Disclaimer: Consult a medical professional for medical advice. Stopping psychiatric drugs, especially abruptly, can be dangerous, as withdrawal effects may be severe, disabling or life-threatening. This article is not meant to deter anyone from recovery, or what they find helpful. Rather, this article is meant to shine a light on what leads to, or hinders, long-term outcomes and to offer relevant, and perhaps unknown solutions. This article does not represent the views, opinions, or experiences of any employer or organization with which I may be affiliated.
“They said it wasn’t a gateway drug. My homie was taking subs (Suboxone) and he ain’t wake up. The whole while, these billionaires, they kicked up, paying out Congress so we take their drugs.” ~ Macklemore (from his song, Drug Dealer)
In Macklemore’s lyrics, you could substitute “OxyContin” for “Suboxone” and it would accurately describe two of the main reasons why the opiate crisis got so bad: false marketing and corporate greed. I believe we are at the beginning of another epidemic, and it’s playing out in the addiction treatment industry (ironically, the very place designated to treat the first epidemic).
I have been working in the addiction treatment industry for the past 15 years. I am also an individual in long-term recovery. I came into recovery in 2004, right as the ripples of the opiate crisis were beginning to hit the shores of treatment. Since 2004, I have seen the recovery rate drop and the relapse and overdose rate rise. This is my professional assessment, not scientific data, yet, most of us know someone struggling with addiction, or unfortunately, who has died from addiction: most likely, due to opioids. We may also know people in recovery; but probably fewer.
During my professional and personal time in addiction recovery, I began to see an increase in the medications used in treatment. I started to wonder, “How many medications does it take to get sober?” I asked that question because I wasn’t seeing a lot of people recover using the medications. In fact….
The biggest correlation I’ve noticed with relapse and overdose is the amount of psychiatric medications being prescribed.
It used to be against the law to treat narcotic addicts with narcotics (The Harrison Act). In 2000, the Drug Addiction Treatment Act (DATA) changed that. DATA gave physicians the ability to treat opioid dependency with narcotic medications, mainly buprenorphine (the main ingredient in Suboxone), which is considered a schedule III drug. Physicians were also allowed to use schedule IV drugs, schedule V drugs, or any combination thereof.
To put this in perspective, schedule IV drugs include benzodiazepines, one of the most addictive substances known to man. “In the US, prescriptions for benzodiazepines more than tripled and fatal overdoses more than quadrupled in the past 20 years” since 2000, the year DATA was passed. ”Benzos” are becoming an epidemic in their own right.
An example of a schedule V drug could be Gabapentin, which has been moved to schedule V in some states, due to its well-known abuse potential. Gabapentin has also been shown to affect the brain’s ability to form new synapses, which is crucial in recovering from addiction. I have seen a single client prescribed an opioid, a benzo, a stimulant, and gabapentin numerous times a day, every day, as part of treatment prescribed by an addiction treatment professional—regardless of the fact the client continued to relapse on illicit drugs. When I ask myself, “How is this possible?” the Drug Addiction Treatment Act answers the question.
I have also seen the schedule II drug methylphenidate, which is “often abused for a high,” administered in treatment. Methadone is another schedule II drug administered to those seeking recovery. Suboxone was created as an alternative to methadone due to methadone’s addictive nature. In 2009, 1 out of 3 prescription painkiller deaths were due to methadone.
Speaking of death, the combination of opioids (keep in mind that methadone and suboxone are both opioids) and SSRIs (Selective Serotonin Reuptake Inhibitors) can lead to serotonin syndrome, which is potentially life-threatening. I have seen this combination prescribed numerous times in treatment settings.
Clearly, there are some issues with what is called MAT (medication-assisted treatment), part of the “harm reduction model.” It’s not just these glaring contraindications that pose a problem. It’s also the way in which some medications affect the brain.
I’ll use Suboxone as an example. Suboxone has been shown to negatively affect the emotional state and potentially lead to relapse. Even a low dose of Suboxone “will block an estimated 80% of a person’s feelings” while “higher doses can make an individual practically numb.” A client once told me, “they (psychiatric medications) were keeping me numb. I feel more human without them.” Feeling is one of the developmental tasks of recovery.
In the words of Gabor Maté, renowned addiction expert, “We can’t just hand out more and more medications. We have to look at the stresses that, on a social level, affect people.” Many people suffering from addiction also have trauma—repressed unconscious pain. A numbing agent may be helpful, or essential, early in the feeling and healing process. However, many individuals are staying on medications for a prolonged period of time.
In this article, psychiatrist Steve Reidbord acknowledges the need for true healing while pointing out, “Antidepressants are exactly that, just a crutch….quick relief without addressing the underlying problem…there is nothing wrong with that…the danger is in mistaking this for treatment of the underlying problem.”
A 2019 British Parliament Inquiry found, “while these [psychiatric] drugs help some people in the short-term, there is growing evidence that long-term use leads to worse outcomes.” Additionally, trauma isn’t healed through medication. Trauma is healed through feeling the pain and re-integrating that information back into consciousness; from which it was separated (dissociation). We must “feel in order to heal,” says Jim Pullaro, PhD, in his book Fear Memory Integration, and it’s hard to feel if we are numb.
Is it detox or a disorder?
Addiction is a very damaging dis-ease. It can take up to 18 months or longer for the brain (chemistry) to recover from the effects of addiction. During this time, symptoms of the recovery process (and the damage from addiction) can still present themselves. They are called PAWS; post-acute withdrawal symptoms.
It’s crucial during this time to be mindful of biochemical influences, as they can either aid or disrupt the process. In a 2012 video series on The Neurobiology of Addiction, psychiatrist and addictionologist Dr. Montes outlines the problem of misdiagnosing the effects of addiction as separate disorders. For example, diagnosing a patient with major depressive disorder, instead of substance-induced depression (a post-acute withdrawal symptom), leads to a treatment that is counterproductive to the recovery process (e.g. prescribing an anti-depressant).
He elaborates, “Patients get exposed to antidepressants, antipsychotics, stimulants, benzos, and all of these medications that they’re getting are going to worsen addiction; that’s finally proven.” He continues, “The negative emotional state (that individuals are feeling) is the normal reaction when you finally stop using drugs—because your brain is changing.” This is part of the healing process and it takes time for the brain to return to “normal.”
In 2012, Montes believed that because of these misdiagnoses, we would see an explosion of mental health disorders in the coming years. According to this 2020 article, “the National Survey on Drug Use and Mental Health found nearly 20 percent of the adult population suffer from some type of mental illness. This is up from 18.1 percent just a few years ago.”
I believe what we have are the ingredients for an epidemic of co-occurring disorders: mental health and substance use challenges. Judith Grisel, a professor of psychology and neuroscience at Bucknell University, said, “Drug addiction is like a leaky bucket. When the bucket runs out of water, it’s willing to do anything to get filled again, but substitute opioid prescriptions are like pouring more into the bucket, rather than repairing the hole.”
Why aren’t we repairing the leaky hole?
As an industry, there is a lot of money and momentum behind the current initiatives. Suboxone is part of the opioid addiction market which, according to this article, is expected to reach $42 billion by 2021. Profits are increased for distributors, pharmacies, physicians, and treatment providers alike. That’s a pretty big incentive to keep this as the gold-standard of treatment.
Once again, this isn’t to say it isn’t helping people; it’s to say that’s only part of the story; a story which up to this point has mostly excluded the adverse effects. I knew a client who was clean for years and was then prescribed suboxone. Within a week, he was dead from an overdose. Why isn’t this part of the conversation?
It’s not like there aren’t healthy and effective alternatives. For example, this woman decreased her need for opioid medications by 75% using meditation, but there’s not a lot of money in that.
Keep in mind that the difference between an honest data set and a manipulated one is worth billions. Another reason I believe we aren’t “repairing the hole” is summed up well by Chris Davis, a former Purdue sales rep. In the aftermath of the opiate crisis—after it became clear Purdue lied about the addictive nature of OxyContin and continued to push the drug to the detriment of many—Chris summed it up this way, “None of the people working for Purdue, from the very top people, all the way down to little territory reps like myself. Nobody was dumb. I’m not dumb. The people above me weren’t dumb. The people above them weren’t dumb. All the way into Connecticut, nobody’s dumb. But we all acted dumb.”
This is a cognitive bias that, we as professionals, are subject to in the addiction treatment industry. It’s called pluralistic ignorance, and was illustrated in a study done regarding the views of binge drinking on college campus. Most people felt weird about the drinking—they felt it was wrong—but participated anyway or didn’t say anything because they assumed everyone else was okay with it, based on outward appearances and actions. Once again, most people felt weird about it, but didn’t say anything because they assumed they were alone in that feeling.
I have had many conversations with clients and staff in the addiction treatment industry. Occasionally, I’ll hear a success story. More often, I’ll hear a horror story. Regardless, almost everyone I talk to in the industry agrees there’s something “off” about all this.
Do we have the resources to implement new initiatives?
In the U.S.A., we spend about $30 billion a year on addiction treatment. When we account for every aspect of drug use and its effects, the cost comes out to $1 trillion a year. So, we definitely have enough money to spend on unique alternatives or comprehensive solutions. This isn’t to say we aren’t doing that at all, but it is to say that we are falling short—by leaving out things that have been shown to work, or leaving out information about the things that are undermining our objective.
For example, many treatment centers and sober living environments create a space for nicotine use despite the increased likelihood of relapse, yet won’t make it nearly as important to provide healthy food or a space for meditation or yoga, despite their clear connection to recovery.
In the words of Carolyn Reuben, President of Alliance for Addiction Solutions, “We believe that there is a disconnect between what science knows an addict needs and what society provides as treatment.” As far as I know, insurance doesn’t cover healthy eating; however, it does cover psychotropic medications. So, we’re in a weird place that we can only get out of individually, and in small cultural ecosystems.
But we can get out of it.
What’s the solution?
This isn’t all doom and gloom. There is real hope and there are real solutions. The first that comes to mind is Alternative to Meds, an 8-week residential center in Arizona dedicated to weaning clients off medications and restoring biochemistry through nutrition and holistic care. Alternative to Meds shows a great success rate for their clients: between 75% and 87.5% depending on medication class (benzos, mood stabilizers, anti-depressants, anti-psychotics) fared better without the medication, even after 4 years. Many clients reported better quality sleep, more fulfilling relationships, and improved symptoms.
That’s almost the total opposite of “normal” rates. For example, in this study on anti-depressants, after 1 year, only about 11% of clients had a remission in symptoms and only 5.1% had sustained remission.
This reminds me of Pareto’s Law; something Tim Ferriss, famous author and entrepreneur, cites as one of his tenets of success: 80% of the outputs come from 20% of the inputs. We give a lot of attention and resources to pharmaceutical medications, however, rarely do they correlate with healing in the long run. Alternatively, holistic practices like emotional healing and acupuncture have been shown to be very effective in treating addictions.
Dr. Bessel van der Kolk, world-famous trauma expert, said, “Our research shows yoga is a very nice treatment for PTSD (trauma), better than any medication anybody’s ever studied.” Consider that natural lifestyle changes are like an upward spiral; feeling a little uncomfortable at first but better over time, whereas medications tend have the opposite trajectory: feeling good at first but worse over time.
Exercise has also been shown to dramatically assist in recovery from addiction. There are communities like Phoenix Multisport (an active sober community, based in CO, offering activities and events such as climbing) which claim that 75% of the people who come to their programs stay sober. Participation in Phoenix showed benefits in physical health (93% improved), mental health (91% improved), and quality of life (91% improved).
It’s time that we become willing to think, and act, outside the box—to follow the lead of places like Phoenix and Alternative to Meds. By doing so, we can explore and offer relevant, but perhaps unknown solutions. We can transform this traditional treatment culture, and the associated outcomes, from the inside out: into a newfound sense of hope, possibility, and most importantly, long-term outcomes. In the words of my Mom, “We don’t need a second opioid epidemic under the guise of fixing the first one!” Instead, we can challenge the status quo.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.