Sun. Jul 3rd, 2022

“Just Say No” Doesn’t Work—But Here’s What Will

It’s time to look at drug abuse as a chronic condition.

A month out from Bella Monte, Chayce seems to be sailing on the highs of falling in love while trying to make a life in Fresno with her new boyfriend. She hasn’t touched heroin, she tells me, but admits she hasn’t been sober sober. Feeling anxious one day, she went to get weed from a guy she met on Twitter; when she jumped the curb driving into the parking lot, wrecking her tires, “he gave me five Norcos”—an opioid—“and I popped all five right there.” She laughs it off, but then her mood slumps. “In rehab,” she says wistfully, “I didn’t have one day when I wanted to get high, not one. I was like, Why would anyone ever want to numb this feeling? It just sucks that the cravings are back.”

Earth to willpower? If that’s what you’re thinking, you’ve got company: As a society most of us have been sold on the idea that anyone, even a hard-core IV heroin user like Chayce, can and should “just say no.” But based on a firm body of science, experts now consider opioid addiction as much of a chronic illness as diabetes or heart disease—all physical conditions with high relapse rates that require constant vigilance and specific lifestyle choices to manage. I spoke with 20 women now in recovery, and almost every one of them told me she relapsed 10 to 20 times before getting sober. These were all smart, motivated people who haven’t touched heroin for at least three years—it was clear to me this wasn’t just about weakness. “We need to convince ourselves culturally that treatment is not just locking yourself in a closet and saying a prayer,” says UCSF’s Ciccarone. “If a heart attack patient is told to cut down the red meat, stop smoking, and take her medication and then comes in with a second heart attack, we say, ‘Oh, Ms. Jones, we need to try harder this time.’ We must do the same for a heroin patient instead of getting utterly dismayed if they relapse.” Chayce’s mother, Tracie, felt the stigma repeatedly with her daughter: “People have treated her like crap and told her to suck it up,” she says. “I wouldn’t expect that if she had another disease.”

To understand why “just saying no” so often doesn’t work, it helps to know how opioids actually change the brain. These drugs hijack the body’s natural reward system: Once the brain is keyed to heroin, users typically stop enjoying food and sex; only the drug lights them up. The effect is so powerful they get addicted to the sheer act of injecting themselves. “I was shooting beer from a 40-ounce, just to shoot something,” says Sara Kaiser, 32, a nurse in Connecticut, who used heroin for six years. The brain effects are why going cold turkey has dismal success rates. “Relapse rates after detox are over 80 percent within a year,” says David Fiellin, M.D., professor of medicine, emergency medicine, and public health at Yale. “And those individuals are also at high risk for overdose.”

The good news is there are drugs to wean you off: Medication-assisted therapy (MAT) is widely considered to be the best treatment we have today, when used with other therapies like intensive out-patient therapy and support meetings. MAT includes buprenorphine (often in a combo pill called Suboxone), a weaker opioid that when carefully administered over time can reduce relapse rates up to 80 percent, and methadone, which shows similar results. The treatment isn’t perfect—several women confessed to Glamour that they did misuse the drugs by taking more than the prescribed dose. But as part of a continuous effort, along with therapy and lots of support, these meds can help patients start to make the profound lifestyle changes they’ll need to avoid relapsing.

A consistent theme in my interviews was this: Like a cancer recurrence, in which no one blames the patient, and oncologists try new therapies a second or third or fourth time, opioid-use disorder should be seen as an ongoing illness; when one treatment fails, friends and family should rally in support of the patient, and doctors should try another therapy—because eventually many do recover. Frustratingly, few patients and caregivers know any of this. “When we first put Sara into a 30-day rehab, I figured it was just ‘Clean it up, one and done,’” says her father, Ray Kaiser. But then Sara relapsed before eventually getting sober with methadone and intensive outpatient treatment. “It took me a while,” he says, “to realize it was a disease, and that every time she relapsed, she’d learn something from it and recover quicker.”

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