With prescription narcotics abuse reaching epidemic levels across the United States, federal and state authorities are struggling to reign in opioid addiction. The narcotics crisis was cross-bred accidentally from good intent - the push to make pain the “fifth vital sign” - and extremely poor foresight, as physicians were mandated to treat pain without increased training in appropriate prescribing or management of adverse effects like addictions. Now with a rush to reverse skyrocketing addiction and overdoses, we risk another wave of obvious consequences: as the supply of opioid pain pills dries up, those already addicted to pills are likely to turn to a cheaper more plentiful narcotic - heroin. In turn, the pressure to transition from pills to injected heroin can only result in an an infectious disease explosion among a population already squeezed to the margins.
Now more than ever, narcotics treatment programs are critical to prevent pill addicts from turning to injectable opioids. However, inherent flaws limit classical narcotic treatment models. Traditional treatment removes individuals from house and home to centralized live-in facilities, advising that they discharge to a new town with new friends to minimize the chance of relapsing into old behavior patterns; this works well for the globally mobile, but fails in the provincial backwaters of America where the old urban drug centers are relocating these days, and where those in recovery may have never before lived more than a few miles from the place they were born. Old models see quitting addiction as a singular opportunity, and relapse as moral failing; we now appreciate the strong physical component of addiction and the normative cycles of quitting and relapse - cycles that do not lend themselves to repeated bank-breaking stays at expensive inpatient retreats. Moreover, the outdated perception of drug addiction as an affliction of the urban, dislocated, and homeless has long ceased to tell an accurate story: addiction today is an increasingly suburban and rural phenomenon. Overdoses are no longer back-alley, anonymous affairs – they are likely to happen in livingrooms and bedrooms, with extended family nearby, witnessed by children, guaranteeing the cyclical trauma of calls to 911, flashing sirens of police and ambulance carriers at the front door, child protective services coming to retrieve siblings and cousins and breeding innate mistrust of authority. Drug deaths often afflict breadwinners and heads-of-household, and morbidity and mortality among this demographic compounds intergenerational poverty that drives futures of hopelessness and addiction.
These evolving dynamics of addiction place outpatient opioid replacement medications like buprenorphine (branded under the names Suboxone and Subutex) at the forefront of treatment. Designed to kill the sheet-drenching terrors of opioid withdrawal and the siren call of continual cravings, buprenorphine allows narcotics addicts to return to work, school, families, and the business of living life without prolonged interruptions for relapses and treatment. Ironically, prescribing buprenophine requires extra training, a special DEA waiver and programmatic oversight, and is not permitted by mid-level providers such as physician assistants - restrictions that are draconian compared to the minimal requirements needed for medical providers to write unlimited quantities of narcotics. To successfully head off a secondary public health crisis from the crackdown on pill users, outpatient narcotics treatment must become a routine part of every primary care practice - with minimal barriers to start-up, training in every primary care residency across the country, and support rather than the current intrusive oversight on already extant buprenorphine providers.
If the coming crackdown on safer prescription narcotics is not accompanied by a move toward mass treatment of opioid dependence, the consequences are predictable and inevitable: a mass transition from pills to heroin as the pill supply dries up, accompanied by an explosion of avoidable infectious diseases - HIV and hepatitis C, MRSA abscesses and other routine superficial infections, and the rarer bogeymen of heart valve infections, bone infections, and “flesh-eating bacteria” that particularly afflict those desperate enough to put contaminated needles under their own skin. The social and financial cost of these acute and chronic conditions will haunt our national health well past the rash decisions made on narcotics policy today. At this critical policy juncture - with pressure on all side to stem the flow of manufactured narcotic pills - now is the time to throw open the floodgates on cost-effective, evidence-based narcotics treatment. Most of all, addiction must be understood as the complex medical and psychological condition that it is - leaving behind forever the notion of addiction as moral weakness to be scorned, and finding the common ground to meet those in the throes of addiction on their own terrain.