Opioid Abuse Disorder is a recognized medical disease. As with most medical disorders, it reflects biological and behavioral roots.
Many patients develop OAD because of acute injury treated with drugs prescribed by a physician. Indeed, it is unlikely we will be able to adequately treat pain in the foreseeable future without this class of drugs. Opiates, however, even when prescribed for painful conditions, carry the risk of dependence or addiction in any patient.
There is no safe dose, no safe opioid agent, no safe patient.
In many ways, patients with this disorder are like adolescents with diabetes. They commonly require intensive therapy and close supervision to maintain stable blood sugars. Treatment must be ongoing with careful observation and changes over time in medical management.
Some patients discontinue medications and become acutely ill. When this occurs, physicians start over again; they do not forsake patients or judge them. Medical management for diabetes is effective when provided by expert clinicians; the same is true of opiate addiction.
It is a chronic relapsing disease and it must be treated medically, most often with long-term management with methadone, buprenorphine or similar drugs under the strict supervision of trained professionals. This is the only treatment that has been demonstrated to be effective.
If patients do not obtain treatment, for many the outcome is death. The failure to get medical treatment occurs for a variety of reasons. Among those are the lack of availability of trained clinicians in settings that can provide ongoing and long-term support. Such is the case in Kentucky.
Unfortunately, even when medical treatment is available, there is pressure to focus on therapy based on faith, short-term detoxification, or 12-step programs. For alcohol, for some patients, these may be effective. For opioids, abstinence-based treatments have been shown to be ineffective and to dramatically increase the risk of death.
At present, Kentucky is Ground Zero for the lack of adequate medical-treatment resources, and a strong cultural bias in favor of faith-based therapy and halfway houses. Under these circumstances, we should expect to see more opiate deaths, despite all other current efforts.
In Kentucky, our current drug crisis has caused death, dramatically increased the number of patients with hepatitis C, been a primary trigger for the dissolution of families, and caused hundreds of children to be born addicted. If we cured the disease today, we would still have an entire generation of infants, children and adolescents who have never had nor will ever have a normal life.
This does not bode well for the future of Kentucky.
One unfortunate consequence of failure to obtain medical treatment is often exposure to the criminal-justice system. Rather than placing these patients in treatment programs, they are incarcerated which leads to further exposure to the drug culture and an education about new drugs and methods to support their habits. This frequently leads to an acceleration of the need for opiates, injection, and the sharing of needles.
Patients who do receive the best medical care, including long-term support with methadone or buprenorphine, can do very well. Most, however, require intense supervision and support. Even with all of the methods of drug treatment and psychological and social support applied to the best of our ability, some will intermittently return to opioid use and abuse. Some will even accelerate their previous behaviors and some will subsequently die.
But the debate about how to reduce the deaths from opiates is largely over; more of our friends, our children, and our loved ones will die if not provided medical treatment. Any other method of management is ineffective and courts a continued disaster.
We cannot continue to follow the path that we are on, believing that people with the disease, some our friends and loved one’s, can fight this battle by themselves. Opioid abuse disorder is established in Kentucky, but with expert medical care many, if not most, patients can lead healthy productive lives. Like alcohol abuse, it will not be cured. But we can do a much better job of reducing the impact of the disease and diminishing the number of citizens in the next generation who are affected.
Dr. Rae Brown is a professor of anesthesiology and pediatrics at the University of Kentucky/UK Healthcare and chairs the Food and Drug Administration’s Advisory Committee on Analgesics, Anesthetics and Addiction Products.