greater risk than those who avoid treatment and continue to use opioids regularly! Tolerance, a resistance to drug effects after repeated exposure, is a main mechanism that the brain uses to protect itself against toxic effects of drugs. But during early abstinence, the "protective" effect of tolerance is lost and the brain is overly sensitive to the effects of opioids. This loss of established tolerance is one of the mechanisms contributing to post-detoxification deaths. Because detoxification not followed by a medication to prevent relapse increases the risk of drug-related death, some would call this an "iatrogenic" (caused by treatment) death.

Yet a better alternative exists: namely, medications shown to prevent relapse and, most importantly, prevent overdose. These medications include opioid agonists (attach to the same brain receptors as heroin, e.g. methadone or buprenorphine), or an opioid antagonist (blocks the effects of heroin, e.g. oral or long-acting injectable naltrexone). Any one of these medications greatly reduces the likelihood of an accidental overdose death. Yet it remains all too rare to see patients discharged from a detoxification facility or a residential drug rehabilitation program being offered a medication to protect them from relapse and overdose. It is critical patients transitioning to the community remain under medical supervision; the use of medication to treat addiction is generally advised for at least a year post-detoxification to substantially decrease the risk of relapse.

If we know that medication-assisted treatment reduces relapse and death, how can we explain that that a "medication-free" approach remains dominant in the U.S.? The "drug-free" 12-step model may offer a useful framework for treating addiction to alcohol or cocaine since available medications may have limited effectiveness, and this model is certainly one of the few options available to prevent relapse to stimulants or cannabis, for which we do not have clearly effective medications. But the "medication-free" approach cannot be justified as the only treatment of opioid addiction, where overwhelming evidence exists to support the greater success of a medication-assisted approach. We doubt that any other (medical) treatment associated with higher risk of relapse and death would continue to be practiced without public outcry and critical review by the medical community. The World Health Organization has clearly endorsed a medication-assisted treatment approach to treat opioid dependence in developing countries. But, ironically, this evidence-based treatment is still not sufficiently accepted at home -- and the medical examiners' offices are witnessing the results of this cultural resistance.

The time has come for clinicians in this field to be vocal about the scientific evidence and to question whether it is justifiable to preferentially refer patients to programs promoting opioid detoxification followed by a "medication-free" approach to recovery. Patients deserve the opportunity to make a well-informed choice about which path they take to recovery. A public health campaign should be launched to inform those seeking help and their families about the gap between what is being offered to patients and what is actually known to be effective at preventing relapse and death.

When this happens -- and it should happen soon -- this issue is apt to sharply divide the addiction treatment community. Confronting unexamined assumptions about opioid addiction will reveal deep-seated ideologies regarding what has been a time-honored "medication-free" approach that grew out of the AA tradition of self-help. But while we respect the past, our actions should be informed by the present -- a contemporary, scientifically-based, medical approach to recovery. We know too much about the neurobiology of addiction -- and the significant role that medications have in preventing relapse -- to pretend otherwise. It is time we put this hard-won scientific knowledge to use to save more of the lives we are entrusted to serve.

Adam Bisaga and Maria A. Sullivan are professors of psychiatry at the Division on Substance Abuse at Columbia University College of Physicians and Surgeons.

Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.

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