CLEAR MAP OF A DARK WASTELAND
BAD MEDICINE, LETHAL CROSSROADS AND DEAD ENDS IN AMERICA’S OPIOID CRISIS
by Clark Miller
Published January 16 , 2019
Updated April 7, 2021
The numbers, as they say, are staggering.
Opioid-related and other drug overdose deaths increasing steadily, now sharply, over decades, 70,000 last year. Seemingly perversely, as population “dose” of the promised, publicly funded U.S. medical industry cure for the medical model “brain disease” of compulsive substance use – dose of substitute opioids that are addictive, diverted and abused – has expanded over the same years.
The more medical cure provided to the diseased brains, the more deaths mount.
(from The Guardian – November 29, 2018)
The national trends hold in Kentucky, where overdose deaths due to synthetic opioids (like fentanyl), also to heroin, and prescribed opioids each continued to increase following and concurrently with increases in provision of the medical “fix”, the designated “treatment” for the non-medical behavioral symptom of compulsive opioid use.
Provision by medical prescription of the substitute opioid buprenorphine (Subutex, Suboxone), funded by expanding allocation of public healthcare funds to greatly increase its availability follows the model of France’s decades-long opioid substitution treatment (OST) experiment with essentially unrestricted dispensing of “bupe” by primary care doctors.
France, for those efforts, remaining fifth highest among 20 European nations in high-risk opioid use and where levels of diversion, illicit trafficking, and abuse are . . . staggering, and where opioid-related overdose deaths have increased, not fallen, over most recent reporting periods.
The numbers are staggering, not just most tragically the deaths by overdose of vulnerable Americans trapped in opioid and substance use epidemics.
This post is about those costs, and about the betrayal of public health and welfare by interests with the cultural capital to construct fictions used to divert public resources away from longstanding evidence-based (EBP) therapies and psychosocial supports that address the conditions driving compulsive, problem substance use, public resources diverted instead to fuel worsening crises.
A public betrayal just as in yesterday’s use of the constructed fictions that normalized runaway over-prescription of addictive opioids for any and all pain, as a medical “gold standard”, against all relevant lines of longstanding evidence, without medical indication, for the non-medical condition of centralized chronic pain, creating today’s worsening crisis, fueled by the next medical gold standard – indiscriminately dispensed substitute addictive opioids, without evidence based treatments as the first line or even integral intervention.
Costs of the uniquely American epidemics in deaths of Americans trapped in compulsive substance use are wrenching, the costs beyond those deaths incalculable.
But how did we get here? And why are we trapped, fueling lethal epidemics with more of the addictive, abused substances that generated the crisis, trying to put out fires with gasoline?
The first question is the easier one; the second apparently too discomforting and disturbing to face, impossible to consider or conceive, lying outside acceptable constructed truths, outside of allowed discourse, outside of what “goes without saying” because it “comes without saying” without scrutiny, protected from critical thought. A question threatening to expose the healthcare institutions Americans trust in to protect and cure them from illness as broken, blinded, compromised systems generating harm.
“Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”
– Pierre Bourdieu Outline of a Theory of Practice (1972)
In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.
The how has been covered, by writers and observers like Beth Macy in Dopesick, Sam Quinones in Dreamland, and Chris McGreal in American Overdose, others who dare to report the truth about the criminal, negligent, and grossly incompetent behaviors of American institutions, media, medical and pharmaceutical industries, and necessarily the medical providers, required to write the prescriptions.
The larger, incalculable costs are driven also by forms of incompetence – the incapacity for and abdication, by America’s most trusted and vested institutions and professions, of critical thought, of responsibility and obligation to research-informed practice, to practice within scope of competence, to avoid harm predicted by lack of understanding or ability to conceptualize the problem “treated”.
That accounting starts with the deeper “how” of the opioid crisis, how as Quinones sets out in Dreamland, an entire medical and healthcare industry – with academic researchers, institutional oversight bodies, and a clueless, uninterested media along for the ride – rationalized and normalized rampant use of addictive substances for the widespread condition of common (non-cancer) chronic pain – pain that is generally psychogenic in nature, not due to biomedical causes (tissue damage, inflammation, cancer) and with no effective, durable biomedical or pharmacological treatments, instead longstanding evidence-based psychotherapies like CBT, with durable relief.
That is, in a remarkably willful failure to adhere to appropriate, safe, indicated practice, those institutions with the collaboration of major media constructed fictions in order to dispense addictive substances, indicated against and with no evidence for appropriate use, for a non-medical condition.
The rest is history – of crisis, epidemic and death – now repeated in the medical “fix” response to the medically created lethal epidemic.
Fabricated, evidence-free clinical models predict harm and deaths
Now repeated,
by the same unfathomably repeated error – provision of addictive, diverted, abused opioids for a problem, the behavioral symptom of compulsive substance use – that is non-medical, the supported evidence-based treatments (EBPs) all longstanding psychotherapies and psychosocial supports, with no bodies of evidence to support pharmacological or medical treatments as effective, and the fictional “disease” or “hijacked brain” model of “addiction” invalidated by all longstanding lines of relevant evidence.
The mounting costs beyond the staggering death counts deserve and require accounting and understanding beyond the focus and length of this post, and require cessation and prevention, as harm reduction.
Costs that include and will be generated for decades to come by the effective brainwashing of America, the hijacking of the vulnerable, trusting collective mind by medical authorities, institutions, rewarded popularizers and complicit media, to believe in a pill for every ailment, including the overtly non-medical conditions of common chronic pain, compulsive substance use and of depressed mood.
That hijacking driving opioid, substance use, and depression epidemics locked in by the set and fixed trajectories of Americans trained for decades by false promises to seek medical attention for fixes that will never come, predict harm, have never been supported by evidence, no more than the assurances of safe effective relief for their chronic pain from addictive opioids.
While there are no bodies of validating evidence (replicated randomized controlled trials, RCTs) to support clinically significant benefit from medications for compulsive substance use, common chronic pain, or depression, despite decades and billions of dollars of public healthcare resources successfully diverted, research is not required to invalidate the constructed fictions of medical treatments for the non-medical conditions.
Because the fictions are absurd on their face. Millions and millions of deaths, of lives impaired or ruined by substance use, by impairing depression, suicide, related physical illness and discomfort – those costs mounting, over decades of promises and assertions of medical treatments.
And all it would have taken, for the vulnerable Americans and their families, to avoid all that pain and loss, the impaired lives and lost lives, was to take a prescribed pill. From any doctor. Who wouldn’t? Why not? The medications are widely available, the economics are on the side of even the more expensive ones.
America’s collective brain has been dosed with these medical fixes for decades now, with the predictable result: no gains, no signs of benefit in epidemiological data, instead continuously worsening epidemics as higher and higher doses of the cures are enthusiastically provided by the manufacturers and dispensers.
The mass implementation of harm-predicting, entirely inappropriate medical/pharmacological “treatments” that are not treatments, because the condition being treated is not remotely a biomedical condition, is a GENERALIZED ERROR, A USEFUL CONSTRUCTED FICTION, Bourdieu’s DOXA, the runaway dispensing of opioids for common chronic pain just the most acute, the current, most egregious example, requiring construction of two fictions – that chronic non-cancer pain is a biomedical condition with medical treatments, and that addictive opioids were an effective and safe option for treatment.
It’s something we can evaluate. Just as chronic pain was successfully created – by lies – as a biomedical problem that could be treated with medications, decades of a similar collaboration of medical authorities, popularizers and media have created fictional portrayals of the problems of depression and problem substance use (“addiction”) as diseases or biomedical condition of the affected brains, to be treated with medications. Decades of institutional support and application of the medical cures, with billions of dollars in funded research and development of “treatment” infrastructure.
What are the results of that focus on medical approaches and investment with diversion of public health resources away from other approaches? An opioid crisis, worsening epidemic of depression, and worsening epidemics of problem use of substances including alcohol and methamphetamine.
The more public healthcare resources diverted and the more medical cures and fixes provided, the worse and more deadly the problems become.
Nicotine – an epidemic exception that proves the rule
Tobacco is the exception that proves the rule. While prevalence of smoking of tobacco by adults and youth has decreased over the years, indications are that those results are attributable to education campaigns and economic disincentives. Apart from those psychosocial and behavioral interventions:
1) medical setting interventions routinely provided and paid for with public funds are not effective,
2) every visit to a medical provider and medical encounter for such interventions, like nicotine replacement or medications, predicts harm by working to instill in patients beliefs in biomedical explanations and treatments for compulsive substance use, belief in the disease model of “addiction” a key predictor of relapse,
3) recent trends in the U.S., France and Canada point to reversal of longstanding downward trends shifting to increases in prevalence of tobacco smoking in teens concurrently with marked and continuing increases in vaping of nicotine along with evidence of vaping as a “gateway” for tobacco use and
4) medical industry endorsement of a “harm reduction” plan to encourage inhalation of nicotine has evolved, in less than a year, to become a pediatric nicotine dependence epidemic.
The covered-up epidemic – Food is the new Meth
All of that leaves out consideration of the substance use problem set to eclipse – in illness, mortality, and public health costs – all others combined: addictive use of food, no different in features that identify use of a substance as a “disorder” or “addiction” than opioids, tobacco, methamphetamine, other compulsively used substances.
That compulsive substance use problem is driving worsening and latent obesity and diabetes epidemics, including in children. While mood, stress, and family dysfunction, are known to drive compulsive use of food beginning early in life, pediatric and adult obesity continue to be conceptualized and “treated” under medical conceptualizations and settings – while incidence and public health costs climb, just as for other compulsively used substances.
The medical industry’s opioid crisis, with 72,000 new deaths last year, is the tip of an iceberg.
Lethal Lesson Unlearned
Ignoring the roots, causes – the underlying sources of emotional pain and distress and of distorted thoughts driving and defining compulsive substance use – of these public health epidemics has been a predictor of failure: a set up for public resources to be wasted on fictional medical models and approaches that cannot manage, cannot serve as treatment for conditions that are profoundly misunderstood, misconceptualized, fabricated to be something they are not.
Those complex inner states, unique to each problem user – the psychic products of early experiences, trauma, ongoing stressors – are what drive behavior, choices. And out on the streets, users are making choices that evolve with circumstances and are driven largely by those inner needs, partly by the street and broader economies of substances of abuse. Those economies include dealer- and doctor-provided substances of abuse and increasingly the drug fentanyl, supplied largely as a synthetic opioid powder from China, many times more potent than heroin and easily added to other drugs. It’s increasingly sought on the street for its potency and the rush of the high, despite elevated risk of overdose.
Fentanyl is the New Black Tar
And there’s a problem, in this evolving street economy of chemical relief for inner pain and distress.
As documented by Sam Quinones in Dreamland, back in the 80s and 90s a new, potent form of heroin from Mexico called “black tar” hit the streets of the southwest and West Coast, then much of the rest of the U.S. , replacing the much less potent diluted white powder heroin that had been around and upending the street economy. Also increasing overdose deaths due to the potency. Nobody saw it coming, any more than they did the explosion of abuse and dependence generated by another economy of abuse: doctor-provided OxyContin and other opioids around the same time period.
Now there’s fentanyl, and new wrinkles in the economy. Wrinkles that the fictional, constructed “brain disease” model, in its reductionist, uninformed conception, cannot begin to understand or address: that the substance use problem is a moving, evolving target, always will be, so that attempts to treat symptoms – like behaviors – rather than the underlying psychic distress driving compulsive use was doomed to failure from the start.
Steepening increases in yearly overdose deaths over most recent years are driven by OD deaths involving fentanyl, with contributions from benzodiazepines, used with buprenorphine to enhance its abuse potential. Where there is desperate need there’s a way, and the way is a perpetually moving target. There is no defined disease to treat here.
It was hoped that substitute opioids (used in opioid substitution therapy, OST) like buprenorphine (Subutex, Suboxone) would prove beneficial by binding aggressively (high affinity) to nerve cell receptor sites outcompeting opioids posing more risk of overdose and diminished functioning due to euphoric/sedative effects, bupe with lower excitation effect (activation) at those receptor sites. For many reasons, bupe in OST has failed to significantly reduce high risk opioid use and OD deaths, instead contributing to economies of opioid abuse.
But fentanyl – and whatever will inevitably follow fentanyl, be mixed with fentanyl, or be alternated with fentanyl to meet users’ needs – as an even more potent substitute, is the new game-changer, because it seems buprenorphine can’t compete. At the nerve cell junctures (synapses) drugs like fentanyl, with exceedingly high activation and affinity, appear to shift the dynamic biochemical equilibrium beyond the capacity of bupe to have an effective moderating or “bridging” effect.
But forget biochemistry. Seriously. Ultimately that’s not what problem substance use is about, at all. When a new, more potent opioid hits the streets with the capacity to provide a return to, to re-experience the lost euphoric rush and sustained euphoric escape that provides relief from psychic pain, all bets are off. The psychological associations and emotion-laden memories will drive compulsive use, bupe or no bupe.
As described to Christopher Moraff writing in Filter –
During more than a year of reporting on Philadelphia’s drug culture, I’ve met dozens of active heroin users who are being prescribed Suboxone or its generic equivalent. Almost invariably, they sell the drug in order to buy more-powerful fentanyl. Many are also homeless—and housing stability is probably the most critical component of holistic recovery.
But some physicians say something else could be going on.
“Fentanyl has a tighter binding than Subs so it’s way easier to break through Subs,” said Dr. Aaron Blackledge, founder of Care Practice—an outpatient clinic in San Francisco. In other words, according to Blackledge, while buprenorphine is strong enough to kick an opioid like heroin off the brain’s receptors, it may be no match for high-purity fentanyl—to say nothing of even stronger analogs of the drug, like carfentanil. “And then with the transition to Subs there is this strange disassociation that comes with getting on Subs. [Like an] out-of-body experience. It may depend on how you take it. I have [patient] do it with microdosing.
“I know methadone is hard to come off, but it’s the only thing that seems to work for me.”
Jullian, a middle-aged heroin user from New Jersey who used to intermittently switch to Suboxone bought on the street to take a break from the daily risks of illicit drug use, told Filter that as his body became more accustomed to fentanyl, the buprenorphine became less effective.
“It just stopped working for me,” he said. “There was a time I would take 2 mg at start of the day and be pretty much fine, but then it started not working the same. The last time I took it I was literally sick for four days.
Recently, when Jullian decided he was ready to quit heroin for good, he opted for daily trips to a methadone clinic rather than visit a Suboxone doctor. “I know methadone is hard to come off, but it’s the only thing that seems to work for me.”
Also in Filter, reporting from the street in Philadelphia in 2017 –
For starters, most users already know they’re getting fentanyl, and more and more have developed a taste for the strong rush it provides—as shown by feedback from my sources and research assistants, as well as the increasing prevalence of fentanyl-only results. Two people have told me that they use fentanyl strips to confirm the presence of the drug, rather than avoid it.
America’s crisis of drug-overdose deaths has largely spared California. At 11.2 deaths per 100,000 people in 2016, California’s rate of fatal overdoses is among the lowest in the nation. But there are signs that is changing.
The epidemic is now largely driven by fentanyl, a synthetic opioid significantly more dangerous than heroin. According to the California department of public health, fentanyl was associated with 81 deaths across the state in 2013, then 135 in 2015, and then 373 in 2017. Though on the rise, that’s still very few compared to other regions.
“We’re a little bit behind everybody else, but we’re still following the same timeline,” Michael Marquesen of the Los Angeles Community Health Project said recently. “I’m sure it’s going to show up everywhere.”
. . .
Fentanyl could have arrived in California before it did other regions of America, and burned through Los Angeles’ vulnerable homeless population. But it didn’t. According to the National Drug Early Warning System, in 2016, fentanyl and its analogues accounted for just 0.2 percent of Los Angeles County drug seizures reported by police. There were 373 deaths attributed to fentanyl in California in 2017; meanwhile, states with much smaller populations, such as Ohio and Pennsylvania, saw 3,446 and 3,656 fentanyl deaths, respectively. Deaths attributed to fentanyl remain low in California compared to most other states. Why?
California’s demand for illicit opioids is largely met by the Sinaloa cartel And, for now, the type of opioid that the cartel has chosen to export to California is black tar heroin.
People who use heroin tell me it is difficult to mix fentanyl into black tar heroin. Fentanyl is commonly a powder and black tar heroin is, as its name suggests, usually sticky to touch. It’s hard to sneak a powder into a substance that’s viscous. In contrast, China white heroin, which predominates in other parts of the country, is a powder, and therefore easily adulterated with fentanyl without giving consumers a clue. In most areas where fentanyl has come to account for a majority of drug-overdose deaths, it has infiltrated supply via markets for China white heroin.
California’s success in avoiding the worst consequences of America’s opioid epidemic is therefore not the result of any government action or less drug use. Instead, Californians largely owe thanks to West Coast drug dealers’ traditional preference for black tar heroin over China white.
But that preference is very likely shifting.
It simply makes no sense for a criminal organization to continue producing and distributing heroin when fentanyl is increasingly available. Heroin requires the cultivation and maintenance of a poppy field, then the transportation of relatively bulky cargo across highly secure borders. Fentanyl can be cooked in a basement laboratory and sent through the US postal system. This reflects analyses showing that drug prohibition tends to incentivize shifts toward the sale of more concentrated forms of drugs.
There is no shutting down the desperate ingenuity of American capitalism and profit motive nor that of mood-altering chemical innovation in the evolution and use of ever more potent and creative means to meet as pressing a human need as escape from psychic pain, to gain relief, respite, from the inner distress, fears and pain driving compulsive substance use. No shutting down by prohibition or threat, or punishment, nor by shaming, nor by a fictional higher power or fictional medicinal cures, or the bizarre, countertherapeutic prescriptions of a religious subculture.
There are only the longstanding, evidence-based therapies established as effective in moderating and providing relief from the causes, the drivers of those compulsive, driven behaviors – the unmet psychic needs, injuries, distress and distortions – therapies that have never been incorporated into the criminal scam comprising treatment as usual (TAU) – what Americans have been brainwashed to pay for and believe constitutes “treatment” – for the fabricated condition of “addiction”. Those longstanding psychotherapies and psychosocial supports that are evidence-based practices (EBP) have never been supported in any meaningful way by public healthcare policy and resources, our resources that are instead diverted away to unsupported medical fixes and harm-predicting TAU fueling worsening epidemics.
While American Medicine’s fix for American Medicine’s generated opioid crisis – addictive, diverted and abused opioids substituted for other opioids – doesn’t work, and really doesn’t work with new opioids like fentanyl and carfentanil on the streets, it does function as integral currency and consumable in the addictive drug economies of abuse on the street and in prisons. Works partly to provide a euphoric/sedative effect or as a distress- and pain-moderating “bridge” between periods of use of a preferred injectable like heroin or fentanyl. And it’s appreciated as a drug of abuse in prisons, easy to get in and bringing attractive profits for dealers who know how to, after trading a preferred injectable like heroin for someone’s doctor-provided subs, funded by public healthcare resources. The economies of bupe abuse.
The trusted, authoritative, privileged and public-healthcare-funds-controlling medical industry (okay, yeah, the industry that gave us the opioid crisis and this and this and this), operating under an absurd fictional “brain disease” model of compulsive substance use, operating entirely in ignorance and darkness, out of scope of competence required to understand the causes and nature of problem substance use that includes developmental psychology, behavioral psychology, ACE, trauma, underlying emotional and cognitive distortions – can only do harm, only help to fuel that street economy of diversion and abuse.
In a covered up and misreported dark wasteland of ignorance, deceit and fake cures – all bets are off.
At this lethal crossroads.
“Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.”
– Pierre Bourdieu Outline of a Theory of Practice (1972)
In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.
But . . . Methadone!
Some observers – media writers – surveying America’s wasteland of uncontrolled epidemics, seem to glimpse dimly the writing on the wall: the clear indications of the endorsed-by-consensus, increasingly funded, medical substitute opioid fix failing as a treatment, or even as harm reduction, overdose deaths sharply rising the more fix is provided, that substitute opioid fix functioning instead as an integral product and currency in illicit economies of abuse and illness.
And surveying that grim landscape have begun casting about for an alternative to today’s gold standard, buprenorphine, for another medical fix (because problem opioid use like all problem substance use is, after all, a medical condition, a disease of the brain. Isn’t it?), generously offering the treatment recommendation of easing restrictions on and expanding provision of methadone, the substitute opioid replaced by bupe based on higher risk of abuse and overdose for methadone.
These writers wondering if it wouldn’t make sense to re-allocate, re-divert, public healthcare funds away from the failed Suboxone campaign and to methadone programs, more than that, to more relaxed and extensive provision of the addictive, abused opioid methadone, by relaxing federal guidelines and restrictions enacted to protect patient safety.
Methadone clinics
In Dreamland, Sam Quinones’ devastatingly unflinching indictment of American institutions and trusted medical and media authorities complicit in the lies generating the opioid crisis, methadone clinics are described as playing a crucial role in the wildly successful expansion of cheap, potent black tar heroin from Mexico into the U.S. – up the West Coast, into midwestern cities and everywhere in between – because those clinics are hubs for trade and use of illicit and licit drugs of abuse (p 64) –
Methadone clinics gave Xalisco Boys the footholds in the first western U.S. cities as they expanded beyond the San Fernando Valley in the early 1990s. Every new cell learned to find the methadone clinic and give away free samples to the addicts.
One Xalisco Boy in Portland told authorities of a training that his cell put new drivers through. They were taught, he said, to lurk near methadone clinics, spot an addict, and follow him. Then they’d tap him on the shoulder and ask directions to someplace. Then they’d then spit out a few balloons [packaged black tar heroin]. Along with the balloons, they’d give the addict a piece of paper with a phone number on it.
“Call us if we can help you out.”
The value of each Xalisco heroin tiendita was in its list of customers. “This is how they would build and maintain it,” said Steve Mygrant, a Portland-area prosecutor. “It was an ongoing recruiting practice, in the same way a corporate business would identify customers.
And in Indianapolis and Columbus, Ohio (pp 143-144) –
Camping out in front of the town’s methadone clinic, he gave away samples of his dope and soon had a client list of desperate junkies avid for the black tar they’d never seen before.
. . .
They met at the town’s methadone clinic off Bryden Road the next morning. The clinic was a hive of illegal dope trading. Almost anything a user wanted was for sale. He gave Chuckie a few free samples and his beeper number.
That afternoon, Chuckie called.
“That’s some killer stuff you got,” he said. “I gotta whole buncha people want some of that.”
Reporters glimpsing dimly the writing on the wall and missing, blinded to, the graffiti next to it. The signs and reports everywhere, of what should be obvious, signs of why bupe seemed, at least on a superficial and unexamined level, to make sense as a safer alternative to methadone. Methadone, highly regulated and dispensed in clinics, in Appalachia the gathering places for illicit trade and use of opioids and other drugs.
From Beth Macy’s Dopesick (pp 215, 218) –
“I’m walking around the methadone clinic parking lot for two hours with a four-day-old baby,” Patricia said. “And it was loaded with addicts. It was a place where Tess’s circle of addicts would become even bigger than it already was.”
. . .
As early as 1963, progressive researchers conceded that designing the perfect cure for addiction wasn’t scientifically possible, and that maintenance drugs would not “solve the addiction problem overnight,” considering the trenchant complexities of international drug trafficking and the psychosocial pain that for millennia has prompted many humans to crave the relief of drugs.
America’s opioid crisis has proven those progressive researchers wrong – it’s not that maintenance drugs could not “solve the addiction problem overnight”, it’s that those drugs do not constitute treatment of any sort for “addiction” and instead, from longstanding and mounting evidence, are contributing to worsening epidemics.
Blinded to the signs on the street, to the clues at the methadone clinics. Signs that are confirmed by research, like results reported in this study with high external validity, observations and data from patients in natural community treatment settings providing methadone and demonstrating
1) low retention rates, trending downward at 6 months and
2) high incidence of abuse of additional drugs including opioids
The top line is for methadone, with retention (patients staying in the program to utilize the “treatment” and associated supports to reduce high risk opioid use) at less than 50 percent at 180 days and clearly, as for Subutex and Suboxone, trending downward.
Substances abused (detected in urine screens) for methadone users included:
Other opioids – 17 percent of the 48 percent methadone participants remaining at 180 days (heroin or oxycodone)
Other substances 38 percent of those who had not yet left the program (alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids, and cocaine)
Note that those figures for other substances abused are predicted to be underestimates because
Drug screens can be and are relatively easily and often defeated
Other opioids screened for appeared to include heroin or oxycodone, not additional opioids (like Subutex, fentanyl, others)
Commonly and increasingly abused over-prescribed substances including gabapentin and quetiapine were not screened for
Those results fit with the more recent observations of these researchers, commenting on prevalence of abuse of illicit opioids during OST and after ending use of substitute opioids, comparing buprenorphine to heroin –
From results of an 11-state survey, patients in medically-supervised OST (bupe) programs use additional opioids or other drugs of abuse at high rates, constituting misuse, and do not retain in treatment and/or return to other opioid use after medical OST “treatment”.
“Because the study data lacked information on patients’ use of illegal opioids like heroin, the results likely underestimate the proportion of patients using opioids during and after buprenorphine treatment. “The statistics are startling,” says Alexander, “but are consistent with studies of patients treated with methadone showing that many patients resume opioid use after treatment.”
And writing in Commonwealth Magazine (without links to original material) describing use of methadone and buprenorphine in correctional systems in Massachusetts and other New England states, Andrew Klein (identified as Senior scientist for criminal justice, Advocates for Human Potential) –
Second, it may be problematic to continue individuals on opioid medication if they are unable or unwilling to abide by the rules. The Middlesex jail, for example, has found that the majority of individuals entering with prescriptions for methadone or buprenorphine are mixing their prescribed medications with additional narcotics, benzodiazepine, and alcohol. A large Medicaid study across New York documented that more than a third of persons being treated for opioids using agonist medication (medication that activates the opioid receptors in the brain) were obtaining narcotic prescriptions outside of their maintenance prescriptions.[i] In one instance, an individual was found to have received 49 prescriptions for hydrocodone, oxycodone, or methadone while on medication assisted treatment for opioids. Both increased doses and mixing of medications while on agonist maintenance can make overdoses more likely.
. . .
Studies increasingly reveal that diversion of medication, especially buprenorphine, is the rule, not the exception, in the community. With a study finding that more than 11,000 children and adolescents were reported to poison control centers for exposure to buprenorphine between 2007 and 2016, the last thing jails and prisons should be doing is increasing that deadly exposure in the community.
Again, it can be presumed that these are underestimates of abuse of prescribed methadone, including high-risk abuse with other sedating drugs, unless each program measured comprehensively (and from these reports, these programs did not) a full range of commonly abused substances including in addition to “narcotics” synthetic illicit fentanyl and fentanyl analogs and prescribed medications commonly abused for sedative effect including quetiapine and gabapentin.
The reported widespread abuse points to prescribed opioid substitutes including methadone and buprenorphine being used most frequently for sedative/euphoric effects at elevated risk and potential public health costs, rather than by individuals motivated for reducing dependence and for gains in personal, community and social functioning.
And from this recent study in the UK, concluding –
One confounding factor common to the inappropriately interpreted studies is that subjects provided OST were typically followed up with for short durations through provision of OST and after the “treatment”. A recent, large UK study is relatively more robust, powerful and externally valid because a large number of opioid-dependent patients (11,033) in natural care settings – not under supervision or criminal justice mandates and controls – were followed up to 12 months after end of treatment, potentially moderating confounding effects due to presumed greater exposure to protective effects of naloxone responders while engaged in community services and recovery-supportive environments.
That study’s conclusions appeared to attribute no significant overall reductions in risk of opioid-related overdose deaths (“drug related poisonings” = DRP) associated with buprenorphine or methadone OST, “Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively.”
How has radically liberalizing and expanding dispersal of addictive substitute opioids over past decades worked out in France?
In France, a decades-long experiment liberalized provision of buprenorphine (Subutex and Suboxone), promoting and allowing essentially unrestricted dispersing of the substitute opioid as a fix for the country’s opioid problem and with these predictable results:
Consistent evidence – as the national dose of substitute opioid medical “fix” and “anti-addiction drug” buprenorphine has steadily and substantially increased – of a concurrently worsening, lethal epidemic – outlined in this post:
Rampant, runaway diversion and abuse of the prescribed, addictive substitute opioids in France and the U.S., enough in France to fuel buprenorphine abuse epidemics in another country –
Lack of evidence to support the claim of efficacy for MAT/OST in reducing OD deaths or for other benefit, instead evidence for diverse harms – described in this post:
OST falsely constructed, branded as “treatment” thereby diverting public resources, attention, and policy away from existing evidence-based treatments for problem substance use including opioid use
Evidence falsifying and dismantling claims by the medical/harm-reduction industry that diverted substitute opioids are primarily or largely used in self-treatment by individuals motivated to stop high-risk opioid use, instead affirming misuse and abuse of diverted prescription opioids – described in this upcoming post:
Update, Opioid Crisis – Word from the Street: The Bupe Economy is About Abuse not Self-Treatment
And remarkably lax, non-compliant, incompetent, and negligent levels of provision of addictive substitute opioids by the barely-regulated physicians –
More Specifically,
Observations noted in this 2015 report linked widespread diversion, trafficking, and abuse to the “pill mill” characteristics of the French “framework for its prescription”:
“Its wide availability linked to the framework for its prescription and the possibility of injecting it has promoted its misuse,” reveals a study by the French drug and drug addiction observatory Observatoire Français des Drogues et des Toxicomanies.
And, “How can a doctor provide real patient care when dealing with 300 drug addicts? At this stage, all they are doing is renewing prescriptions.”
An earlier look described French doctors as untrained and unprepared to understand the needs of substance users, instead serving as dispensers of the substitute opioids:
“The French system encourages physicians unfamiliar with addiction to prescribe buprenorphine and trusts patients to use it properly. . .”
Including the interviewed doctor who “does not screen patients to ensure that they, in fact, are opiate-dependent and need treatment.”
“Because of its widespread availability, Subutex was serving as a first opiate for some drug users and a re-entry opiate for some who had previously injected heroin. The report found it to be highly addictive and hard to stop. And it was increasingly being used in dangerous combinations with alcohol, benzodiazepines (such as tranquilizers) and even cocaine. . .”
“Many stay in treatment for years, including some who want to quit, prompting criticism that substitution therapy doesn’t address the underlying problem of opiate dependence.”
A more recent report on prescriber practice is consistent with concerns that French model opioid use “treatment” is not so much treatment as it is unregulated and dis-integrated provision of the substitute opioids. Results of the 2015 report on French physician adherence to guidelines aimed at protecting patients and the public from diversion and abuse of a widely-prescribed addictive opioid are troubling and appear explanatory:
“We showed that the physicians we interviewed rarely took into account the guidelines regarding buprenorphine prescription. The actual prescribing of Buprenorphine differed from the guidelines. Only 42% of independent Family Physicians (FPs), working outside the national health care system, had prescribed buprenorphine as a first-time prescription and 40% of FPs do not follow up patients on buprenorphine. In terms of compliance with the guidelines, 55% of FPs gave theoretical answers that only partially complied with the guidelines.” [despite that] “physicians declared a high rate of participation in continuous addiction therapy training. 38% of FPs and more than 80% of Network or Hospital physicians reported having attended continuous medical training (CMT) in addiction therapy.”
(Rhetorical Question Alert)
What types of outcomes might we predict from easing patient safety regulations and controls on dispersing of methadone, an opioid with significantly greater euphoric effect, greater potential for abuse and lethal overdose than buprenorphine?
Here’s one clue, from Quinone’s Dreamland (p 190) –
Generic methadone, for years strictly an addict-maintenance drug, suddenly started killing, too. As media reports of OxyContin abuse and overdoses spread, some doctors began prescribing methadone for pain instead. . . some doctors figured that methadone was an equally long-lasting painkiller. Plus methadone was generic and cheap; insurance companies covered it. Methadone prescriptions more than quadrupled – from under a million in 1999 to 4.4 million in in 2009 nationwide – mostly for headaches and bodily pain.
. . .
As methadone prescriptions rose, so did overdose deaths involving methadone – from 623 in 1999 to 4,706 in 2007.
The Research
Observers, reporters, social media experts, brainwashed for decades along with the rest of America to believe in the absurd fictions protecting status, control and funding for medical and pharmaceutical industries and practioners, now seeing, dimly, the writing on the wall as a buprenorphine substitute opioid campaign fails – but missing the signs on the streets.
And missing the fine print – dense, inscrutable to the untrained, uncomprehended, easily distorted and hijacked by constructed authoritative experts and their popularizers, just as in medical creation of the opioid crisis – the research.
Research that provides the only objective keys to a way forward, to establishing credible, reality-based clinical understanding of compulsive substance use and its treatment, to begin avoiding additional harms and deaths.
That longstanding research establishing:
That compulsive substance use is not remotely a biological or medical condition, not a disease of the brain or disease at all, accordingly despite decades and billions of dollars diverted to those fictions, no bodies of evidence to support clinically significant benefits from any biomedical treatments
Instead is established as the behavioral symptom of underlying psychic and emotional distress, the indicated evidence-based treatments all longstanding psychotherapies and psychosocial supports
The core elements of standard, universal “treatment” (treatment as usual, TAU) for “addiction” in the U.S. – disease model, group therapy, 12-Step and self-help (AA) orientation, and counseling provided by individuals without training or competence in provision of behavioral health therapies – each established by longstanding research as ineffective at best, and predicting harm
Why Addiction Treatment Doesn’t Work
Those longstanding practices constituting standard, universal “treatment” in residential “rehab” and in outpatient programs, often funded with public healthcare dollars, most accurately described as overtly a criminal scam, as documented in the remarkable film The Business of Recovery –
The overlooked, distorted, avoided, fine print – the research
establishing that essentially everything known and accepted as valid and credible about addiction and its treatment, what “goes without saying”, is wrong, false, a body of constructed fictions that predict harm, help drive the worsening epidemics.
Constructed, popularized fictions that are critically important, required to protect the status quo, protect the continuing diversion of public health care resources to industries with the cultural capital to create the fictions – just as overtly empty fictions were used to rationalize the never research-supported runaway prescription of opioids for chronic pain, creating the opioid crisis – fictions promulgated in major media pieces like the myths highlighted in a recent NY Times pictorial piece on compulsive opioid use – that for opioids continued use, inability to stop use, and return to problem use are driven largely by the discomfort of withdrawal, “like a demon crawling out of you. You’d rather just die and be done with it than go through that”, driven entirely or largely by avoidance of being “dopesick”. The fiction that problem substance use is a chronic relapsing condition, brains hijacked by drugs a key feature of that condition, a primary barrier to change and cause of continued use.
Because, “For many, opioids like heroin entice by bestowing an immediate sense of tranquility, only to trap the user in a vicious cycle that essentially rewires the brain.”
“Essentially rewires the brain“
Fictions necessary to support and enable continued diversion of healthcare resources to medication approaches to moderating “cravings”, to intervene in brain chemistry.
At the beginning of this post, we took a look at how that’s been working, that is, how medical model fictions help fuel worsening lethal public health epidemics.
The research, available for decades, tells a very different story than those fictions, a story that could have helped prevent or moderate the failed outcomes, the deaths and worsening epidemics, wasted public health resources diverted to and invested in fictional medical models and evidence-free medical approaches.
“Epidemiology” – the distribution and determinants of health conditions
Examining the incidence and course, the patterns, of substance use problems in a culture is a powerful way to evaluate the disease model, because occurrence of the conditions in the population must be either consistent or inconsistent with characteristics of a chronic disease of the brain, with a medical condition.
Fortunately, there are large bodies of data and evidence that allow evaluation of incidence (occurrence), progression, and outcomes for large numbers of Americans over past decades for substance use problems including alcohol, opioids, tobacco, and cannabis, in the form of national epidemiological studies with numbers of individuals studied in the tens of thousands for each survey. Those include multiple NESARC studies – National Epidemiological Studies of Alcohol and Related Conditions – and related, similar studies over past decades.
Because of the importance of these studies in allowing evaluation of the very nature of substance abuse problems, their treatment, and associated public policy:
1) Heterodox, advocacy, and research and academic voices have mined the studies and data toward gaining understanding of the nature of “addiction” and its treatment in the context of a longstanding and increasingly worsening national substance use epidemic.
2) In contrast, medical, media, and establishment academic institutions – with the cultural capital to construct “knowledge” as needed – have ignored the longstanding surveys.
The surveys and how results are inconsistent with any medical or disease model of compulsive substance use are thoroughly discussed and analyzed here, and here for example.
More formal academic research and statistical analyses of the data are the focus of work by Dr. Gene Heyman, a research psychologist at Harvard University, for example here, here and here. Heyman, for example, applies statistical and analytical methods to demonstrate that consistent findings of these surveys – that the large majority of individuals with substance use disorders (the purported chronic brain disease of “addiction”) quit and don’t return to problem substance use – represent persistence of avoidance of problem use, rather than individuals repeatedly stopping and relapsing again.
It’s important to understand some features of these surveys
They start with identification of a study population – relatively large groups of individuals representing a cross-section of the national population.
Individuals included were identified as initially meeting criteria for substance use dependence – until recently the term for the most severe substance use problem. So, survey individuals were identified as initially having an “addiction”- under the medical or disease model the chronic, relapsing brain disease.
Surveys have tracked over years individuals identified with alcohol, cannabis, tobacco, and opioid dependence.
Those individuals, identified as having the medical industry’s model of substance use as a chronic brain disease, were tracked over the ensuing years and decades and surveyed regularly regarding their use of mood-altering substances, along with whether they had been in treatment for substance use.
As described further, here, for epidemiology of compulsive tobacco use, results of these large surveys for alcohol use, opioid use, cocaine, and cannabis use, consistently established that the large majority of individuals with the most severe form of compulsive substance use (diagnosed with the “disease”) quit without treatment of any type and do not return to problem use.
The contention that those longstanding, established and analyzed epidemiological patterns can be consistent with a disease, let alone a disease of the brain, is absurd on its face.
These results, available for years, are sufficient to render the disease model and “hijacked brain” suggestion unsupported and invalidated.
Think about it. As established by multiple, large surveys, available for many years:
Individuals with the “chronic relapsing brain disease” stop because they decide to
After years of use
Most often with no treatment at all, essentially never involving medical treatment of any kind
With fully “hijacked” brains according to the medical model
Think a bit more about it –
the patterns cannot be spontaneous remission of a disease state
Because these individuals identified with the “disease” are ending the disease consciously and intentionally as a choice to change a behavior. That’s not remission or anything that can be consistent with the model of a diseased or “hijacked” brain.
Are predictions for causes, patterns and course of relapse based on the fictional “hijacked brain” model supported by the evidence?
Like those popularized in the NY Times Piece “A Visual Journey Through Addiction” ?
In the field of substance use treatment, the term “relapse” is used most often to mean a return to compulsive use of a substance leading to problems in life or functioning, after a period of lack of problem use, following a period of problem use typically associated with diagnosis of a substance use disorder.
Relapse is common and may occur within days of stopping use, or years into a period of no problem use. The patterns of relapse for individuals and populations have been studied and described, including by for example researcher Alan Marlatt of the University of Washington.
Predictions of pattern of relapse based on the hijacked brain model would follow from the proposed direct effects of the diseased brain on generation of cravings for the drug, impaired regulation of impulses like cravings, and degraded cognitive functioning and emotional regulation. Because these triggers all tie directly to “hijacked” neurophysiology, the diseased brain model predicts a course for frequency of relapse after quitting correlated with severity of the disease state, consistently lessening over time in a process of biological healing:
Initially high through first weeks of withdrawal, with frequent intense urges
Reducing over time as a function of gradual neurophysiological disease state healing but remaining apparently at a level of pathology to account for the disease as a “chronic relapsing disease”
Factors independent of the disease state are secondary
Impulses, or “cravings”, or urges, that the individual cannot control are triggers for return to use
But it turns out based on decades of research, that the course, triggers for, and pattern of relapse is nothing like that.
I. Part of that research establishes that two primary predictors of relapse are not urges or cravings at all, but instead:
Lack of skills for coping with stress
Belief in the disease model of addiction
II. Additional study of the natural history and correlates of relapse provide evidence inconsistent with predictions of a diseased brain model:
In this survey relapsers to alcohol, tobacco, other substances reported on their experience of antecedents, or “triggers” to use again
“Inner states”, not urges or cravings per say, were reported by 58%. Of those: negative emotions accounted for 37%; urges for 7%
Interpersonal stressors were reported by 42%. Of those: 15% reported conflict; 24% reported social pressure
There were no reports of a sense of “loss of control” or of a brain with baseline urges or compulsions untied to inner or environmental stressors
In summary, results of these surveys highlighted the importance of mood states versus impulses with lack of control, and of situational, environmental stressors especially social stressors.
III. A large survey of individuals who had stopped compulsive use of tobacco, by smoking, provides further evidence inconsistent with the diseased brain fiction. This was a four-country survey of relapsers to smoking from a general, non-clinical population in Australia, Canada, United Kingdom and United States.
There were no effects of urges or severity of smoking (HSI) on relapse risk over days 1 – 30 after stopping “during which nicotine dependence would be most likely to influence quitting success”
Self-efficacy (= self-confidence) had a strong effect (statistically significant), through duration of study, day 1 to 3 years
There was a negative correlation, statistically significant, between self-efficacy and frequency of urges – the stronger a participant’s beliefs about being empowered and competent in making changes, the fewer urges were experienced
In summary, results of this survey disconfirmed urges or impulsivity as a factor, even over the first 30 days after stopping, when the diseased or “hijacked” brain would be most vulnerable to those factors, instead confirmed deficiency in self-confidence, or belief in one’s ability to stop smoking as a strong factor, consistent with other findings that establish belief in having a chronic, relapsing disease as a factor predicting relapse.
IV. Additional evidence from the study of patterns and factors driving relapse includes:
Relapsers report situational (coming from their lives, not their brains), negative inner states driving those urges and lapses
Intensity of urges does not decline evenly over time, instead is modal (peaks unpredictably), increasing and peaking in episodes, associated with a lapse or relapse
The evidence we have on course and patterns of relapse are inconsistent with the unsupported fiction – the media popularized fiction that “goes without saying” – of compulsive substance use as a medical condition, disease state, or “hijacked brain”.
On the street, in communities, in the dark wasteland of vulnerable Americans trapped in created epidemics driven by profitable fictions and fake cures –
Simply put, every problem opioid user, like those described in the NYTimes piece, has been dopesick, has been through withdrawal, and lived to tell about it. And knows from the experience that although extremely unpleasant, it is survived, with the promise of renewed health and functioning on the other side, if . . . change seems possible, if the person has been provided the indicated, longstanding evidence-based psychotherapies that build motivation and sense of self-efficacy.
Users return to compulsive, problem use after making it through withdrawal, typically over and over again, after the distress of withdrawal has been tolerated, after they’re through it and their brains – brains adapted over billions of years of natural selection to return to biochemical homeostasis – are predictably well along that natural track.
Returning to problem use due to other factors, factors described and known from longstanding observation and study of the nature of relapse and associated research:
Damaged sense of self efficacy,
driven largely by
Belief in the fictional Disease or “hijacked brain” model
that robs the person of motivation and development of self confidence to make the changes required for recovery
by instilling the lethal, false promise of a pill to treat the non-medical condition of a compulsive behavior driven by inner psychological states and outside stressors
by the media-popularized construction of problem substance use as a medical condition, leaving vulnerable, trusting Americans dependent on medical and medically-endorsed interventions that have no benefit like
Exposure to standard “addiction treatment” in the U.S.
Established by decades of research as a criminal scam that predicts harm including by
Abstinence violation effect
Associated with exposure to the bizarre prescriptions and practices – established by decades of research as providing no benefit, instead harm-predicting – of the dominant “treatment model” in the U.S.: the 50-year-old prescriptions of a religious subculture
Participation in meetings of the religious subcultures Alcoholics Anonymous and Narcotics Anonymous
Established as predicting return to problem substance use at failure rates of 85 to 95 percent and
Use of nicotine a known risk factor, “gateway” drug for continued or return use of opioids and alcohol
The unpredictable environmental stressors that trigger risk of relapse, well after withdrawal symptoms have subsided, primarily stressors arising in the interactions of deficits in personal skills and emotional regulation with problems in interpersonal relationships and community functioning,
The indicated and required treatments for protective effects all psychotherapies that public healthcare funds have been diverted away from to fund evidence-free medical fixes helping to fuel worsening crises
The Times, like essentially all other sources reporting on the crises, continues to normalize and endorse the lethal folklore of problem substance use and its treatment in ways that fuel the worsening epidemics, for example in this recent report on overdose reduction efforts in Dayton, Ohio, leading with an image of an AA or NA meeting, messaging to vulnerable Americans trapped in substance use epidemics the lie that meetings of those religious subcultures provide benefit of some type, rather than the established harms.
Related posts –
How Media Reporting Fuels Worsening Substance Use Epidemics
Biological Homeostasis and Adaptation are not Diseases
