A few ways society can reduce opiate overdoses

With the recent overdose death of beloved actor Philip Seymour Hoffman in the news, this is a good time to discuss the causes of such tragedies. First and foremost, overdoses happen because people use drugs. People use drugs because they like the way the drugs make them feel. These facts will never change, so there will always be some overdoses. But there are some things we might do as a society to reduce them. If you care, and want to help to end these tragedies, then I hope you’ll join me in supporting the following changes. It seems that each of these issues could’ve been involved in Hoffman’s death.

Opiate overdoses commonly come about in a few ways:

1. Someone gets heroin that is far stronger than usual. They then take what they think is a normal safe amount for them, but it is actually unsafe.

2. Someone detoxifies fully for a while, and out of sheer ignorance of the issue of tolerance, chooses to use the same amount of opiate that they used back when they had a high tolerance – which they now no longer have, because they have been detoxified.

3. Mixing opiates with sedatives, tranquilizers, alcohol, etc.

4. Someone is engaging in simple reckless binge use.

#1 is a problem caused by black markets. The solution: legalize drugs. The whole prohibition versus legalization debate is more involved than I want to get into on this post, so I’ll try to sum it up quickly with visual aids.

There are reasons that the 22 karat gold Rolex watch you buy here:

 

Is more likely to to be made of real 22 karat gold by the Rolex corporation than the supposed “22 karat gold Rolex” watch that you buy here:

 

One guy operates in the broad daylight, the other guy operates in the shadows of the black market. For more thought on prohibition versus legalization, check out this page: How Prohibition Makes Any Drug MORE Dangerous

#2 & 3 are problems of ignorance. The solution: education. Let people know the dangers of mixing drugs, and teach them an understanding of tolerance. None of these measures will guarantee against overdose, because people need to choose to remember such information, but if they understood the loss of tolerance, then they’d probably use smaller doses if they choose to use after a period of abstinence. If they knew the dangers of mixing, they’d probably be more apt not to take those deadlier mixtures.

#4 is the interesting one to me, because it’s so heavily influenced by the system designed to help people with these problems. The addiction treatment system and recovery group culture teaches people that any substance use will immediately progress to uncontrolled binge use. This teaching needs to stop, because it is untrue, and belief in it can lead to reckless binge use. You can help to bring about this change by learning and discussing the facts I will show you below.

The system of help for people with substance use problems teaches them that they are broken. It teaches them a number of bad things that become boogiemen. For example: triggers. The concept of a trigger is that there are things that will remind people of substance use, and when “addicts” see these things, they’ll be “triggered” to use substances – beyond their control. Life then becomes a task of avoiding these triggers. People are told to avoid weddings because there will be alcohol served, or to stop driving on the highway that passes the city where they used to score drugs, etc. As one particularly absurd example, I spoke to someone who went to a supposedly progressive rehab about a decade ago and witnessed that some heroin users weren’t allowed to eat with spoons. Why? Because the spoons would make them think of cooking up heroin, and that would make them want to do heroin, and then they would uncontrollably end up doing heroin. That is, the sight of a spoon would trigger heroin use.  They were eating breakfast cereal with forks in this rehab. What good could come of teaching people that spoons will make them use drugs??? Is it practical to live your life trying to avoid the sight of a spoon?

The trigger idea also includes emotional states, fatigue, and even hunger. People are taught that if they feel stress, then they’ll be “triggered” to use if they don’t deal with the stress right away in the perfect way. It’s a more touchy feely version of the trigger theory, but it is just as absurd and self-defeating as the belief that a spoon will cause you to use heroin. The belief in triggers becomes a self fulfilling prophecy that sabotages people’s efforts at change.

Another example – people are taught that they will lose control of themselves once they use any amount of any intoxicating substance and that they will end up “worse than before.” Why? Because they have a disease that is “doing push ups in the parking lot” while they are in their support group meeting. First, this is false. So, it shouldn’t be taught. Second, if you really believe that you will lose all control of your consumption of drugs and alcohol once you have one drop or hit or whatever – then that is EXACTLY what you will proceed to do. It’s called a response expectancy. It’s been demonstrated by many experiments, especially what we call “placebo” experiments. The same pain relief action that happens with opiates can also be triggered by giving someone a placebo that they think contains a pain reliever. Placebo alcohol can make people’s psychomotor skills impaired. Placebo caffeine can increase alertness (citation for last 3 examples). Meanwhile, when you give alcoholics real alcohol, but disguise its flavor so they don’t know what they are drinking – they do not proceed to drink or “crave” “uncontrollably” – but they’ll do so when you give them placebo alcohol.

In the case of alcohol, it’s also been demonstrated by ethnographies showing that in hundreds of cultures around the world, people behave the way their culture tells them that alcohol will make them behave. In some places, they think it’ll make you loving – and so people have that response to alcohol. Those same people may think alcohol has nothing to do with violence, and they show no violent behavior even when completely drunk. In other places, just the opposite is true – they believe alcohol makes you violent, and thus an entire village full of people will beat the shit out of each other when drunk. And still in some places, they believe neither of these things – and they just get buzzed or drunk with no significant change in behavior. The bulk of our behavioral response to drugs and alcohol is “caused” by how we expect ourselves to respond to it.

Here in the US and some other western cultures, we believe there are special people who “lose control” of their drug and alcohol consumption. We label them as “addicts” or “alcoholics” because we don’t approve of their choice to get high or drunk, and think they must be out of control because they’re not conforming to what we think is proper behavior. Sometimes we even label them before they’ve even had a single dose of drugs or alcohol, predicting their doom because of the “alcoholism” or “addiction” that “runs in their family” – and then they live up to what we’ve taught them is so. We teach them that one day, they will “relapse”, because of their disease, and it will be bad – that they will most likely use substances in even higher quantity and frequency than before – and that they will probably die. We also tell them that use of a lesser drug will inevitable progress to use of the more extreme drug – for example, former heroin users are told that having a drink or smoking a joint will trigger them uncontrollably back into heroin use.

I know it’s probably hard to believe for those who haven’t been to rehab or 12-step meetings, but these institutions teach people that substance use is black and white: either you use drugs and alcohol in a fully destructive fashion – or you don’t use them at all. They teach them that a middle ground is absolutely impossible. They teach them that this will always be the case,  no matter what the user intends, no matter what the circumstances of his or her life, no matter what substance they use. It’s scare tactics all the way. And it works for some, when they are fully onboard with abstinence from all substances. But for others, especially young people, it sets them up for massive problems – and their usage patterns often quickly escalate upon leaving their first treatment program, because they’ve been brainwashed into believing it will.

Why should we be surprised when our self-fulfilling prophecy comes to pass?

A randomized controlled trial showed that people become more likely to binge use AFTER they’ve been exposed to the disease/loss of control theory based support groups. In fact, they become 5 times more likely to binge than those who received no help at all, and 9 times more likely than those who received a CBT form of help (which teaches that people are in control of their feelings and behaviors).

Another study found that the best predictor of whether someone will “relapse” is how strongly they believe in the disease model of addiction.

Most people go untreated and most of them quit their problems. Once you get addiction treatment (via professionals or support groups), you become more likely to relapse and have your problems for a longer time. The numbers for heroin addicts are shocking – a large historic study found that in demographically similar groups of heroin addicts, about 30% relapsed after quitting on their own, with only 10% going back to “heavy use”, and a smaller percentage going back to “addiction” – but in the group that got treatment, 70% relapsed to “addiction.”

Again -why should we be surprised when our self-fulfilling prophecy comes to pass? We should stop teaching people that they are not in control of their substance use. This message is hurting people. It creates a response expectancy in them that helps to facilitate the “relapse” disasters we hear about that often end in overdose.

Philip Seymour Hoffman’s story seems to fit the mold of someone whose behavior was strongly influenced by the teachings of the recovery culture. He had some drug problems in his college years, went to rehab, was taught that if he didn’t stay completely abstinent of all intoxicants, then he would suffer a full blown relapse. He stayed abstinent for 23 years, and then he somehow got into painkiller use. He was probably prescribed them for an injury, and succumbed to both what he’d been taught in rehab, and the current hype about prescription painkillers’ addictive powers. He used them problematically for a year and then progressed to heroin use. He went to rehab yet again, convinced that he was “out of control”, and sometime between last year and this week, he resumed heroin use – obviously in a binge type fashion (50 bags of heroin were reportedly found near his body). I am convinced that the negative beliefs taught to him by the recovery culture contributed to his overdose death. He was led to believe that any use of any substances was a total loss and sign of imminent destruction – he then proceeded to destroy himself.

I hope you look at the facts I presented above, and start discussing them publicly, so we can change our culture’s damaging addiction beliefs together. If this change happens, less people will feel powerless over their drug and alcohol use, and that will mean less binges, and less overdose deaths. Mind you, this is a long term strategy for cultural change, which will then set the stage for entirely different behaviors. It cannot happen overnight, but you can have a real effect if you have the guts to check out this information and talk about it publicly. You will face people who say you are heartless – but spreading the truth is a more compassionate act than standing by while people are misled.

Update Feb 6:

It’s hard to keep up with the emerging details, but they’re painting an increasingly clearer picture of someone deep in the recovery culture belief system – stifled by a label, hopeless, and thinking fatalistically:

• The New York Times reports that at the Sundance Film Festival 2 weeks before his death: a magazine publisher who did not immediately recognize him asked him what he did. Mr. Hoffman replied, “I’m a heroin addict.” 
• In the same exchange at Sundance, the UK Telegraph reports that he said: “Bingo. I just got out of rehab.”
• A BBC report paints a picture of someone who hadn’t mentally moved on from an “addict” mindset: Philip Seymour Hoffman first checked himself into rehab after graduating in drama from New York University in 1989. He was a heroin user and addicted to alcohol. In an interview in 2011 he said that problem was “pretty serious” at the time. “I know, deep down, I still look at the idea of drinking with the same ferocity that I did back then. It’s still pretty tangible,” he told the Guardian. “Just because all that time’s passed doesn’t mean maybe it was just a phase. That’s you know, that’s who I am,” he added.
• Fox News and others have reported that he’s had heavy 12-Step meeting attendance (both AA and NA) over recent times.
• TMZ, who broke the story of his “relapse” and trip to detox last May, reported that: “Ironically and sadly, we’re told Hoffman went to AA meetings over the last 4 years and was considered a “guru,” because he had been sober for so long.” Which means his return to 12-Step meetings preceded his first “relapse”, by about 2 years (considering the fact that he’d been fully abstinent until mid 2012). TMZ also reported that Hoffman recently told friends  “If I don’t stop I know I’m gonna die.”

Why should people think of themselves in this way? You don’t have to identify as “an addict” – you can outgrow your desire for drugs. But once you take on the label of addict, that seems less likely.