When a family member, spouse or other loved one develops an opioid addiction — whether to pain relievers like Vicodin or to heroin — few people know what to do. Faced with someone who appears to be driving heedlessly into the abyss, families often fight, freeze or flee, unable to figure out how to help.
Families are sometimes overwhelmed with conflicting advice about what should come next. Much of the advice given by treatment groups and programs ignores what the data says in a similar way that anti-vaccination or climate skeptic websites ignore science. The addictions field is neither adequately regulated nor effectively overseen. There are no federal standards for counseling practices or rehab programs. In many states, becoming an addiction counselor doesn’t require a high school degree or any standardized training. “There’s nothing professional about it, and it’s not evidence-based,” said Dr. Mark Willenbring, the former director of treatment research at the National Institute on Alcohol Abuse and Alcoholism, who now runs a clinic that treats addictions.
Consequently, families are often given guidance that bears no resemblance to what the research evidence shows — and patients are commonly subjected to treatment that is known to do harm. People who are treated as experts firmly proclaim that they know what they are doing, but often turn out to base their care entirely on their own personal and clinical experience, not data. “Celebrity Rehab with Dr. Drew,” which many people see as an example of the best care available, for instance, used an approach that is not known to be effective for opioid addiction. More than 13 percent of its participants died after treatment,1 mainly of overdoses that could potentially have been prevented with evidence-based care. Unethical practices such as taking kickbacks for patient referrals are also rampant.
For nearly three decades, I’ve been writing about addiction and drug policy. I’ve dived into the data and written several books on the subject, including an exposé of tough love programs for troubled teens. I’ve also had personal experience: What got me interested in the area was my own struggle with heroin and cocaine addiction in the 1980s.
To try to help sort fact from fiction, I’ve put together an evidence-based guide about what the science of opioid addiction recommends for people trying to help a loved one suffering from addiction. This guide is based on the best research data available in the addictions field right now: systematic reviews, clinical trials of medications and talk therapies, and large collections of real-world data from many countries — all using the highest level of evidence available, based on the standards of evidence-based medicine.
Accurately assess the problem
If you are concerned that a loved one may be addicted to opioids, it’s important to first understand the nature of addiction. In the past, researchers believed addiction just meant that someone needed a substance to function without suffering withdrawal. But now medical experts such as the National Institute on Drug Abuse define addiction as compulsive drug use that continues regardless of negative consequences.
That’s different from just depending on a daily dose. The latter is called physiological dependence; it affects almost anyone who takes opioids daily long term. “Physiological dependence is the normal response to regular dosages of many medications, whether opioids or others. It also happens with beta blockers for high blood pressure,” said Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse. Although many chronic pain patients are physically dependent on opioids, few develop the life-threatening compulsive pattern of drug use that signifies addiction.
To that point, pain treatment is not the most significant risk factor for addiction. Far greater risk comes from simply being young and from using alcohol and other recreational drugs heavily. Ninety percent of all drug addictions start in the teens — and 75 percent of prescription opioid misuse begins when (mainly young) people get pills from friends, family or dealers — not doctors. Opioids are rarely the first drug people misuse.
Once addiction develops, it is often not hard to recognize. Signs of recent opioid use include pinpoint pupils, sleepiness, “nodding” and scratching. Common signs of addiction include constant money problems; arrests; track marks and infections from needle use; lying about drug use; irritability and, when drugs can’t be obtained, physical withdrawal symptoms such as shaking, dilated pupils, nausea, diarrhea and vomiting.
Importantly, when opioid addiction occurs, it is rarely someone’s only mental health problem. The majority of people with opioid addictions have a pre-existing mental illness or personality disorder (typically, half or more are affected). Common conditions include depression, anxiety disorders, post-traumatic stress disorder, attention deficit hyperactivity disorder, bipolar disorder, and antisocial personality disorder (more common in men) or borderline personality disorder (women).
Some studies find rates of these pre-existing problems among people with heroin addiction as high as 93 percent. Two-thirds have experienced at least one severe trauma during childhood; among women with heroin addiction, rates of child sexual abuse alone can be that high or higher.
Addressing these underlying issues is usually essential to successful treatment — but unfortunately, many treatment programs are just not equipped to do so, despite claiming otherwise.
On “Intervention,” and other addiction-related reality TV shows, families are advised to plan a confrontation with their loved ones, aimed at delivering an ultimatum: Accept the treatment we’ve chosen for you or face “tough love,” even expulsion from the family. But the data doesn’t support this approach.
“Don’t do it,” Willenbring said. “Interventions are almost always destructive, and sometimes, they destroy families.”
“The pure tough love approach does not seem particularly effective and is sometimes quite cruel and potentially counterproductive,” Compton said.
Research on a compassionate, supportive alternative, known as Community Reinforcement and Family Therapy, finds that it is at least twice as effective at getting people into treatment, when compared with the traditional type of intervention or with 12-step programs like Al-Anon for family members. In CRAFT, family members are taught how to reduce conflict and positively motivate addicted loved ones to begin and sustain recovery. Both parties are also taught self-care skills and ways to help avoid relapse. CRAFT’s technique has none of the risks of cutting a family member out of your life.
That said, this doesn’t mean that families should tolerate the intolerable. “Certainly there are times when people’s behavior is so significantly impaired that they’re impossible to live with,” Compton said, explaining that family members should absolutely protect themselves and their children in such situations. “There quite understandably needs to be limit-setting,” he said, “but that’s different from thinking there will be benefit to being homeless and without support.”
Also, it is often harmful for people with addiction to encounter the criminal justice system: Jail is not treatment. Prisons and jails tend to be neither safe nor drug-free — and interaction with the criminal system, even with drug courts, often restricts access to the best treatment while sometimes punishing relapse more severely than the original offense.
Consequently, do not try to use legal consequences as a way to help people you love, and if possible, bail them out if they get arrested for drug crimes. This doesn’t mean you shouldn’t hold them accountable, but do so in ways that are less likely to lead to lifelong problems. Meaningful employment is an important factor in recovery — and few things are more harmful to the chances of getting a good job than having a criminal record.
Choose treatment supported by research
Because opioid addiction rarely exists by itself, experts recommend starting any search for treatment with a complete psychiatric evaluation by an independent psychiatrist who is not affiliated with a particular treatment program. That way, you know what kind of additional services and care will be needed and can look for professionals who address this.
For opioid addiction itself, however, the best treatment is indefinite, possibly lifelong maintenance with either methadone or buprenorphine (Suboxone). That is the conclusion of every expert panel and systematic review that has considered the question — including the World Health Organization, the Institute of Medicine, the National Institute on Drug Abuse and the Office of National Drug Control Policy.
Families are often wary of maintenance medications because they incorrectly believe that patients are “always high” or have simply “replaced one addiction with another.” But neither is true: Both of these drugs create a high level of tolerance for opioids, and, at the right dosages, both prevent the “high.”
When patients take a stable, regular and appropriate dose, maintenance medications don’t cause impairment, and the patient can work, love and drive. In essence, what maintenance does is replace addiction — which, remember, is defined as compulsive use despite consequences — with physiological dependence, which, as noted above, is not harmful in and of itself.
In contrast, abstinence-based rehabs — typically, inpatient programs that last 28 days or longer, such as the one seen in “Celebrity Rehab” — have not been found to be effective. In the U.K., researchers looked at data from more than 150,000 people treated for opioid addiction from 2005 to 2009 and found that those on buprenorphine or methadone had half the death rate compared with those who engaged in any type of abstinence-oriented treatment.The highest level of medical evidence — a systematic review conducted under the rules of the Cochrane Collaboration2 — shows that methadone and buprenorphine are about equivalent in effectiveness. (Although, as with all medications, some people will find one far better than the other, and methadone seems to be better for those who have used higher doses of drugs for longer.) “They consider it a settled question and say that we don’t need any more studies; that’s how strong the evidence is,” Willenbring said, noting how rare it is for research organizations to make such statements.
“Rehab kills people,” Willenbring said, adding that the model for the 28-day rehab, Minnesota’s Hazelden Foundation, began offering buprenorphine maintenance itself in 2012 after a series of patient deaths immediately after treatment. Hazelden’s medical director, Dr. Marvin Seppala, told me when the rehab announced the change that using these medications is “the responsible thing to do” because of their potential to save lives.
Although it may sometimes be necessary for people to move away from places where their lives have become totally wrapped up in drugs, expensive abstinence-only inpatient programs or unregulated “sober houses,” which are often anything but, are not the only or even necessarily the best way to achieve this. Finding a place where someone can live safely long term is a different challenge than finding treatment; they don’t have to be combined. Outpatient services can often be better tailored to a particular person’s needs.
Vivitrol, a medication that completely blocks the action of opioids, is another, newer medication option. It is being heavily promoted by its manufacturer, particularly for use in criminal justice settings like drug courts. However, it does not have the track record of safety and mortality reduction of methadone and buprenorphine. “It’s an unproven therapy, and there is no good reason to consider it, since we have two therapies that are among the most heavily researched and evidence-based and powerful treatments in all of medicine,” Willenbring said.
Compton is more positive about Vivitrol, even as he agrees that there is more evidence for the other drugs. “I’m grateful that we have options and choices,” he said. Some people who refuse other medications or have serious side effects from them may benefit.
The Food and Drug Administration has also just approved probuphine, an implant slow-release version of buprenorphine, which could help those who find it difficult to take buprenorphine every day and which can also prevent diversion of buprenorphine to people who aren’t in treatment.
Remember that relapse isn’t failure
More often than not, people with opioid use disorders will relapse at least once. The exact percentage is hard to quantify because definitions of relapse and study follow-up periods vary greatly. Regardless, experts say relapse should not be considered failure: It can take months or years to unlearn addictive behavior patterns and develop better coping skills.
Relapse “does not illustrate that there is a problem with treatment,” said Dr. Leana Wen, health commissioner of Baltimore. “It is an indication of the nature of the disease. Relapse occurs, but recovery is possible.” Effective treatment programs view relapses as learning opportunities and help patients investigate what caused them so they can avoid making the same mistakes twice. Shame and punishment do not work: These tend to drive relapse, rather than recovery.
Unfortunately, unlike with most addictions, opioid relapses have a significant chance of being deadly, particularly for those who are not on maintenance medications. This is why evidence-based medicine recommends that maintenance should generally be continued, even if there are repeated relapses and overall improvement is slow. Sometimes, the best that can be done is to keep people alive until they become ready to change.
That’s where another tool to reduce the risk of overdose death is also helpful. Known as naloxone, it is a direct antidote to opioids. Opioid overdoses typically kill surprisingly slowly: People die by losing the urge to breathe, usually over the course of several hours. If administered in time, naloxone reverses this potentially fatal effect. Family members can find out where they can get training in how to use naloxone and obtain it here; many states now also allow naloxone to be sold over the counter at pharmacies.
Some families worry that keeping naloxone on hand might discourage people in recovery or give them a false sense of security, increasing risk. However, being revived with naloxone is generally an uncomfortable experience, which few want to repeat, and data does not bear out this fear. “We have no evidence that the availability and use of naloxone encourages greater drug use and lots of evidence that naloxone can save lives,” Compton said.
And that’s not the only good news: Although the media tends to present a hopeless picture of opioid addiction, studies suggest that most people eventually recover. For example, a study of more than 500 people who had been addicted to prescription opioids found that half of the addictions lasted for five years or less. The odds of eventual recovery were 96 percent, with about 80 percent ending in 10 years or less. Heroin addiction does tend to last longer and be more severe, but again, most people will get better, with time.
Families and loved ones can improve the odds for people with addiction by helping motivate them to get treatment; seeking evidence-based care; keeping naloxone on hand; and treating addicted people with the empathy, support and respect they’d offer if they faced any other life-threatening medical problem.