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Hi again. It’s me this time. No guests. I want to tell you about the debate I just had with a high priest of the Disease Church. Not the bishop, Nora Volkow. But her second in command, George Koob.

Those of us who oppose the disease label have been trying to organize a real debate for a long time. Nora Volkow has consistently ignored these requests or else replied No through her staff. But Koob made an excellent second choice. Judging by his picture and digital presence, I expected a slightly stodgy, soft-spoken academic/scientist type who saw addiction as a disease.

In fact Dr. Koob is the second author of the paper first-authored by Volkow in the January issue of the New England Journal of Medicine, the paper that made a lot of us anti-disease people more irate than usual. Here’s the title: Neurobiologic Advances from the Brain Disease Model of Addiction. And here’s a passage from the first paragraph:

In the past two decades, research has increasingly supported the view that addiction is a disease of the brain. Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned…

I used this quote to launch a counterattack that was published last week in the Guardian. I was pleased to see my little fusillade appear on page 1 of the US edition last Tuesday. And it’s snagged over 600 comments and 2,700 shares in the first week. So a lot of people seemed to agree with my criticisms of the disease model (specifically the claim that the disease label led to an “effective” response to addiction and reduced stigma). But, if you happen to browse the comments, you’ll see that many others thought I was out to lunch.

I actually wondered whether Koob had already read my article. Because he seemed hopping mad from the first words of the debate.

Here’s how it went.

I was sitting in a flashy looking studio in Arnhem. Yes, even in my town we have studios with lots of computers and screens and expensive looking microphones. So I was sitting there in a sound-proof room in front of a state-of-the-art mic, and George Koob was in Washington. The debate was set up by CBC (Canadian Broadcasting Corp — Canada’s national radio) and will be broadcast a few weeks from now. I’ll let you know.

I was nervous. More nervous than I’ve been in any kind of talk or interview for a long time. My voice came out raspy at first. Yet I’d done my homework. I’d reread lots of stuff on changes to the dopamine system, Berridge’s review of his incentive sensitization model, findings on the desensitization of the striatum and the resultant loss of connectivity with the prefrontal cortex. I’d also scanned articles showing that these brain changes are common to drug addiction, porn addiction, obesity, “internet addiction,” and even compulsive shopping — so I had a few arguments ready.

I’d also read a few Koob papers (which I forgot I’d already read thoroughly until I found my yellow highlighting throughout) and felt completely caught up on his theory of the “dark side” of addiction, viz withdrawal, viz the rebound invoked by the “antireward” system. I was ready to talk brain science, because I had no doubt (and I still have no doubt) that George Koob is a top neuroscientist, highly respected and rightfully so. Not to mention the director of the National Institute on Alcohol Abuse and Alcoholism.

But within minutes of the word Go, I realized that I’d done all that cramming for nothing. This debate wasn’t going to be about the neuroscience of addiction. It wasn’t going to be smart, sophisticated, strategic, or fun. It was going to be a slug fest.

The moderator/host (a seasoned radio/TV person in Toronto) started things off by asking Koob: Why do you say addiction is a disease?

He replied something like: What else could it be? And when she asked for a bit more substance: Because it changes the brain. It’s as simple as that. That’s what he said, almost verbatim. And I thought: that’s the most vacuous argument he could possibly make. Everybody knows that the brain is always changing, it changes whenever we learn something, it changes massively throughout development, and there’s this thing called neuroplasticity which is basically the brain’s job description. But that’s what he said: addiction is a disease because it changes the brain. So I had to retort with…well, some version of what I just said.

It didn’t get any better. He sounded angry throughout. He was belligerent at times. He talked about how four people he was very close to had died from alcoholism, because they could not stop drinking. Absolutely could not stop. And he specifically accused me (and us anti-disease folk) of trivializing addiction by not recognizing that it’s a disease. I told him I’d lost a friend to addiction too, but I wasn’t pleased with myself for stooping to such arguments. He even said that I wanted addicts to be stigmatized and that’s why I opposed the disease label. Which was exactly the opposite of what I’d just said: that I felt the disease label merely entrenched the stigma of addiction, and there were much better ways to overcome stigma, like connection, compassion…all the things Johann Hari writes about….and understanding what it really is without giving it a simplistic label.

I’d better stop. I don’t remember everything, and maybe my memories are blurred by the adrenalin I was surfing through most of the debate….which lasted about 45 minutes.

But here’s the point I want to make. I’m pretty sure I “won” the debate because I said smarter things and backed them up better than my opponent. And I’m pretty sure I came off smelling sweeter because my tone wasn’t as antagonistic as his.

BUT IT DOESN’T MATTER.

The problem is that we weren’t talking. We were just fighting. We weren’t listening to each other. We weren’t getting to know each other’s views any better. We certainly weren’t arriving at some kind of middle ground that might benefit from both our perspectives.

And that is so sad!

…by Gina Murillo (comments by “Gina”)…  

So much of what we’re trying to hash out about drug courts here wouldn’t be an issue but for poor drug policy (the War on Drugs — as discussed in the comment section following the last post). The War on Drugs causes far more harm than good. I agree with Marc that Johann Hari makes that case more compellingly than just about anyone else, with the possible exception of Ethan Nadelmann, executive director of the Drug Policy Alliance. (I’m not a huge fan of TED talks, but highly recommend his powerful talk on why we need to end the War on Drugs.)

This really all comes down to how society has been conditioned to view different substances and behaviors. Alcohol and tobacco are far from harmless, but are not only socially acceptable, they’ve both been glamorized to one extent or another. They both kill many times more people each year than all illegal substances combined, even in the midst of the opiate “epidemic”. Yet, we manage to find (admittedly imperfect) ways to deal with the harms they cause as best we can. We do this because we recognize that the harms of prohibiting these substances would likely be significantly greater than simply finding more effective ways to live with them.

Imagine people being arrested for possessing cigarettes (one of the toughest addictions to quit and the #1 cause of preventable death in the U.S.) and facing a drug court judge with the threat of jail or a longer prison sentence for failing to quit smoking. Sure, probably fewer people would smoke and fewer would suffer debilitating disease as a result. But at what (and whose) cost? After all, if legal consequences are so effective at changing negative behaviors, why don’t we criminalize all behaviors we’d like to extinguish for society’s benefit? For another example, how about obesity courts? Health care costs attributed to obesity in the U.S. alone are staggering, with the number of deaths increasing steadily each year — making it the #2 cause of preventable death (behind good ole’ tobacco). And the data strongly suggest that households with just one obese parent are at least twice as likely to raise obese children who are doomed to a shorter life expectancy than their parents. Using drug war logic, this ought to be as good a reason as any to criminalize obesity or the behaviors (and foods) that “cause” it.

Sound crazy? That’s how crazy drug criminalization and drug courts seem to me now. Having dealt with my daughter’s heroin addiction for the past five years, it really hit me, after her most recent “relapse” (for lack of a better term) a little over a year ago, that it wasn’t so much her addiction that was causing the pain and trauma we were both experiencing as it was dealing with the woefully ineffective — and often counterproductive and EXPENSIVE — U.S. legal and treatment systems.

Whether to decriminalize or even legalize powerfully addictive drugs like heroin is a topic of ongoing heated debate. Decriminalization of the use and possession of all drugs is a no-brainer to me. Legalization is more tricky, but still requires an honest and intelligent discussion about the inherent risks and potential benefits. Because while we labor under the delusion that prohibiting a given substance outright is the ultimate form of control, it is in fact the mechanism by which we relinquish all control to criminals, who have in turn been empowered by such policies to build massive global organizations. The only way to undercut that power is to minimize the enormous profits that are generated by prohibitionist policies.

Those who have considered the idea of legalization in any serious way are quick to couple it with proposals for control, which should address, at the very least, protection of minors (who are, incidentally, not protected from heroin availability at present), and, especially in the case of opioids, prevention of leakage or diversion to others, policies for supervision and safety, and strict constraints on who might be eligible for prescriptions. One model of a successful quasi-legalization policy comes from Switzerland, which implemented heroin-assisted treatment (HAT) with great success to stem the tide of its own heroin epidemic in the late 1980s and early 1990s. Here is a brief description of the outcome from an article by Johann Hari in Huffington Post:

Switzerland also had a huge heroin crisis. Under a visionary president — Ruth Dreifuss — they decided to try an experiment. If you are a heroin addict, you are assigned to a clinic, and you are given your heroin there, for free, where you use it supervised by a doctor or nurse. You are given support to turn your life around, and find a job, and housing.

The result? Nobody has died of an overdose on legal heroin — literally nobody. Street crime fell significantly. The heroin epidemic ended. Most legal heroin users choose to reduce their dose and come off the program over time, because as they find work, and no longer feel stigmatized, they want to be present in their lives again.

I would clarify Hari’s description further by pointing out that (1) while Switzerland didn’t legalize heroin, per se, it did make it de facto legal for a very specific subset of the heroin-using population; (2) HAT is a treatment of last resort offered only to those for whom all other methods of treatment have failed; and (3) most HAT patients actually become re-engaged in their lives once stabilized on HAT, regardless of whether they ultimately choose to taper off.

HAT has been so effective in Switzerland that it’s no longer even controversial there, and HAT trials have been implemented in a growing number of European countries and Canada. Very recently, a couple of forward-thinking lawmakers have even made attempts to introduce legislation that would authorize HAT trials in Nevada and Maryland.

I dream of the day our society can, in the inimitable words of Ethan Nadelmann, learn how to live with drugs sensibly, so that they cause the least possible harm and produce the greatest possible benefit to all. Because if there’s one thing we need to recognize, it’s that drugs aren’t ever going to go away, no matter how many laws we pass or how many people we put in jail.

 

…by Judge Allison Krehbiel with Marc Lewis…

I (Marc) was in Minnesota last fall, invited to speak at a conference on addiction to a large university audience. I met many fascinating people during my visit, but the most memorable moment was an unexpected tour of the trenches where the War on Drugs is still being fought, day by day, and perhaps gradually replaced by a more optimistic response to addiction.

Through the mediation of my hosts, the judge who presided at the local drug court invited me to come and observe. And despite my distaste for the legal system, I figured that as an “addiction expert” I was obligated to see what went on. I had only the vaguest idea of what a drug court was — some creepy hybrid of the American justice system, disguised as a generous compromise for addicts in a country notorious for punishing them? So at 1 pm on a hot October day I pushed through the wooden doors and entered what looked like a stage set from Perry Mason or Law and Order: wooden benches, wooden docks, a couple of flags, a wooden jury box, an expressionless reporter sitting below the judge’s podium, and before long the judge herself, grey haired, robed in black.

All rise! We did, and so did my pulse. The last time I’d sat in court I was next to my own lawyer, waiting for sentencing. Judge Krehbiel radiated steely purpose and total authority. I had to remind myself I wasn’t the one on trial. And I began to recognize the druggies, the accused, the probationers and those awaiting sentencing, the jobless meth addicts interspersed among friends and family members in the front rows. I sat down in the back, breathing again, unchallenged, undisturbed. And my expectations began to crumble.

The judge’s sonorous voice called each person by name, and one by one they stood up and walked the short distance to her podium, or stood in place answering questions. But instead of scolding or threatening, the judge spoke to them gently, asked how they were doing. Have you gotten your job situation straightened out? Is your sister still willing to mind the kids while you go to meetings? How’s it going with the stomach problems? You look a lot better than you did last month. Congratulations, Charlene! Three months clean! We knew you could do it! And a chorus of applause would follow. The ones waiting their turn clapped, smiled, and hooted. Charlene gazed at her feet with a grin that looked a lot like pride.

But could this visit to the border region of criminal culpability actually work for these people? Was there an exit door? Or was the whole thing a ruse, a delay that would last until one false move sent them to jail?

Here’s what Judge Krehbiel has to say about what goes on in her court:

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I’ve been a judge for fourteen years, and for ten of those years, I’ve presided over drug court.  Of course, all of the drug court participants find my drug court while passing through the criminal justice system and to many outsiders, drug courts seem to “coerce” recovery.  I don’t see it that way.

Any individual who chooses the drug court path has weighed the alternatives.  They can exercise their constitutional rights and take their chances at trial.  They can opt for regular probation or request execution of their prison sentences.  Or, they can accept a plea negotiation that requires successful completion of a drug court program.  If they opt for the latter, they have chosen, to a certain extent, to be coerced to make decisions that will ultimately improve their lives and hopefully steer them away from the courthouse.

The success of the participants is largely dependent on the quality of the drug court and the attitude of the judge. In my view “compassionate coercion” is essential. My task is to help rather than punish. Yet judges must also realize that, though we may be learned in the law, few of us also hold medical degrees. We function as part of a team.

As the “drugs of choice” (a “choice” that is heavily influenced by street availability) change, so do expert opinions on how best to treat individuals suffering from addiction. For example, the recent increase in opiate addiction (and with it, the return of heroin) caused much discussion among drug court professionals as to whether medically assisted recovery is really recovery at all. I’ve not yet come to a conclusion as to the issue.  However, there are a few things about which I am certain.

First, medical providers and appropriate drug court professionals must be able to freely converse regarding patients/participants. The prescribing doctor needs to know exactly what the court expects of his or her patient and the drug court professional needs to know exactly what the doctor requires. In my experience and on more than one occasion, methadone prescribed to one participant was used by another participant. Medical professionals untrained in addiction don’t catch such infractions — probation agents do. Second,  judges and other court professionals have to accept that there are widely diverse paths to recovery, many of which deviate from a criminal justice approach. Although ninety meetings in ninety days might work for a life-long alcoholic, Xyprexa might be the better bet for an opiate addict. [Note: Judge Krehbiel corrected this text on 20 May, after her mistake was pointed out by readers: She says she meant Suboxone (buprenorphine), not Xyprexa — an error that actually underscores her frank admission that she’s no doctor!] In fact, in states where marijuana is legal, it might be prescribed to ease the agony of opiate withdrawal. In short, we must be curiously open to advances in the treatment of our chemically dependent  clientele. We have to look beyond the justice system and recognize the personal, social, and medical factors that interact to shape their lives.

As I stated earlier,  I don’t have a degree in medicine and therefore, I cannot,  nor should any other judge, dictate whether or not a drug court participant is prohibited from taking prescription medication.  However, I can compassionately coerce that participant to sign a release of information that allows a probation agent and treatment provider to share information with the prescriber of that medication. If the issue is pain, is there a non-addictive alternative to Vicodin?  If the issue is anxiety, is there a non-addictive alternative to Valium?  These questions can only be answered if there is open communication amongst all the professionals engaged in recovery assistance.

The goal we all aim for is the same: allowing people to reach their full potential and live a life outside the restraints of addiction.

Hon. Allison L Krehbiel

Fifth Judicial District Court

 

P.S. I know that this is a contentious approach to addiction “treatment.” But my goal here is to put a lot of different approaches on the table, reflecting the range of what’s out there. Also, having met Allison and chatted with her after the court proceedings, I can attest to her sincerity, dedication, and concern for her participants’ welfare, whether or not one agrees with her views.

I’d like to hear what you guys think.

 

…by Shaun Shelly…

Percy Menzies’ post has stirred up a lot of controversy! Here, Shaun’s extensive rebuttal gathers some of these arguments, plus many of his own, and launches them in torpedo-like fashion. Shaun’s command of the research landscape is awesome, but let’s take care to keep a balanced perspective.

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In the previous post on this site Percy Menzies makes what appears to be a persuasive argument for naltrexone as a favourable intervention when addressing heroin use disorders. Where Dr. Menzies and I agree is that people who have a heroin use disorder should have a wide range of options for treatment, all the way from non-pharmaceutical to antagonist to agonist. Having said this, I have some major problems with his argument, and I believe that the promotion of naltrexone as a valid response to the heroin epidemic, compared to agonist and partial agonist therapies, is flawed.

The first thing we need to know is that opioid substitution therapy (OST) works. It is the gold standard recommended by the World Health Organisation, and for the last 50 years methadone has been proven to reduce mortality, reduce crime, improve health, improve retention in treatment and allow people the space to resolve many of the issues that have made drug use so meaningful to them. It also reduces the spread of HIV. Through robust head-to-head clinical trials, buprenorphine has also been shown to be effective, in some cases more so, in some cases less, but it is effective and has a better safety profile.

Dr. Menzies suggests that the treatment of heroin use disorders is “overwhelmingly dominated” by OST. This is simply not true. According to a 2015 SAMHSA report, only 22% of people between the ages of 22 and 34 accessing treatment for heroin use disorders received OST. Even judges playing doctor are ordering people to stop OST. Further, Dr. Menzies argues that if OST was made more available it would “exacerbate the existing problem, as the pool of opioids will greatly increase along with abuse and diversion.” The data simply do not support this: In Switzerland, where 92% of people in heroin use treatment are receiving agonist therapies, the number of people with a heroin use disorder is dropping by 4% per year and no one has died from a heroin overdose since the programme was started in the early 90s. Similarly in France, where buprenorphine is the norm, 70% of heroin users have access to OST and there has been an 80% reduction in heroin-related deaths and a 75% drop in HIV prevalence among injecting drug users. 20% of French physicians prescribe buprenorphine compared to 3% in the US.

As far as diversion is concerned, diversion is a function not of greater availability but of lack of availability. The diversion of methadone and buprenorphine occurs because they have a street value — because people cannot access these medications or because the services that offer them are not attractive to them. This is basic economics, and it has been proven throughout history. Increased access through appropriate services will reduce diversion!

The most concerning aspect of Dr. Menzies argument is his promotion of naltrexone in lieu of OST. Naltrexone has been available since 1984 in the oral form for treating opioid dependence and XR-NTX, the extended release injectable version, since 2010. Naltrexone is an opioid antagonist. In other words it has affinity with the opioid receptor but has no intrinsic value and therefore no efficacy. Theoretically this blockage causes the dissipation of Pavlovian learning over time. But for this to occur, the naltrexone needs to be taken over time, and retention and compliance are listed as a major problem in all the studies. The 28-day injection (XR-NTX) was developed, and this has improved compliance, but in many studies patients do not complete the course — in a phase four trial only 36% of participants completed the treatment. Dr. Menzies and his organisation, Assisted Recovery Centers of America (ARCA), also describe naltrexone as an anti-craving medication on their website. But what does the data say?

A Cochrane and other reviews have shown that naltrexone performs no better than placebo in reducing heroin use. Craving has only been shown to be reduced with the XR-NTX formulation, but studies suggest this is linked to period of abstinence independent of the drug. Further, due to the antagonist nature and subsequent upregulation of opioid receptors, once naltrexone is stopped it significantly increases the risk of overdose. Some studies have suggested that this risk can be 7 times higher than with methadone.

Further, the studies that were used to secure FDA approval for XR-NTX in the treatment of heroin use disorders were done in Russia, where OST is outlawed. It is a basic principle of clinical trial ethics that if there is an existing treatment option, placebo controlled trials are not ethical. There have been no head-to-head trials in the US for naltrexone vs. OST. A Malaysian trial ended prematurely because the difference between buprenorphine and naltrexone was so great that it would not have been ethical to continue!

Dr. Menzies is suggesting that we use a medication that has: not been through head-to-head clinical trials with a known effective treatment (OST); that performs no better than placebo unless autonomy is taken away and it is given in a 28-day formulation; and that has been shown to significantly increase the risk of mortality on termination. He further suggests that it may be especially useful for “patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.” This despite the recommendations of the World Health Organisation and the UK National Institute for Health and Care Excellence (NICE) guidelines recommending that only employed, fully informed, short-term users who want total abstinence and are well informed of the consequences of naltrexone would benefit. Studies looking at retention and efficacy have shown that people who are homeless, injectors, or have co-occurring disorders are not suited to naltrexone. At US$1000 a shot, I wonder how long the “not well-to-do” will be compliant.

In the interests of autonomy, disclosure and choice, naltrexone should be on the menu, as Dr. Menzies suggests. But based on the evidence, Dr. Menzies’ post promoting naltrexone as the most promising response to the heroin epidemic appears to be less of a reasoned argument and more of a biased stance that capitalises on the fear and stigma so many have towards opioids and those who use them.

For a more complete argument against the use of naltrexone, complete with references, please see my piece in The Influence.

…by Percy Menzies…

I met Percy, a treatment provider and policy person, in Minnesota about six months ago. We have had some spirited discussions since then. In his view, the culprit in the opiate crisis is access — drug availability — a position that’s put him in direct opposition to Johann Hari and others who favour decriminalization/legalization. He is also a champion of naltrexone…an evidence-based treatment we don’t hear much about. Here’s what he’s got to say:

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Access to drugs is by far the strongest factor contributing to the spread of addiction. The unprecedented quantity of heroin being produced by Afghanistan, Burma and Mexico is causing a sharp increase in heroin addiction and deaths in bordering countries including the US. Addiction rates are rising in Europe, Asia, Africa and many other countries. The access is almost certain to grow as more opium poppies are grown in these countries. The heroin problem in the US is compounded by the huge increase in the use of prescription opioids to treat chronic pain. Indeed, the US consumes in excess of 80% of the world’s legal opioids! We have not seen a problem this big since the days when morphine was an unregulated drug and used indiscriminately.

How do we grapple with this growing problem? A little history before we attempt to answer the question. The treatment of opioid addiction is overwhelmingly dominated by opioid substitution treatment (OST) based on a hypothesis that opioid use causes permanent changes to the opiate receptors necessitating prolonged opioid use as a form of harm reduction. Using an opioid to treat an opioid addiction is tricky and works best when access is controlled. It started when President Nixon in the 1970’s reversed the long-standing policy against maintenance treatment with opioids and authorized the opening of methadone clinics. Heroin addicted patients were required to go to the clinic each morning to ingest a carefully controlled dose. This highly restrictive and controversial program was planned as a temporary measure and served a dual purpose. It protected society from the criminal activity of drug addicts and at the same time provided heroin addicts treatment.

If opiate substitution treatment is the only way to go, could we develop or look at existing opioids that could be administered in a less restrictive environment? Buprenorphine, a powerful, but safer opioid, developed in the 1970’s as an injectable drug for the treatment of acute pain, emerged as the best candidate. The oral formulation as a sublingual tablet was found to be highly effective in curbing the cravings for opioids. Although abuse was an ongoing problem, buprenorphine emerged as a safe, effective medication that could be prescribed by a physician. Researchers believed that adding the opioid antagonist naloxone (better known by the trade name Narcan) would deter patients from injecting the sublingual tablet.

The introduction of buprenorphine in 2002, better known by the trade names Subutex and Suboxone took a rather convoluted path. The approval occurred when the nation was in the throes of a man-made epidemic of prescription opioid use. To prevent buprenorphine turning into “pill mills,” physicians were required to obtain a DEA-waiver and there were limits on how many patients could be treated at any one time – 30 the first year and 100 thereafter. Too few physicians bothered to get the exemptions, and although the sales of buprenorphine soared to in excess of $2 billion per year, we have not seen a drop in reduction of heroin use or overdoses. Why? Too few physicians with the required exemption and too few treatment slots for buprenorphine, the experts told us. After much debate and lobbying, the compromise is to increase the access by allowing physicians to treat up to 200 patients at a time.

We are facing an unprecedented epidemic. Why not remove all restrictions on the use of methadone and buprenorphine and throw open the floodgates for OST? Why not treat addictions as we have treated chronic pain in the past? Will this solve the problem? Not by any stretch of the imagination. It will only exacerbate the existing problem as the pool of opioids will greatly increase along with abuse and diversion. We have to offer patients treatment options including non-opioids.

Marc Lewis in his very thoughtful post on visiting a harm reduction facility in Belgium observed: “Methadone provides a solution to heroin epidemic, but not a great solution. Something is still seriously wrong here, and this form of treatment, connection and care can make it livable. But only just.” Marc’s observation that many patients in the clinic he visited balanced their methadone dose with heroin obtained on the street also applies to buprenorphine. As long as there is access to heroin, treatment options centered on buprenorphine or any other opioid are going to be problematic.

My clinics have treated thousands of patients addicted to prescription opioids and heroin by offering them clear treatment options. We refer them to methadone clinics when appropriate; offer buprenorphine as a detox and maintenance medication when necessary; and when they want to be completely abstinent from all opioids, we start them on naltrexone. A monthly injection of naltrexone (called Vivitrol) is a highly favorable alternative to continuous opioid addiction, especially when street drugs are mixed with OST. Our patients can always go back on buprenorphine or methadone if they change their minds. For many patients it is refreshing to know that they don’t have an incurable disease, and a spectrum of treatments options gives them a fighting chance to feel empowered and to quit using drugs. Even if only 15-20% of patients are likely to benefit from naltrexone/Vivitrol, is it not ethical to offer it as a treatment option? Especially for patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.

Access is the major culprit in the spread of addiction and a major contributor to relapse. Increasing access to opioids as part of treatment may help some people, but it is only going to worsen the big picture.

Percy Menzies holds a Master’s degree in pharmacy from India and is the president of Assisted Recovery Centers of America, a clinic based in St Louis, Missouri, that treats in excess of 400 heroin addicts a month through evidence-based treatments.