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I tried it, I enjoyed it—I was almost overwhelmed with the magic of it. Everything was okay for six to 10 hours. Everything was beautiful and peaceful…So, I went back for more.
This was the beginning of Lana Sandas’ addiction to street heroin. The young Australian woman from suburban Sydney would quickly become embroiled in an $800 per day heroin habit and live on the street to support her habit. Years later, she’s a motivational speaker and mentor, and has managed to create a successful career.
Sandas’ uplifting story has been heard around the world, featured in major news media outlets like The Guardian and reshared thousands of times on social media. But there’s a reason she’s been so celebrated: her story is rare.
According to a national poll from the American Psychiatric Association, nearly one in three people know someone addicted to opioids in the U.S. To give a ballpark figure of the full scope, there are about 2 million Americans who have a substance use disorder involving prescription pain relievers and 591,000 who have a substance use disorder involving heroin, according to 2016 data.
While many of us know someone who is struggling with opioid use, the poll also found that most people think there is hope that sufferers can overcome their addictions. In fact, four out of five Americans believe people can recover from opioid addiction.
While an optimistic attitude about the future is fundamental for the addiction recovery process, there are some hard realities when it comes to opiate rehabilitation, specifically when discussing heroin use.
According to a study from 2019 about the probability of staying clean after receiving treatment, only about one-third were able to achieve and maintain abstinence after about 10 years had passed. The rest of the group continued using heroin in some capacity despite being in long-term treatment.
The Stigma Surrounding Opioid Addiction
Opiates were introduced to American society in the 1800s with morphine, which was used to relieve pain, asthma, headaches, alcoholic withdrawal symptoms, gastrointestinal diseases, and even menstrual cramps. Since then, we’ve learned more about the powerful nature of the drug, but generation after generation, a portion of society falls victim to its addictive quality in the form of prescription pain relievers, heroin, and synthetic opioids such as fentanyl.
There is still a stigma attached to many different health conditions, ranging from mental health illnesses to diabetes to HIV. Some progress has been made in breaking down the perceived taboos of having one of these diseases. For instance, mental illnesses, such as anxiety and depression, are being seen in a new light thanks to a new generation that views mental disorders and treatments as legitimate in a way that previous generations have not.
But despite the now widely accepted understanding that addiction is a disease, little progress has been made in busting the stigma around substance use disorders. We still see people struggling with addiction issues, at best, as outcasts, and at worst, as hardcore criminals that should be locked up away from the rest of society. Sandas now fights for women to get access to rehabilitation programs in the corrections system.
Experts like Dr. Thomas Kline, a North Carolina physician who is an outspoken advocate for chronic pain patients, want to bust the stigma surrounding addiction. We asked him about misconceptions when it comes to the opioid crisis and how like-minded people who are interested in specializing in treating addiction should choose their career pathways.
Meet the Expert: Thomas Kline, MD, PhD
Dr. Thomas Kline is a physician and behaviorist who specializes in chronic, painful diseases. He is the former Chief of Hospital in Home Service at Harvard Medical School. He completed his PhD from the University of Oregon, his residency at Stanford University, and has his MD from the University of Maryland. He is also an outspoken advocate on social media for people with addictions to have access to the medication and treatment that they need.
Combatting the Stigma of Addiction
To truly understand the continued cultural stigma against opioid addiction stigma, Dr. Kline recommends going back to the basics by employing the Socratic method. The philosophical framework is meant to stimulate critical thinking to get down to the very root of issues. One of the questions that Dr. Kline invites us to explore is why people have such a negative opinion of people with opioid addictions in the first place.
In her interview with Viceland, Sandas describes growing up with certain internalized perceptions about heroin addicts. But the moment that she realized that “junkies” were just real people facing serious issues didn’t occur until she became one of them.
When you peel away the layers of “why,” as Dr. Kline invites us to do, it comes down to an ingrained belief that drug users are in their situations because of bad choices.
But for many people, it’s not a simple choice of whether or not to shoot up or pop a pill. It’s a near uncontrollable compulsion with biological roots.
Examining the Roots of Opioid Addiction
“Look at the sociology of a person who is completely shunned from their families. It ruins their friendships, it ruins their relationships,” he said. “Imagine what it’s like living with that and here it wasn’t even your fault. They used to blame diabetics, too, but it’s also a genetic disease.”
People have specific genes, some with abnormal mutations, which are in charge of building the receptors. “All biology now is about cellular receptors,” Dr. Kline said. “Four people out of 1,000 have a mutation that when they take an opiate by mouth, they have an abnormal dopamine reaction. They get pleasure that is beyond description. This occurs with the very first pill the person takes. So, it becomes—in our view as doctors—an ADR, an adverse drug response.”
Dr. Kline sources this statistic from the Substance Abuse and Mental Health Services Administration, although there is some debate about the exact percentage, depending on the source of the data. For instance, the Centers for Disease Control’s (CDC’s) figures may differ.
Regardless of where you stand on this particular issue, the scientific community is in agreement that there is a certain percentage of people with this genetic predisposition which are especially susceptible to opioid addiction.
“If it were due to bad choices, bad personalities, it should not trigger this kind of physiological response on the first pill,” Dr. Kline said. “If a person is stuck in a lifeboat, they know if they drink seawater, they will die in 30 minutes, yet most of them will drink seawater eventually. But they can’t stop because of the nature of the disease. It’s the same here.”
Today, scientists are studying the various genetic predispositions that people have for all kinds of drugs, which is called pharmacogenetics. Over time, we will continue to gain more insight about different genetic predispositions to all kinds of substances, but at present, research is still limited.
Understanding the Two Types of Addicts
If you are debating pursuing a career in chronic pain management, it’s important to understand that there are different types of addiction that you may come across. Scientists break them down into two categories, which separate behavioral addictions from chemical addictions.
“The new definition of Type 1 addiction usually occurs when you’re involved with a substance or an activity that ruins your daily life,” Dr. Kline said.
Dr. Kline relates a story from the Unbroken Brain by Maia Szalavitz. When Szalavitz was a teenager, she got swept up in the wrong crowd and began using street drugs, which escalated into injecting heroin and cocaine multiple times a day through her college years. She eventually overdosed and was arrested for drug dealing. She sought treatment multiple times, but she was eventually able to recover.
Type 1 addiction can be influenced by circumstances, familial problems, dissatisfaction, and trauma. In Szalavitz’ view, more than a disease, addiction can be looked at as a learning disorder—but one that can be overcome.
“These drugs can ruin your daily life, but you have the ability to stop,” Dr. Kline added.
The same external factors may be present in Type 2 addiction cases; however, the second category of addiction is much more difficult to overcome because it is rooted in a problem with brain receptors.
“Four people out of 1,000 have a mutation and that makes the receptor wrong,” Dr. Kline said. “Nobody has an ‘addictive personality’ in Type 2. It’s a brain disease. These people come from all walks of life.”
One recurrent finding that has been pointed out in various studies is that those with this genetic mutation have a dopaminergic dysfunction.
“Those are the ones that drink all the time and will start to go into withdrawal soon after they stop their continuous infusion of alcohol,” Dr. Kline said. “All of these Type 2s have terrible withdrawals, which points out the fact that this is a real brain disease.”
Type 2 is also characterized by intense seeking behavior without regard for consequences, which is absent in Type 1 addicts’ behavior, Dr. Kline said.
For example, “If you’re a Type 1 and you want more cocaine, you’re usually not going to go shoplifting in order to get some more money,” Dr. Kline pointed out. Type 2 heroin addicts, by contrast, are known for resorting to petty theft in order to get high, which is identifiable in Lana Sandas’ case.
Careers in Treating Opioid Addiction and Pain Management
If you’re thinking of starting a career in addiction treatment or in chronic pain management, you should consider the various specializations within this realm, which will enable you to treat different kinds of patients.
Pain Management Psychiatry
First, it’s important to make the distinction between those who struggle with chronic pain and those who suffer from addiction to opioids, although these two groups of people often overlap. About 50 million people in the U.S. struggle with chronic pain. Unsurprisingly, substance abuse disorders occur at a greater rate in individuals who have a chronic pain condition than in individuals who do not.
Pain clinics employ an array of healthcare professionals of different educational levels. According to the Psychiatric Times, a variety of disciplines have become increasingly involved in pain management. The psychiatrists who have received specialized training in pain play an important role in helping patients with chronic pain.
These professionals diagnose and manage a patient’s prescriptions, which often includes the use of opioids, but also help them to navigate their mental health struggles.
In addition to prescribing patients medication, pain management psychiatrists also help patients manage the occupational, social, or romantic problems caused by their chronic pain, which can lead to feelings of isolation, worthlessness, and depression.
Becoming a pain management psychiatrist takes about 12 years. For the first years of their schooling, psychiatrists follow the same path as other prospective physicians. After earning a bachelor’s degree in psychology, they must attend medical school with a concentration in pain management.
Physician Assistants and Nurse Practitioners
Pain clinics are increasingly turning to physician assistants, nurse practitioners, and nurses to treat patients. This is because of the growing number of those in need of chronic pain treatment, as well as primary care physicians’ fear of the regulatory scrutiny that comes with maintaining patients who have chronic non-cancer pain on opioids.
Nurse practitioners and physician assistants may examine patients to identify the cause of their discomfort, develop a treatment plan to enable them to resume as much regular activity as possible, and even provide diagnoses and prescriptions. They usually work under a supervising physician.
These two career paths each take about six years to complete (including bachelor’s degree program completion time.)
Types of Therapy for Combatting Opioid Addiction
If you are more interested in helping those that are struggling with a pre-existing, active addiction to opiates, it’s important to understand the differences between Type 1 and Type 2 addictions, as it will determine the kind of treatment that will be effective.
Dr. Kline believes that talk therapy can be very effective for Type 1 addiction. Those with unresolved issues in life that they are masking with drug use may find that rehabilitation programs that include talk therapy can help launch them into a new chapter of addiction-free life.
He gave the example of a young gay man from a conservative Christian family. Once the patient was able to talk to therapists and resolve his family conflict in his 30-day rehabilitation program, he was able to successfully stay drug-free.
In these cases, cognitive behavioral therapy (CBT) can be effective. CBT teaches recovering addicts how to deal with triggers in three ways:
- Recognizing circumstances that lead to drug use
- Avoiding situations that trigger relapses
- Coping with thoughts and emotions that lead to using
Techniques and exercises learned in CBT can be practiced outside the therapist’s office, individually, or in a group setting.
To become a cognitive behavioral psychologist, you need to hold a PhD in either clinical, counseling, or school psychology from a program that includes coursework and clinical training, in cognitive-behavioral theories and treatments.
Counseling for Type 2 addicts is another story, but there is still hope for these cases. “They need to be treated with a very specialized sociologically driven counseling system. It needs to be separated from the usual counseling for Type 1 that’s being done,” Dr. Kline said.
“Type 2 heroin addicts do not need supportive talk, as they did not begin heroin due to unhappiness. Rather, they started accidentally when the grip of powerful chemical addiction kicks in,” he continued. “Living in conditions of blame and shame and inadequate social support should be addressed, but not by traditional talk therapy, [which is] largely wasted, since their ego strengths are just fine.”
At present, the best option to address Type 2 addiction is to look for medication-assisted treatment (MAT), which uses medications in combination with counseling and behavioral therapies.
But there also needs to be a shift toward increased access to MAT, which comes back to making a greater effort to break the stigma associated with some of the medications used to treat opioid dependency.
“Type 2 addicts really do need some sort of baseline opiates in their bodies all the time. And addicts don’t like that. Nobody likes taking medicine forever, but the medicine for this disease is opiates in a controlled amount,” Dr. Kline said.
According to the FDA, the use of buprenorphine, methadone, and naltrexone has been shown to be safe and effective in combination with counseling and psychosocial support.
You can gain the credentials to administer and dispense FDA-approved MAT medications through a Certification of Opioid Treatment Program, which are accredited by the Substance Abuse and Mental Health Services Administration (SAMHSA). Between 2017 and 2018, more than 15,000 physicians became certified to treat patients with opioid addiction by using MAT.
No matter which path you choose to take—whether you want to become a pain management psychiatrist, a cognitive-behavioral therapist, or a MAT physician—take a piece of Dr. Kline’s advice with you: “Actually talk to addicts. Do old fashioned, observational science, interview them, and most importantly, listen to them.”
Nina Chamlou is an avid writer and multimedia content creator from Portland, OR. She writes about aviation, travel, business, technology, healthcare, and education. You can find her floating around the Pacific Northwest in diners and coffee shops, studying the locale from behind her MacBook.