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HHS secretary misunderstands addiction

While Health and Human Services Secretary Tom Price was in West Virginia last week, he described methadone and buprenorphine treatment for opioid use disorders as just "substituting one opioid for another." This statement swiftly drew widespread criticism from the medical community, including former Surgeon General Dr. Vivek Murthy.

On the surface, Dr. Price is correct: Both methadone and buprenorphine (brand name Suboxone) are synthetic opioids. However, taking them in the context of a treatment program is hardly the same as swapping heroin or non-prescribed pain medication for an equal vice. When addicted people come into treatment, it is typically because of the downsides of illicit opioid use: family, legal, financial or health issues and so on. Medication-assisted treatment provides an alternative form of opioid (safe, regulated, long-acting) that blocks the cravings and withdrawal symptoms that typically derail recovery from addiction. It also improves outcomes across the full spectrum of functioning (legal, health, employment) compared with no treatment or non-medication treatment.

Like many chronic health conditions, opioid use disorder (OUD) is typically a relapsing disorder that may be fatal if untreated. The rates of relapse for OUD are similar to those seen in Type II diabetes and hypertension. Also similar to diabetes and high blood pressure, OUD responds much better to a combination of medication and non-medication treatments than to non-medication treatment alone. For example, the risk of fatal overdose in patients treated in abstinence-only settings (AA/NA, residential treatment, etc.) is typically at least twice that of patients receiving methadone or buprenorphine treatment. However, unlike people in treatment for diabetes and high blood pressure, people in need of treatment for OUD are subject to a dizzying array of judgments, opinions and criticism. "I just quit cold turkey, and you should too." "I knew a guy who took methadone once, and he just seemed real out of it." "I don't know why you should have to depend on a drug to act like a normal person."

Imagine saying these things to a diabetic, one who is in danger of losing a foot to the disease and who is in constant pain from neuropathy: "I had high blood sugar once, but now I don't. You should be able to do that, too." "I knew someone who took insulin once, and he seemed weird on it. I don't think you should do what your doctor tells you to do." "I don't know why you need insulin to be able to process sugar like a normal person. You're just depending on a drug to live your life." These statements sound ridiculous and even offensive because they are.

Perhaps the most concerning thing that Dr. Price said, however, was subtle: Speaking about his perception of why "substituting one drug for another" was a problem, he said "Folks need to be cured so they can be productive members of society and realize their dreams." It is this attitude that might be the most poisonous: You are not welcome until your symptoms are gone. We do not apply this logic to other illnesses. We do not tell hypertensive patients that until they have 120/80 blood pressure every single day, they can't be productive members of society and realize their dreams.

Addiction is a chronic illness, one that people often work to manage all their lives. The notion that addicted people are "sick" and need to be "cured" is outdated and inaccurate; it implies a magical solution that will rid someone of their symptoms. The problem is that this very mindset is typically what led people to addiction in the first place; if you want a "magical" solution to physical and emotional pain, there is no more magical solution than heroin (at first). Of course, this is a mirage; nothing that good comes for free. The other problem with telling addicted people that they need to be "cured" before they can be productive members of society and realize their dreams is that this is delaying the very thing that would likely lift them from addiction — engaging in meaningful and valued activity. The current opioid epidemic was created in part by easy access to a seductive drug that allowed people to fall out of society. We need to be pulling those very same people back in just as they are, and helping them to start repairing their lives with treatments that are supported by data, not waiting around for a magical fix that may never come.

Minu Aghevli (minu.a.aghevli@gmail.com) is program coordinator of the Opioid Agonist Treatment Program within VA Maryland Health Care System. The opinions expressed here are her own and do not necessarily represent that of the VA.

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