Back then, I wasn't the stereotypical junkie. These days, however, I would be a proper poster child for opioid addiction. In recent years, there's been an epidemic of women, the majority of them like me—white, middle class or working class—using and abusing opioids. That includes heroin, which, between 2002 and 2013, increased in use among women at twice the rate of men—and prescription painkillers, which about 1.5 million misuse each month. The problem is literally killing them. Between 1999 and 2015, opioid overdose rates quadrupled among men but sextupled among women.
The statistics are sobering. But more distressing is that if and when these women seek help, the most common treatment—a 28-day stint in rehab based on the 12-step, abstinence-only model—rarely works and can even be dangerous. A large-scale study found that with this practice, which is the basis for 80 percent of treatment for all substance abuse in the U.S., few people receive effective care. I saw this during my own stay in rehab, where counselors told me that only 1 in 27 people would end their addiction through the program. I met many women there who had "failed" rehab multiple times.
In my three decades as a journalist specializing in covering addiction, I've also seen people reclaim their lives through a different, science-backed approach called maintenance therapy, or medication-assisted treatment (MAT). It has been around since the 1960s and has more recently been endorsed by recovery experts and government agencies. And yet the approach has been marginalized—vilified, really—by traditional treatment centers, and even some doctors. The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone's system can leave them less able to naturally cope with physical or emotional stress, says Sarah Wakeman, M.D., medical director at the Massachusetts General Hospital Substance Use Disorder Initiative in Boston and an assistant professor at Harvard University. So doctors prescribe steady doses of legal opioids (buprenorphine or methadone) that act on the same parts of the brain as illicit opioids. "With regular use, at the right dose, the drugs don't produce a high, but they do prevent withdrawal symptoms, reduce cravings, and, because they create a tolerance to other opioids, reduce the odds of a deadly overdose if someone relapses," says Wakeman. The treatment slashes relapse and death rates, yet it's so stigmatized as "just replacing one drug with another"—something I heard countless times in rehab—that fewer than 35 percent of people addicted to opioids have access to these medications. With the opioid crisis at an all-time high, it's time to end that.
To truly understand the heroin epidemic, you have to understand how opioids became broadly available through simple supply and demand. In the 1970s, doctors started recognizing that chronic pain was widely undertreated. They responded by prescribing recently FDA-approved opioids (like Percocet and Vicodin) in high numbers, believing they were less addictive than they are. Between 1999 and 2014, sales of the drugs nearly quadrupled; in 2012 alone, health-care providers wrote 259 million prescriptions for painkillers, enough for every adult in the country to have a bottle. The majority of the prescriptions went to, and continue to be written for, women, since we're more likely than men to experience chronic pain conditions (like multiple sclerosis and fibromyalgia), more apt to visit an M.D. to treat them, and more likely to be given a long-term Rx to match the long-term ache.
Fewer than 10 percent of people treated for chronic pain with opioids become hooked on the meds. But those odds increase exponentially when you add in other factors that disproportionately affect females: mental illness, and having a history of physical, emotional, or sexual abuse. More than two-thirds of women with prescription opioid addictions have mood or anxiety disorders, which can lead them to self-medicate with the drugs. Worse, some antianxiety meds women use to treat their mental health conditions increase the risk of dying from an opioid overdose if they're taken together. And up to 95 percent of women seeking treatment for opioid addiction have experienced childhood abuse. "A woman who initially took an opioid for physical pain may discover it helps her escape from the flashbacks and panic attacks caused by a past trauma, which can lead her to abuse the drugs to cope," says psychologist Carrie Wilkens, Ph.D., cofounder of the Center for Motivation and Change, an addiction treatment center in New York City.
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Eventually, many women addicted to opioids need—and want—help. The majority of them will end up in a 28-day rehab program that requires them to abstain from the drug. In theory, it makes sense—closely monitor people in a safe place so they can get the narcotics out of their systems. In reality, there's little rhyme or reason (or science) behind this treatment. For starters, the time frame isn't research-backed; it was determined largely by insurance companies who decided 28 days was the standard length they would pay for, according to Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers. There's no basis for forgoing opioids altogether either. In fact, data points to the opposite. "Repeated attempts at detox without using maintenance therapy actually decreases the odds of success and increases the risk for overdose," says Wakeman.
And then there's the faith factor. While doctors and agencies like the National Institute on Drug Abuse recognize addiction as a disease, there's no other illness for which meeting and prayer are considered mainstream medicine. The majority of rehab programs use the 12-step model created by Alcoholics Anonymous (AA) despite a large-scale international review that found little evidence that it's effective. And it might be damaging: Steps like taking a moral inventory, making amends, and examining character defects can disparage women with addictions, who likely have, and may be ashamed of, a history of trauma or mental illness, says health and medical writer Anne Fletcher, author of Inside Rehab.
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Surrendering to a "higher power" can be undermining as well—because the implication is that you cannot beat an addiction on your own—especially for the growing number of women who say they're not religious. (There are non-12-step support groups like SMART recovery, an evidence-based program without the spirituality requirement, and Women for Sobriety, a group that aims at empowerment. But they're not as widely studied as MAT.) Even worse, 12-step programs can also put women in direct peril because some men in the groups use the trust established to prey on women sexually. Seducing a newcomer is, disgustingly, joked about as being the "13th step."
When 28-year-old Minnesotan Danielle entered residential rehab, she faced another common obstacle: She was a single mom. She first got hooked on painkillers prescribed after her C-section and progressed to heroin given to her by her then-boyfriend. It's a common path in that 80 percent of new heroin users misused prescription pain medications first. Like roughly 90 percent of people who become addicted to Rx painkillers, Danielle had a history of substance use in her teens and twenties; she'd smoked pot, drank heavily, and dabbled with opioids. Finding a treatment center where she could bring her toddler daughter was a struggle. Few outpatient programs offer affordable day care, and less than 7 percent of residential ones have room to accommodate children. This puts moms like Danielle in a gut-wrenching position—stay with their kids or temporarily put them into foster care so they can get treatment.
Danielle eventually found a rehab that allowed her daughter to stay with her, but later relapsed after giving birth to her second child. She was desperate and decided to try something she'd learned about in rehab: methadone.
A Fair Trade?
Danielle was wary of methadone, having heard treatment medications were just substitute addictions. It's a common, and damaging, misconception. People who take methadone or buprenorphine are told by peers, counselors, and some doctors that they're still hooked, or not "really recovered."
But addiction, by definition, is compulsive drug use despite negative consequences. Taking a daily medication to improve your health doesn't meet this definition. "Maintenance therapy brings a person who is addicted to opioids back to equilibrium the same way that insulin restores normal blood sugar levels for someone with diabetes," says Wakeman. With it, patients are able to go to work, build a family, and socialize. It's safe, even recommended, for pregnant women since quitting opioids during pregnancy can kill the fetus.
Still, that widespread stigma has kept MAT as a "last stop" treatment, despite four decades of conclusive evidence backing its use. Research shows the approach reduces relapse and cuts the death rate by 50 percent compared with those who attend abstinence-only rehab; other findings show up to 90 percent of people on methadone maintenance are successful at beating their opioid addiction. Danielle is one of them. Every day, she goes to a clinic to get an individually tailored dose of methadone (buprenorphine, because it was introduced under less restrictive federal regulations, can be taken at home). After almost a year, she tried coming off the meds due to the side effects (constipation and drowsiness, the two most common) and lingering stigma, but her cravings quickly returned. She realized avoiding relapse was much more important than some vague idea that medication is "bad." With two years of recovery behind her, she says, "I'll be on methadone as long as I feel like it is helping."
How long should that be? Doctors don't know. Some patients can taper off after a few months, others may need to take the meds for years, even the rest of their life, says Wakeman, though what is clear is that many people will relapse if they stop MAT after six months or less. And like insulin for someone with diabetes, MAT works best when combined with lifestyle changes, which is why patients are often urged to combine the meds with cognitive behavioral therapy, where they learn to identify and change self-defeating thoughts ("I'll never beat this") and behaviors (e.g., hanging out with friends who are still misusing opioids) that often drive addiction.
In an ideal world, MAT would be an option for everyone with an opioid-abuse problem, and experts are trying to dispel stigma so the treatment can become more accessible—something that U.S. surgeon general Vivek Murthy backed late last year in a landmark report on drug addiction.
Until then, mounting evidence suggests another drug could also help end the opioid epidemic: pot. Cindi, a 45-year-old native of Orange County, California, has been to 12-step rehab four times to treat her painkiller addiction (it started with a script written for a severe sore throat). But she ultimately recovered in a much less conventional way, by replacing opioids with medical marijuana. Although addiction experts stress more research is needed, several studies link medical marijuana availability to lower risk for opioid use, addiction, and overdose deaths. One California rehab now uses medical marijuana for opioid addiction treatment.
Ultimately, most successful recoveries, like my own—I recovered despite going to 12-step rehab, not because of it—involve finding new passions in work, relationships, hobbies, spirituality, or all of the above. Because as surgeon general Murthy wrote in his report, "We must help everyone see that addiction is not a character flaw—it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer." To overcome opioid addiction, women need a life we can embrace. And a treatment system that doesn't ignore the evidence.
This article originally appeared in the June 2017 issue of Women's Health. For more great advice, pick up a copy of the issue on newsstands now!