The media in the past few years has been rife with stories of heroin overdoses, deaths, and increasingly powerful opioids hitting the streets in our communities.  Indeed, in Massachusetts, an average of 4 people die every day from opioid overdose.  That statistic has remained fairly steady for the past 3 years despite efforts to get the “epidemic” under control.


Government—federal, state, and local—has grappled with the sharp rise in heroin and other opiate abuse by creating commissions and passing laws expanding treatment options, but all of these efforts are based on the assumption that opioid addiction is a “disease,” or a “brain disorder”, and ultimately a public health problem.  Indeed, those assumptions are also held by the American Medical Association and other well-respected public health organizations.  Not long ago, a few hundred  doctors got together at a conference and defined addiction as a brain disorder.  The evidence?  Changes take place in the brain when people do drugs.  (Wow, really?) 


The notion that addiction is a “disease” much like diabetes or congestive heart failure seems absurd, but there’s a reason for it.  If you define addiction as a disease, you can use taxpayer monies and insurance dollars to fuel the $35 billion-per-year treatment industry, whether it yields positive outcomes or not.


If addiction is defined as a public health dilemma, a disease, or a brain disorder, then what ends up being the solution?  More government, of course!  And specifically more government-funded health care approaches to a “solution.”  For example, the use of Narcan—a drug that reverses opioid overdose—has greatly expanded in many communities, the idea being that we can use it to save lives.  If we only spend more money on Narcan and treatment, the argument goes, we can get a handle on the problem.  This notion gains credence by the stories we hear in the media about people being dramatically brought back from overdose after Narcan is administered.  Undoubtedly, Narcan does save lives, but not always.  Carfentanyl and other stronger opiates are hitting the streets now and are resistant to Narcan.  So the drug may already be headed toward obsolescence based on the strength of the street opiates.


Despite all the Narcan being used, and all the resources being poured into treatment, we still have 4 people per day dying from overdose.  Why?  There are a few reasons.


First of all, I’ve worked as a substance abuse counselor for a number of years, and have watched the same clients cycle in and out of treatment over and over again.  There are success stories, but overall treatment providers are spinning their wheels.  One of the reasons this is the case is that they continue to treat addiction as something that “happens to” people rather than something people do to themselves.  For decades now, the public has had it programmed into its collective head that “addiction is a disease, and it’s not the fault of the addict.”  So, billboards go up all over the place warning us against the “stigma” of addiction.   The result is that the focus is taken off of individual behavior and individual decision-making and is placed upon society at large.  If only addicts wouldn’t be “stigmatized” we could make progress, or so goes the argument.  The problem with that is we really aren’t making much progress.  The fight against the “epidemic” continues to be one step forward and two steps back.


Secondly, another reason we’re losing the war on opioid dependence is the overuse of “harm reduction” strategies.  Harm reduction is the philosophy that “we’re not going to get everyone to stop doing drugs, so let’s reduce harm to them instead.”  Essentially, it’s a surrender of the goal of abstinence from substances in favor of acceptance of drug use, but dressed up in all kinds of fancy clinical language.  No doubt, some harm reduction strategies can have their place, but the addiction treatment industry treats them as an end in themselves rather than a means of getting people off of drugs.


I’ll give you an example: methadone clinics.  I worked at one for four years, and can tell you that it’s a very profitable business.  Clients come in and are placed on methadone, a drug that replaces heroin in the body, thereby eliminating drug withdrawals and cravings.  It certainly can be useful for a heroin user who finds it difficult to endure withdrawals.


The problem is that methadone is extremely difficult to get off of once you’re on it.  And it requires daily visits to a clinic for dosing, which is a pain in the derriere for clients, some of which routinely refer to methadone as “liquid handcuffs.”  To get off methadone, you have to taper off of it very slowly to avoid withdrawal symptoms, and it can take months if not years.


There are other harm reduction drugs, e.g., Suboxone and vivitrol, which can be useful short term. But the problem with these treatments is that people equate the drug with their recovery.  What happens when they can’t get their medicine, and they haven’t developed adaptive coping strategies for when the you-know-what of life hits the fan?  Very often it’s back to the street drugs.


And then there’s my favorite harm reduction tactic of all, said Bruce sarcastically—the taxpayer-funded shooting gallery.


You read that correctly.  In a few communities, special rooms are set up where heroin users can “safely” inject their heroin.  Medical staff are on stand-by in case there’s a problem.  But these programs send the wrong message, as there is no such thing as “safe” heroin use, even in a supervised setting.  Not with the dope that’s hitting the streets now, cut with elephant tranquilizers and God knows what else.


From the perspective of a drug counselor (or this particular conservative drug counselor), many of these strategies are problematic because at the end of the day, they enable drug users’ bad behavior.  If you can do your heroin in a special room, or if you can “always” go back to treatment if you “slip up,” or if you can “count on” friends, medical staff, police, fire and ambulances to always jump to your rescue with Narcan if you have an overdose, then there’s little incentive to make positive behavior changes—such as stopping the use of drugs permanently.  One wonders if these “harm reduction” methods actually increase potential harm to drug users over the long haul, because there’s little focus on achieving abstinence.  Instead the addictive behavior continues into perpetuity.


Ultimately the opioid epidemic is not a health epidemic, although abusing opiates can cause a variety of health problems.  Rather the opioid epidemic is a bad behavior epidemic.  I teach my clients using techniques such as cognitive-behavioral therapy that their addictive behavior is a choice.  They can’t blame it on their parents.  They can’t blame it on society.  They can’t blame it on genetics.  They can’t even really blame it on doctors or pharmaceutical companies, although some doctors do overprescribe, and some pharmaceutical companies aggressively market drugs like OxyContin.  Those doctors, and those companies, should certainly be taken to task for these actions, but they still don’t force people to abuse drugs. 


Despite all of the contributing factors one can think of—environmental or medical or genetic or anything else, individual people make individual choices about whether or not to abuse drugs.  Even in the throes of being “dope sick” (in withdrawal), no one ever accidentally puts a needle into his or her arm.  And indeed there are people who stop doing opiates “cold-turkey.”  They’re miserable and sick for a few weeks, but then they emerge from it drug free.  An old song reminds us:  Sometimes you have to go through hell before you get to heaven.


Virtually every client I’ve worked with who has successfully recovered from addiction—be it from opiates, alcohol, cocaine, meth, and so on—has reported that their recovery is due to the better choices that they made for themselves and continue to make for themselves.  They may have used tools such as medication and treatment centers, but at the end of the day, they choose not to use substances.


So, are there societal solutions to the “opioid epidemic?”  Not unless you invent a magic wand that can make people stop doing drugs.  Clearly, strategies that enable people’s bad behavior, such as the public shooting galleries, are unhelpful.  I do think there is a place for treatment, not to mention support groups such as Narcotics Anonymous or SMART Recovery.  But an addicted person can go to a thousand meetings or go through treatment hundreds of times and still choose to use drugs.  Why?  Because they still haven’t learned to make better choices.  I believe effective treatment programs are ones that teach better decision making.  There’s an old saying: Recovery is about thinking with your head, not with your balls.


Solving the opioid crisis therefore means teaching people to make better decisions—to get off of drugs if they’re already addicted, but also to not start abusing drugs in the first place.  Prevention is often overlooked in the current public dialogue about addiction, which tends to be reactive rather than proactive.  But if we can head it off at the pass, and keep people from becoming dependent from Jump Street, then haven’t we nailed it?


And making better decisions is all about people taking responsibility for themselves. Those who manage to do that succeed.  Those who blame everyone else but themselves for their behavior, rarely become drug free.  I tell my clients: Want to stop doing drugs?  Then stop doing drugs.  There’s no Abracadabra, no Presto, no magic wand, no miracle cure.  There is only you and the needle, and you get to decide whether to keep plunging it into your arm.