The photo was so startling that it almost seemed staged. In the driver’s seat, the man’s head is dropped back, his eyes closed, mouth agape, one hand draped on the steering wheel in front of him and the other in his lap. In the passenger seat, a woman is slumped toward him, the straps of her tank top off her shoulders. Both appear to be out cold.
In the backseat, a young boy, the woman’s grandson, dressed in a blue T-shirt with a brightly colored dinosaur on it, looks blankly at the camera.
The photo, taken by Ohio police officer Fred Flati, went viral when his chief and the mayor posted it on the city’s Facebook page. Flati said he decided to take the photo because it wasn’t the first time he’d seen something like this, and he knew it wouldn’t be the last. He is one of 18 officers in the East Liverpool police force, and in the past year, the opioid epidemic has ambushed his town and other small cities like it along the Ohio River.
“Some nights the entire shift is tied up with just overdoses,” says the police chief, John Lane. “If we have any other calls, they just have to wait. We just don’t have enough people to be dealing with this problem.”
More people died of drug overdoses in 2014 in the U.S. than in any other year, and 60% of them were because of painkillers. Over the past 17 years, rates of opioid-overdose deaths have quadrupled, fueled by overprescription of painkillers and the proliferation of cheaper forms of heroin and synthetic opioids.
The Flati photo captured the depths to which the opioid epidemic has penetrated U.S. communities, and just as the officer hoped, it has sparked a difficult debate over what created the problem and what’s making it worse. Policymakers are increasingly siding with doctors in embracing one way to rescue people with addiction from the overwhelming cravings of their habit. Suboxone mimics the narcotic effects of heroin and painkilling opiates without the addictive high. The medication can lower addicts’ risk of overdose death by more than 50% and their risk of relapse by more than 50% as well. After four years on the medication, a third were not abusing opioids and no longer needed suboxone to maintain their sobriety.
Opponents, including those from leading national drug-rehabilitation programs, maintain that suboxone and its predecessor, methadone, which is used to treat heroin addiction, are also habit-forming. Chief Lane is among them. “We have people here abusing methadone and suboxone,” he says. “They just trade one drug for another.”
Such concerns have led to restrictive policies governing which physicians can prescribe suboxone and how many patients they can treat at any one time—far fewer than the more than 2 million people nationwide who abuse opioids and stand to benefit from the medication. Without treatment, addicts in search of their next hit turn instead to the black market, which is increasingly responding to the surging demand with dangerous counterfeit opioids that are contributing to even more deaths.
To break the cycle, the Obama Administration unveiled a bold $1.1 billion proposal that would encourage the use of medicine like suboxone to treat people with addictions and allow nurse practitioners and physician assistants, as well as doctors, to receive the proper training to prescribe the drug.
The idea of using drugs to help addiction recovery has already caught on outside the U.S.; both in Switzerland and in England, health authorities actually dispense small amounts of heroin to addicts as a way to wean them off if they haven’t been successful using methadone or suboxone. “We tend to look at addiction treatment in a black-and-white way,” says Dr. Joji Suzuki, director of addiction psychiatry at Brigham and Women’s Hospital. “These drug-based treatments are effective, but overall the medical culture has not embraced them.”
The key is to think of these measures more as necessary medical treatments, similar to the way people take statins to lower cholesterol or insulin to keep their blood sugar in check. People with addiction may be dependent on the drugs to keep them clean, experts say, but they are not addicted to them, since addiction, as defined in the psychiatric manual, involves severe disruption of daily activities as the craving for the next high takes precedence over all else.
“People tend to confuse the difference between dependence and addiction,” says Suzuki. “Physiologic dependence can occur because you are taking medication on a regular basis, whether it’s an opioid like [suboxone] or blood-pressure medications. The body becomes reliant on them. So are addicts who take buprenorphine [suboxone’s chemical name] physiologically dependent on another drug? Absolutely. But addicted? Absolutely not.”
Study after study supports the effectiveness of drug-based therapies for opiate addiction. People who take methadone and suboxone are better able to keep a job, avoid relapses and gradually reduce their need to continue using heroin or opioids.
That’s key to recovery, because opioids can have lasting effects on the brain, often rewiring reward circuits and permanently altering the way people perceive satisfaction.
“Once the brain is changed by addiction, that mechanism of choice is damaged,” says Dr. Sarah Wakeman, medical director of the substance-use-disorder initiative at Massachusetts General Hospital. “It’s almost like a stroke in that part of the brain. Someone with addiction can no sooner choose not to be addicted than someone with diabetes can choose not to have diabetes.”
Still, there remains considerable stigma around the idea of using drugs to treat drug addiction. People with addiction who are recovering with the help of medications like suboxone are stigmatized by members of popular rehab groups like Narcotics Anonymous, discouraging them from taking advantage of the social support that is so critical to journeying from addiction to sobriety.
Even the good intentions of doctors are stymied by such old-fashioned resistance. Once they are authorized, physicians are restricted in how many patients they can treat with suboxone. Initially, federal regulations required that each doctor could treat only 30 patients at a time with the drug because of still entrenched concerns about addicts’ swapping addiction to heroin or painkillers for addiction to suboxone. That regulation has since been changed twice, and in 2016, the U.S. Department of Health and Human Services expanded the number to 275 patients per doctor and allowed nurse practitioners and physician assistants to prescribe the drug as well.
Still, many doctors don’t prescribe suboxone. About 90% of the prescriptions for it are written by just 6,000 of the 32,000 doctors in the U.S. certified to administer the drug. The certification, issued by the Drug Enforcement Agency, involves eight hours of training on both medical and legal issues, including how the drug works to blunt the narcotic effects of opiates, which patients should use it and its status as a controlled substance.
Even if more physicians, public-health advocates and addiction-recovery groups embrace the idea of using drugs to treat addiction, no medication alone can be the answer to this epidemic. What it would do, however, is increase the options available to people with addiction—and reduce the stigma of looking for help.
The boy in the East Liverpool photo is now living in another state with a great-aunt and -uncle who have temporary custody; it’s his third home in his 4 years. After his mother, who was also a drug user, left him when he was 8 days old, his great-grandparents were awarded custody, and when they could no longer care for him, his grandmother. Now she is serving 180 days in jail and her partner is serving 360 days for child endangerment, public intoxication and driving under the influence.
While incarcerated, neither will receive treatment for drug abuse; cities like East Liverpool don’t have the resources or the training to provide it. “When they get out, they will probably go right back to what they were doing, is my guess,” says Lane. “That’s the problem.” But if perceptions about addiction treatments change, it doesn’t have to be.