COMMENTARY

Doctor Duo Counters Misperceptions on Addiction

Joshua M. Sharfstein, MD; Yngvild Olsen, MD, MPH

Disclosures

January 14, 2020

Over 20 years of marriage, we have found that the best time for us to catch up is during our household chores after dinner. As we wash dishes, sort laundry, and sift through the mail, we tell each other the stories of our days.

For many years, these stories were quite different, because after medical school, our careers went in different directions. Yngvild is a general internist who specializes in addiction medicine, and Josh is a pediatrician who has led public health departments at the city and state level. A classic Yngvild story related how an agent from the Drug Enforcement Administration showed up to conduct a surprise inspection and ended up asking about addiction treatment for her own relative. A classic Josh story described an outbreak of foodborne illness — among participants at a conference on food safety.

A couple of years ago, however, we began to tell each other different versions of the same story. As the opioid crisis was starting to attract public attention, we were both encountering many people — patients, physicians, and public officials alike — who seemed to misunderstand the nature of addiction and what could be done to save lives.

Yngvild was hearing from families who had emptied their bank accounts to pay for 28-day residential programs that did not provide the standard of care. Josh was meeting with elected officials who were reluctant to establish programs and adopt policies that could help thousands of people. Both of us were trying to convince hospital leaders to permit their clinical staff to offer lifesaving medication treatment for opioid use disorder in the emergency department and on the wards. Both of us were failing.

So one evening, we hatched the idea of writing a book. We wanted to explain the science of addiction, communicate the evidence about what works for treatment, and develop a set of recommendations that would be useful for everyone touched by this epidemic.

We were ready to confront the stigma of addiction that kept the problem hidden within families and off the priority list of policymakers. This stigma also discouraged physicians from treating addiction and saving lives in their daily practice.

Three obstacles blocked our path.

First obstacle: We needed a publisher.

So the next day, Josh took a deep breath and texted the editor of his academic book at Oxford University Press. The editor responded that he'd be happy to review a proposal. We sat down and typed out a few questions that we would aim to address in our book, starting with the basics:

  • What are opioids?

  • How do opioids affect the brain?

  • What is addiction?

  • What is the stigma of addiction?

  • What is the opioid epidemic?

We would emphasize this key point: Physical dependence and addiction are not the same. Everyone taking a sufficient dose of opioids for any reason will become physically dependent after a week or so, meaning that some level of tolerance will develop and a withdrawal syndrome will occur after abrupt cessation. By contrast, addiction is a brain disease that involves use despite harmful consequences.

Unlike physical dependence, addiction involves counterproductive behaviors. Addiction is defined by craving, compulsive drug-seeking, and continued use despite negative consequences. It also reflects dysfunction in the brain circuits involved in reward, learning, memory, and motivation. Many people who take opioids regularly and appropriately for pain control or for addiction treatment become physically dependent on their treatment medications but do not develop an addiction to them.

The distinction between dependence and addiction is rarely taught in medical school or tested on board exams. But it is critical to recognizing the difference between a patient doing well on opioid treatment with some common adverse effects and a patient falling into serious trouble.

Our editor gave us the green light to get started. He also gave us a target word count of 60,000 with a deadline in 6 months.

Second obstacle: We had no time to write.

We divided the responsibility in half. Yngvild wrote the chapters related to the basic science and treatment, and Josh drafted the sections on history and policy. Then we swapped chapters for editing.

Josh is an early riser, so he set his alarm for 5 AM and wrote for about an hour a day. He quickly found himself getting drawn into 150 years of opioid history in the United States, dating back to the Civil War. History books began to arrive in the mail. Josh learned that this wasn't our nation's first opioid epidemic. Early in the 20th century, a wave of panic swept the nation about the overprescribing of opioids. Congress soon passed — and courts enforced — laws that criminalized opioid possession and prohibited physicians from providing medical care to people with addiction. Hundreds of doctors were arrested, and patients were sent to large "narcotic farms" in the Midwest. Josh concluded that unless the nation paid attention to evidence of what works to treat addiction, the current opioid epidemic would not be our last.

Ever since the late 19th century, there have been individuals who have sought to address opioid use in the United States as a public health problem—people who have recognized the benefits and risks of opioids for pain, the chronic nature of addiction and the value of treatment that helps people regain control over their lives. However, public health approaches have always struggled to become the dominant responses to the opioid epidemic. Will this time be different?

Yngvild found time to write only when she began to free up entire days on her calendar. Sitting down at her computer, she drew motivation from physicians, family members, and patients who were worn down by the crisis and were starting to give up hope. In addition to describing the results of clinical studies, she decided to tell specific stories from her clinical practice to convince readers that treatment really does work. Indeed, treatment that includes the medications methadone and buprenorphine is associated with significant and substantial reductions in the risk for mortality and the incidence of infectious disease, crime, and unemployment. Treatment success rates are as high as 75% for patients with opioid addiction, higher than for many other chronic illnesses.

A 38-year old man seeks help for a 15-year battle with heroin. The battle has cost him his marriage and left him with hepatitis C, a life-threatening infection of the liver. Once in treatment with methadone, he finds that his cravings for heroin have disappeared, and he is able to focus on rebuilding his life. A decade later, he is happily remarried, has two children, and owns his own furniture business, which employs 30 people. A course of antiviral medication has cured his hepatitis C infection. He returns to the treatment program once a month to pick up his methadone, check in with his counselor, and see his doctor as needed.

Yngvild also was inspired to write about how the language of addiction needs to change. She is constantly frustrated by how many people (including other physicians) call her patients "addicts" or "junkies," say their problem is "substance abuse," or describe their urine samples as "dirty" or "clean."

...unless there is actual dirt in a urine specimen cup, labeling the drug test result as "dirty" does not help the physician or the patient in understanding a response to treatment or the status of an illness. The drug test is a laboratory test just like any other test performed in medicine; the results should be described using precise medical terms.

To reduce the stigma on addiction and its treatment, she called for language that emphasizes the person with addiction and not the disease.

Third obstacle: We did not have a track record of working together.

Over the years, we have met physician couples who cared for patients side by side. We have been amazed to hear them describe each day as an intellectual and spiritual journey filled with joy, love, and mutual respect.

That was never going to be our story. As medical students, we had once attempted to collaborate on a writing project, after which we decided that it would be best for our relationship if we did not do so ever again.

Now, 25 years later, the success of this project would come down to whether we could agree on how to present a broad range of difficult topics. Our two teenagers informed us that our writing a book together was the "worst idea ever."

After we signed the contract, however, our kids came through with a solution to our dilemma: Google Docs. Using this software, which allows two people to see the same document at the same time, we could sit in different rooms and suggest changes to each other in real time, without having to risk an unnecessary argument over sentence structure or the appropriate level of detail.

As the weeks passed, we went back and forth with each other on the best way to phrase our recommendations on marijuana (not a treatment for opioid use disorder) and harm-reduction programs such as syringe exchange programs (underutilized given the strong evidence that they save lives).

We knew that many readers would be resistant to hearing that law enforcement approaches had not been successful. The "war on drugs" remains a powerful way to understand the challenge of addiction. We struggled to find the best ways to explain the evidence that helping people receive effective services and treatment would be more effective than locking them up.

What happens when so many people are incarcerated for so long? One major risk is continued drug use. That's in part because many become or remain addicted to substances available behind bars. It's also because individuals in jails and prisons can be recruited to gangs and other criminal organizations, which strengthens their ability to distribute drugs. Incarceration also reduces the ability of people to stabilize their lives and break free from drugs, as having a criminal record undermines opportunities for legitimate employment after release.

Now that the book is out, we have traveled across the country to present to a wide range of audiences that include families, clinicians, people in recovery, and judges. The book received a positive notice in the Library Journal, which goes to libraries across the country, and even a nice mention in O, The Oprah Magazine.

Gradually, we have seen the country accepting more of the evidence that addiction is a treatable chronic disease and that people with addiction deserve support, not punishment. More physicians and hospitals are offering effective treatment with medications as part of medical care. But progress has been slow, the stigma on addiction and its treatment remains intense, and much more work needs to be done.

In the end, writing a book together was well worth the effort. Our hope: If enough people gain a greater understanding of addiction and what they can do to address the opioid crisis, then perhaps someday soon we can find other things to talk about after dinner.

Dr Olsen and Dr Sharfstein are co-authors of The Opioid Epidemic: What Everyone Needs to Know (Oxford University Press). The excerpts in this article are taken from pages 13, 138, 68, 16, and 209, respectively.

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