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5Feb 2014

Guest post by Maia Szalavitz: What Journalists Can Do to Fight Opioid Addiction

Paul Raeburn
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Guest post by Maia Szalavitz: What Journalists Can Do to Fight Opioid Addiction

[Ed. note: Maia Szalavitz is a health writer at TIME.com who regularly writes about drug addiction. She is also the co-author, with Bruce Perry, MD, PhD, of "Born for Love:  Why Empathy is Essential-- And Endangered" and the author of "Help At Any Cost:  How the Troubled-Teen Industry Cons Parents and Hurts Kids."]

Philip Seymour Hoffman’s overdose death has hit nearly everyone affected by addiction hard, including this former heroin addict. But while I’ve been pleasantly surprised to see how good much of the coverage has been, unfortunately, journalism still has a long way to go before it can truly serve the public interest by providing accurate, fair and useful coverage of addiction and drugs.

First, the good stuff.  The New Republic, TIME and CNN all ran stories calling for expanded access to evidence-based maintenance medication, not just abstinence programs.  The data is unequivocal that long term treatment with methadone or buprenorphine (Suboxone) is the most effective therapy we currently have for opioid addiction.

The Atlantic called for safer injection rooms, noting that these areas where addicted people can inject under medical supervision have reduced overdose death in Canada. Most of those stories— as well as my own for TIME— also advocated greater availability of the nontoxic opioid overdose antidote, naloxone. In addition, there were moving personal essays by recovering addicts Seth Mnookin and David Carr, reflecting on the high risk of relapse, even after decades of recovery. (Indeed, there was so much great coverage I was afraid of getting scooped!)

However, larger systemic problems remain.  For one, “addiction” isn’t a beat— so the vast majority of journalists who cover it are unfamiliar with the research and often have a hard time distinguishing between antidrug propaganda, street myths, advocacy claims and genuine facts.  Mostly, addiction is not covered by health or science reporters who look for data to ground their stories, but by crime or general reporters who often don’t think beyond anecdotes and “getting both sides.”  And even when addiction is covered by science reporters, they sometimes do not realize how political the science is in this area.

This becomes especially tricky in dealing with maintenance treatments like Suboxone, which are often summarily dismissed as “drugs of abuse themselves” or “substitute medications” that “don’t treat the real problem” or “aren’t actually recovery.” 

Philip Seymour Hoffman was not on maintenance treatment and this may well be to blame for his death:  he’d been very public about his prior years of abstinence and a recent stint in rehab suggests that he was either not offered the maintenance option or saw it as unacceptable, probably due in part to the highly stigmatizing way it is covered.  But research shows that the death rate for people on maintenance is 70% lower [PDF] than for addicts who are not enrolled.

The stigmatization of maintenance needs to end and informed journalists can make a huge difference. Every major scientific organization that has looked at maintenance treatment— from the Centers for Disease Control [PDF] to the World Health Organization [PDF]— has concluded that providing addicts with methadone or Suboxone long term, even for life, is the most effective way to reduce addiction related deaths from overdose and HIV.  Opposition to maintenance— even though often voiced by so-called experts like Dr. Drew— is basically the climate denial of addiction science. Few who are knowledgeable about the evidence oppose it.

But maintenance sure makes journalists uncomfortable, probably because it involves the use of drugs that can get people high. Common sense seems to suggest that using an addictive drug to treat addiction is like substituting vodka for gin.

A recent front page New York Times expose, in fact, covered Suboxone as an “Addiction Treatment with a Dark Side,” because it can be misused and is sold on the street and quoted someone using the alcohol analogy.  Similar maintenance exposes have appeared roughly every ten years, in publications ranging from Newsday to the Village Voice to the Baltimore Sun.  They usually result from nonexpert journalists failing to understand the purpose of maintenance.

While it’s true that maintenance drugs can be misused, that’s beside the point.  When you compare overdose death rates and HIV rates where there is access to Suboxone or methadone maintenance to places where there is not, the correlation is inverse.  In other words, the more access there is to treatment with these drugs, the lower the overdose rate is and the less HIV is spread. 

Covering Suboxone as a failure because there is some street use and because it is possible (though rare) to overdose on it is like covering chemotherapy deaths in cancer treatment without highlighting the fact that it saves more people than it kills. Such reporting increases stigma without accurately reflecting the big picture.

Another reason journalists tend to focus on the failures of maintenance has to do with the way reporting is done.  If you go to a methadone clinic or seek people taking Suboxone, statistically, you are likely to find someone who is taking additional drugs and not doing well— that’s the case for about 50-60% of clients at any given time.  The failure rate is even higher with abstinence treatment, except those people can’t be found for interview easily because they have dropped out.

So, when you report at an abstinence rehab, you’ll talk mainly to successes and when you report at a maintenance program, you’ll get mainly “failures” both because the failures leave abstinence treatment and because the successes in maintenance fear public exposure because of the stigma.  Maintenance patients also tend to not hang out at the clinic because they are working, unlike those who aren’t doing well.  This problem of biased sampling is known as a “selection effect” in research and it is one that more journalists should be aware of and address.

Moreover, the fact that maintenance retains people who would otherwise leave treatment is a feature, not a bug.  It means that these patients are still receiving basic medical care, still accessible for prevention messages and reachable for changes in dose or therapy that might improve the situation.  Their maintenance drugs also reduce their risk of overdose by maintaining tolerance.

That tolerance is also significant for another reason:  it means that people on a steady dose who aren’t taking other drugs are not “high” or impaired.  They can work, drive and care for families— and this is why a consensus group convened at the Betty Ford Center in 2007 concluded [PDF] that they should be considered “in recovery” just like those who are abstinent or who must take other drugs like antidepressants to maintain their mental health.  This is why opioid maintenance is not “substituting vodka for gin.”  Unlike alcohol, opioids create complete tolerance when taken steadily.

So, when you cover maintenance, recognize these facts and incorporate them into your work.  If you still disagree with the whole idea of reducing harm rather than requiring abstinence and think it is not really recovery, at least include the other perspective and don’t presume “objectivity” in foregrounding conventional wisdom that abstinence is superior.

In fact, the best thing a reporter who covers addiction can do is constantly question your own assumptions and constantly seek scientific data in the area.  If you are wondering whether, for example, it is possible to kick opioid painkillers like Oxycontin without treatment (yes, actually the majority of heavy users do it this way and 96% recover) or whether most people who try heroin become addicted (no, only about 1 in 6), don’t ask a police officer or treatment provider for their opinion:  search PubMed or SAMHSA or Monitoring the Future.

If more people do this, I’ll really have to stay on my toes on this beat— but it would be a great benefit to the millions of Americans facing addiction problems.

Comments

Here's a recent research paper that hammers home how deeply embedded addiction is in our, and apparently other animal brains....

Drug-seeking behavior in an invertebrate system: evidence of morphine-induced reward, extinction and reinstatement in crayfish.

"Drug-seeking behavior in an invertebrate system: evidence of morphine-induced reward, extinction and reinstatement in crayfish."

This is the kind of deep, nottom-up bench science that will lead to solutions - not silly media headlines.

As the media and public bathe in the bathos of another senseless death from addictive brain disorder - everyone cleverly denies and avoid the straightforward medical facts about this genetic-inherited, incurable disease of specific neurons in the brain.  So to this author.

Has anyone seen a single medical specialist or neurologist share the facts of this disease?  No, of course not.  The mantra of The Disease - addiction in all it's forms - is "I'm not sick, I'm special!"  It' a lie, everyone suffering from addictive brain disorders is very sick and their behavioral SYMPTOMS are ultra desctructive of themselves and others.

But, like dog chasing it's tail - we love to focus on the symptoms of addiction and completely avoid discussin the incurable disease....of course.

There are no cures - nor will their be in anyone's lifetime.  Genetic-inherited systemic disease are incredibly complex and very hard to describe - let alone experiment with treatments.

Maintaince is all we have but we really have zero idea on how to manage the symptoms - let alone the broken parts of The Disease.  The Disease of addiction is likely the most destructive of all human diseases now.

Rehab does not work and, if based on abstience, makes the underlying neurological disorder worse.  But a LOT of money is made selling rehab, so do't expect any real medical science to ever be made public.

People with addictions, along with the critical people enabling them, lie endlessly and are very clever.

Addictions are the "smartest" and most destructive disease humans now face.

Outstanding piece by Ms. Szalavitz, as usual. The gap between (un-)availability and application of evidence-based maintenance medications like Suboxone must be bridged more quickly. I was under the impression that  some form of buperenorphine was found in Mr. Hoffman's apt. Was that not the case? Or was it not prescribed to him?

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