Maintenance is the most effective way to treat addiction, but it’s also heavily stigmatized.
By Maia Szalavitz May 9
Prince’s greatest music hit the radio while I was going off the rails during my own opioid and cocaine addiction. The young man who gave me my first injection was a massive fan and played “Kiss” for me around the same time he introduced me to the needle. I was soon hooked on both Prince and injecting.
That’s why it hit me especially hard when I learned that this musical genius’ overdose death occurred a day before he was due to start treatment. This tragedy makes clear that what likely killed him, and is killing so many others, is not just addiction itself, but the stigma we attach to it and, even worse, to the most effective treatment for it.
If we really want to stop the overdose epidemic, we need to get serious about providing the only treatment known to reduce the death rate by 50 percent to70 percent or more: indefinite, potentially lifelong, maintenance on a legal opioid drug like methadone or buprenorphine. The data on maintenance is clear. If you increase access to it, death, crime and infectious disease drop; if you cut it short, all of those harms rise.
Prince was supposed to see a doctor, known for using buprenorphine to treat addiction, just a day after his death. But most patients — even most celebrity patients — do not actually get this sort of evidence-based care.
Indeed, most people concerned with opioid addiction don’t know that they should be looking for maintenance, or they avoid it thanks to the stigma against long-term medication treatment — research shows that maintenance patients experience prejudice and discrimination from family, friends, health care workers and employers. Even I perpetuated the stigma myself in the past, in an anti-methadone op-ed in the 1990s. At the time, I thought that simply having experienced addiction qualified me as an expert and incorrectly relied on anecdote, not data.
For both methadone and buprenorphine, access is highly limited. Only 30,000 physicians are licensed to prescribe buprenorphine, but most who are licensed don’t prescribe it and each is currently limited to seeing 100 patients. When used for addiction treatment, methadone is regulated to an extraordinary degree — it’s illegal to prescribe outside of those rundown clinics, and NIMBYism keeps them located in poor neighborhoods.
To top it all off, the 12-step support groups that addicted people are urged or even required to attend as part of treatment often see people on maintenance as not “really” in recovery.
These practices are deadly. We’ve got to get over the idea that medication for opioid addiction simply “replaces one addiction with another” and doesn’t count as getting better. To do so, we need a far better understanding of what addiction really means.
In many people’s minds — due to concepts popular in the ’70s and early ’80s — addiction means physically needing a substance to function and becoming physically ill when deprived of it. From this perspective, the biggest barrier to quitting is suffering through the nausea, pain, shaking and diarrhea that accompany withdrawal. And, from this point of view, people who are on maintenance treatments are actually “still addicted.” But this definition of addiction was dropped by experts long ago.
One reason this view fell out of favor was the rise of crack cocaine. Cocaine and stimulants, like methamphetamine, don’t cause physical withdrawal symptoms — if addicted people suddenly stop taking them, they don’t get physically ill. However, they absolutely experience irritability, anxiety and craving that is every bit as intense and likely to lead to relapse as that associated with alcohol or opioids. This makes stimulants like crack highly addictive.
Though we tend to think otherwise, physical withdrawal isn’t the main barrier to abstinence; instead, craving and the sense that drugs are essential for emotional survival are at the core of addiction. In my own case, I put myself through withdrawal from heroin addiction at least six times. Never once during these attempts did I relapse while ill. Instead, I returned to drugs after withdrawal illness had passed — not because I felt physically bad, but because I had convinced myself that “just once” would be okay.
So what is addiction if it isn’t defined by tolerance or withdrawal? Psychiatry, through its diagnostic manual, the DSM, sums it up as compulsive behavior that recurs despite negative consequences. This means that maintenance helps users conquer their addiction by replacing addictive compulsion with physical dependence.
Craving, obsession, intoxication and consequences are gone; tolerance and steady dosing mean that patients are not impaired and can drive, care for families and work. What remains is a physical need for the substance to avoid withdrawal.
And such dependence isn’t harmful, per se: We’re all physically dependent on oxygen, food and water, and some of us (like yours truly) are physically dependent on antidepressants or other types of medication. If the consequences of physical dependence are positive, it’s not addiction. Which is why I don’t sit around dreaming of Prozac, yearning for my next dose, taking more and more and hiding my obsessive behavior.
Importantly, however, unlike in abstinence-only treatment, patients benefit from maintenance even during relapses. That’s because, whether or not people continue taking other drugs in an addictive fashion, the tolerance provided by maintenance pharmacologically makes overdose death much less likely.
The ongoing use of other drugs during relapse explains why so many people see maintenance as a failure and maintenance patients as being constantly high — but retaining relapsers in treatment is a feature, not a bug. It reduces mortality, disease and crime and keeps patients in health care.
Unfortunately, most families and friends of addicted people don’t understand this. They tend to seek abstinence-only inpatient rehab because maintenance is stigmatized, and the media rarely highlights its dramatic reduction in mortality. Instead, we hear about relapse or people selling their maintenance medications on the street. Ironically, that street market exists primarily because we don’t make maintenance accessible enough. Maintenance drugs wouldn’t be valuable if people who wanted them could get them, whether or not they are ready for abstinence.
Prince’s death was awful enough. A man lost his life, we lost a great artist — and we also lost the chance for him to model and destigmatize the best treatment we currently have for addiction.