As a medical student, I always carry naloxone in my backpack. Naloxone is the antidote for opioid overdoses, and is readily available at most pharmacies in Boston. My medical school, Boston University School of Medicine, is located near the epicenter of the opioid epidemic in Massachusetts. Walking around campus visibly over-sedated individuals on the sidewalks are a common sight, and on a regular basis there are overdoses within a one block radius of Boston Medical Center. Historically, addiction has been treated as a moral failure of the individual. But training in the midst of this opioid epidemic has led me to develop a different viewpoint — one that is supported by a growing literature substantiated by neurobiological science — that addiction is a brain disease.
The hospital offers a window into the lives of patients who have had their physical, emotional and social well-being destroyed by addiction. Although most of our patients had a substance use disorder, which often complicated their presenting problem, one patient during my infectious disease rotation stands out to me. I treated a young man, “Trevor,” who was admitted for a joint infection in his hand. After exhausting all the veins in his arms, Trevor had begun injecting heroin into these delicate vessels. The orthopedic surgery team had performed an incision and drainage of the infected joint, and we were managing him post-operatively with intravenous antibiotics, pain control and methadone maintenance therapy.
The story of Trevor’s addiction began when he started using prescription oxycodone as a teenager. This later progressed to heroin. He told us he had posttraumatic stress disorder (PTSD) and would use heroin to self-medicate his severe anxiety.
Like many people with addictions, Trevor was very much aware of the harmful effects of his substance use, but was struggling to overcome it in part due to his unstable, homeless living situation. He expressed that he needed a dual-diagnosis residential program, a program which specializes in treating individuals with a comorbid addiction and mental illness. Unfortunately, his insurance would not cover this at the time because he was not actively psychotic or an imminent threat to himself or others.
I checked in with Trevor every day to talk about his addiction, and he expressed desire and hope for ending his heroin use. His surgical wound was healing well, and soon he was discharged on oral antibiotics and a short supply of oxycodone to last until his follow-up appointment. Although the social worker had left him with a list of phone numbers for various detox facilities, he was not able to obtain placement. After much progress during his hospitalization but with no other options, he found himself back where he had started — on the street.
The day after Trevor’s discharge I received a call from his methadone clinic informing me that he had not come back in the morning for his daily methadone dose. My mind immediately jumped to an image of him lying dead on the street, overdosed. The third-year medical student commented, “He was so convincing … he told us he was trying to quit, but in the end he had us all fooled!” I wondered if this could instead be simply explained by him not being able to get to the clinic. The resident replied, “I have a feeling we’ll be seeing him again very soon.”
The resident was right. The next day Trevor returned to the emergency department. He told us his backpack with the pain medications was stolen, and he was having worsening pain. Once again he requested psychiatric help through a dual-diagnosis admission. The team’s initial reaction was to voice generalized sentiments of distrust towards drug users, and the consensus was that Trevor was back seeking more prescription opioids. One of the fellows, however, had a different take on the situation.
“Well, at least he’s here. Every point of contact with the health care system is an opportunity for us as providers to intervene. You never know when a person might be ready to turn their lives around. Our job as doctors is not to judge them, but to meet them where they are at, and support them in making the decisions to pursue treatment.”
This fellow’s words resonated with me and changed my perspective on the case. Like too many others in the medical field, I had started to fall into the trap of stigmatizing the patient and blaming him for his own poor outcome. When it comes to addiction, we are fast to place the blame on our patients, freeing ourselves of responsibility. This is grossly incongruent with how we manage and treat other medical conditions. Would we give up on a patient who couldn’t manage their blood pressure with diet and exercise and stop prescribing them anti-hypertensives? Would we discontinue insulin for a patient with diabetes who continues to drink sodas while their blood sugar is poorly controlled? Doing so would be viewed as a breach of our ethical commitment to our patients. The stigmatization of addiction as a moral problem, however, causes some physicians to ignore a largely accepted body of research and use anecdotal evidence to argue that we cannot do anything to help patients with addictions. This view is not only problematic from a humanistic and ethical perspective but it is actually unscientific.
The leading neuroscience theory, the “brain disease model of addiction,” endorsed by the National Institute of Drug Abuse and the Surgeon General Dr. Vivek Murthy, states that addiction is a chronic and often relapsing brain disease. Relapse is not simply a lack of will power or poor character. Repeated exposure to drugs causes changes to the brain’s neural circuitry, eventually leading to the characteristic behaviors of addiction. Alterations in the mesolimbic system (the part of the brain that controls feelings of pleasure or reward) cause the environmental factors that have become associated with a person’s drug use to stimulate dopamine release in a conditioned response. Thus, environmental triggers lead to drug-seeking behavior. After repeated exposure to addictive substances the amygdala (which regulates emotion) becomes over-reactive to stress during withdrawal, leading to intense cravings for the drug to help them escape dysphoria. Adaptations of the prefrontal cortex impair decision making; therefore, a person may continue to use a drug even though they fully understand the harms and sincerely desire to quit.
Knowing what I do now about the neurobiology of addiction, it is not that surprising that Trevor had relapsed in his recovery. That is the nature of the disease: his brain had been “re-wired” to seek out and use these substances. His environment, of being homeless in an area of prevalent substance use, had many factors increasing his risk of relapse. Due to systemic failures, we were unable to provide him with the optimal addiction treatment, and we had sent him right back into this environment with an inadequate discharge plan.
Treatment works, and people do recover. There is an abundance of data confirming this fact. Yet there continues to be an enormous shortage of access to addiction treatment services, leading to many people like Trevor with no safe place to go. Nearly 90 percent of people with a substance use disorder go without any specialty addiction treatment, contributing to an alarming death rate. In 2015, there were 52,404 drug overdose deaths in the United States, which surpasses deaths from AIDS at the height of the epidemic.
We can no longer afford to take this issue lightly. In order to curb this epidemic, a coordinated, multifaceted public health approach must be taken to address addiction on a national level, just as was taken to address AIDS in the 1990s. In addition to systemic interventions, the next generation of physicians must adopt a fundamentally different perspective on addiction and pain treatment — one rooted in science, not stigma.