Running head: PROGRESS, NOT PERFECTION 1

Progress, Not Perfection: The Effects of Different Forms of Opioid Addiction Rehabilitation

Kelsey A. Hurt

First Colonial High School Legal Studies Academy

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Abstract

This paper discusses the drugs that led to the opioid epidemic, as well as the treatments that help

opioid users to be rid of their addiction. The author begins by introducing the main types of

opioids and how they affect the body and brain. Several types of traditional treatments will be

discussed, as well as types of non-traditional treatments. The author also discusses what the state

of Virginia as well as the United States are doing about the issue. Finally, the author writes about

relapse and why it is so difficult to get rid of an opioid addiction for good.
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Progress, Not Perfection: The Effects of Different Forms of Opioid Addiction Rehabilitation

The United States is currently going through an opioid addiction and overdose epidemic.

Opioid addiction encompasses the dependence on opiates and synthetic opioids. Opiates are

naturally occurring opioids derived from the opium poppy, while synthetic opioids are opiates

that have been chemically altered. Opioid addiction is commonly referred to as opioid use

disorder. Because the use of opioids is so highly stimulating to the reward and pleasure centers

of the brain, beating the addiction is incredibly difficult (Kosten & George, 2002).

When opioids were first prescribed, medical professionals truly believed they were

non-addictive, so they proceeded to prescribe them frequently. As with many prescription

medications, people began to misuses the drug; medical professionals as well as the public

quickly realized that opioids are, in fact, addictive. According to the United States Department of

Health and Human Services, 80% of heroin users abused prescription opioids before using

heroin, and over 130 people die everyday from some sort of opioid overdose (U.S. Department

of Health and Human Services, n.d.). The opioid epidemic affects every person in the United

States, either directly or indirectly, and the United States as a whole is responsible for getting

individuals the treatment they need.

Types of Opioids

Heroin

Heroin is an opioid that comes in the form of powder or a tar-like substance and is made

from morphine. The drug can be injected several ways, depending on the form it is being used in

(Sunrise House, n.d.). In some instances, people mix heroin with crack cocaine, and this is called

speedballing. Heroin goes directly into the brain and causes a sense of euphoria, and this is why
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it is both so dangerous and so addictive. The section of the brain that it influences affects

common bodily functions like heart rate and breathing, as well as different mental functions

(Dowshen, 2015). The long term effects of using heroin are very dangerous, some including

heart and lung complications. Heroin is highly addictive, and people often turn to heroin use

after having another type of opioid addiction (Mayo Clinic, 2016). The withdrawal symptoms are

often the hardest part of rehabilitation, and they include sharp pain and intense cravings

(Melemis, 2018). Heroin overdose is often times fatal (National Institute on Drug Abuse, 2018).

Fentanyl

Fentanyl is an opioid similar to morphine; however, it is almost 100 times more potent.

The drug can be prescribed medically or sold illegally; according to U.S. Code § 841(a), unless

someone is legally authorized to give someone prescription drugs, it is illegal to give another

person prescription drugs (Criminal Defense Lawyer, n.d.). When sold illegally, like heroin, it

comes in several different forms; the most common form is powder or tablets. Often times, the

tablet form is intended to mimic another opioid, making an accidental overdose very possible. In

addition, fentanyl can replace heroin or be combined with it (National Institute on Drug Abuse,

2018).

Like heroin, fentanyl goes directly to the brain, and affects areas of the brain responsible

for common bodily functions like emotions and pain. Fentanyl has many effects on the body,

some of the worst being nausea, depression, and even death (Healthline, n.d.). The two main

factors that make fentanyl so dangerous are the potency and its resemblance of heroin and other

opioids (Tate, 2018). The potency makes the risk of an overdose higher than that of heroin.

Because it resembles heroin and other opioids so closely, people are unaware that they are, in
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fact, consuming fentanyl. When someone thinks they are taking their “normal” dose, they could

actually be intaking much higher chemical levels than their body can handle (National Institute

on Drug Abuse, 2018).

Prescription Pain Relievers

Prescription pain relievers are often in the form of opioids, and they are prescribed by

medical professionals to patients in attempt to reduce the intensity of how the brain perceives

pain. That being said, prescription pain-relieving opioids go straight to the brain. Some of the

most widely used prescription pain-relieving opioids include hydrocodone, oxycodone, and

codeine (American Addiction Centers, 2018). Some of the more intense side effects that come

with using prescription pain-relieving opioids include nausea and respiratory depression (Mayo

Clinic, 2018). However, users also report feeling a sense of euphoria after use (National Institute

on Drug Abuse, 2018).

Types of Traditional Treatments

Many people begin treatment with detoxification (CRC Health, n.d.). Detoxification

involves clearing the body of opioids, or any drug for that matter. The process is often extremely

mentally taxing and physically painful. Because of this, some people pair detoxification with

medicine to help cope with the pain (Goodman, n.d.). Detoxification should not be confused with

treatment, as it only addresses the physical side of opioid addiction (National Institute on Drug

Abuse, 2018).

Naloxone or Naltrexone Therapy

Naltrexone is a once monthly injection form of Naloxone. Naloxone and Naltrexone are

opioid antagonists, meaning they bind to the receptors in the brain where opioids do damage and
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block the activity of the drug ​(The National Alliance of Advocates for Buprenorphine Treatment,

n.d.)​. Naloxone and Naltrexone are very attractive, and they bind to the receptors so strongly that

they remove the opioid and block it from re-binding (Bloom, 2018). This is why Naloxone works

in an overdose (Harm Reduction Coalition, n.d.). If an addict tries to use heroin, fentanyl, or

prescription pain relievers, they will not work if Naltrexone is in his or her system (Tate, 2018).

Naloxone or Naltrexone Therapy are only successful in very motivated individuals who have a

lot to lose if they continue to use or work in sectors where other Medically Assisted Treatment

modalities are not acceptable, such as pilots or physicians (National Institute on Drug Abuse,

2018).

Methadone

Methadone, at its core, is really just a substitution of one opioid for another in a

controlled, safe, and monitored environment. Methadone is a long-acting opioid agonist. Because

of its long duration of action, it doesn’t produce the same high and euphoria as heroin,

oxycodone, fentanyl, etc. The goal is to give it at a dose that keeps the patient from feeling

withdrawal and craving, but still allows them to function, hold a job, etc (Ambardekar, 2017).

The danger of the drug is that Methadone can be abused. For example, it can be crushed

and injected. It doesn’t relieve the patient of their addiction, but refocuses their addiction on

something less destructive (National Institute on Drug Abuse, 2018). Methadone maintenance

therapy can be quite effective. It decreases homelessness and joblessness among users, as well as

decreases the spread of HIV and Hepatitis C (Ambardekar, 2017).

Buprenorphine
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Buprenorphine is commonly known as Suboxone. It binds the same receptors as other

opioid and has some opioid properties; however, it produces about half the effect of other

opioids. Buprenorphine is an opioid agonist-antagonist, as it binds the opioid receptors very

strongly and out-competes the pure opioids. This provides some safety if a person with opioid

use disorder tries to use heroin, fentanyl, or prescription pain relievers while on buprenorphine

(National Institute on Drug Abuse, 2018). Also, buprenorphine does not have the same risk of

respiratory depression that come with other drugs. People don’t seem to stop breathing when

they misuse the buprenorphine, which is what kills almost all people who overdose ​(The

National Alliance of Advocates for Buprenorphine Treatment, n.d.)​.

Suboxone is a formulation buprenorphine that contains a small amount of naloxone.

Naloxone has no, or very little, activity when taken orally. However, if the patient tries to melt

the suboxone and inject it to get high, the naloxone is active and prevents the user from feeling

any rush, making it less likely to be used inappropriately. Buprenorphine has less abuse potential

than methadone, but there have been cases of illicit use now that it is being used more frequently

(The National Alliance of Advocates for Buprenorphine Treatment, n.d.)​.

Narcotics Anonymous

Almost all addicts have done better when prescribed drugs are combined with

psychological and social counseling. Narcotics Anonymous is one of the biggest support groups

in the nation. It was inspired by the success of Alcoholics Anonymous. Anyone is able to join a

group, meaning it is accessible to anyone who believes they need it (Addiction Center, 2018).

Narcotics Anonymous has two meeting styles, including discussion meetings or speaker

meetings (National Institute on Drug Abuse, 2018). Discussion meetings model a group
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discussion, while speaker meetings typically only have one speaker sharing. While sharing is

encouraged, it is not enforced. In addition, addicts are encouraged to rely on a higher power to go

through recovery with. A higher power can be anything the addict wants it to be; many people

say theirs is God (Addiction Center, 2018).

Types of Non-Traditional Treatments

Equine Assisted Psychotherapy

Equine Assisted Psychotherapy has proven effective in addicts, especially youth and

adolescent addicts. Addiction affects more than just the body, and in adolescents especially, has

major effects on emotional health (National Institute on Drug Abuse, n.d.).

Equine Assisted Psychotherapy focuses heavily on social development, as many

adolescents who struggle with drug addiction also struggle with self confidence

(Bennington-Castro, 2014). In addition to social development, Equine Assisted Psychotherapy

teaches responsibility. Therapists often allow the client to take care of the basic needs of horses,

including grooming and feeding. Taking care of something bigger than themself is often both

calming and rewarding for clients (Filippides, 2016).

Because it is often difficult for adolescents to bond with a therapist, due to either distrust

or defiance, the presence of the horse allows them to connect with the animal in the presence of

the therapist (Filippides, 2016). According to the theories of Ivan Pavlov, a physiologist and

psychologist widely known for his work in classical conditioning, when the good thoughts are

associated with the horse, they will also be associated with the therapist (The Nobel Prize, n.d.).

This allows for a connection with both the animal and the person.
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While Equine Assisted Psychotherapy has been very successful in alleviating the social

effects of opioid addiction, it does not address the physical needs of patients (Foundations

Recovery Network, n.d.). Because of this, it is often paired with some type of medication

(Filippides, 2016). According to an Eagala study in 2013, children/youth ages 10-18 benefited

most among each age group from Equine Assisted Psychotherapy (Eagala, n.d.). This set of data

implies that Equine Assisted Psychotherapy may not work well for younger children, but mostly

middle and high school students.

Eye Movement Desensitization and Reprocessing

Eye Movement Desensitization and Reprocessing is typically used for addicts who

started using opioids due to trauma or emotional issues. The process encourages drug addicts to

first focus on why they began using drugs (the past), what is causing them to continue to use

drugs (the present), and how they can get out of the situation (the future) (EMDR Institute Inc.,

n.d.).

Eye Movement Desensitization consists of eight phases per meeting. The beginning

phases focus on familiarizing the therapist with the client’s current situation, as well as

addressing the stressors that contribute to the situation. The middle phases are when the actual

visualizing takes place; the patient focuses on the image, and identifies how it makes them feel

both emotionally and physically. The therapist’s job is to assist the patient in creating goals. In

the final phases, the client is encouraged to create a log of anything they think might be relevant

to the next meeting (EMDR Institute Inc., n.d.).

Eye Movement Desensitization and Reprocessing cannot be successful in just one

meeting. The patient must be committed for several months for the treatment to be successful.
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While Eye Movement Desensitization and Reprocessing helps to calm the patient over issues

that caused them to start using drugs in the first place, it does not address the actual addiction;

for that reason, Eye Movement Desensitization Reprocessing is often paired with a form of

medication (EMDR Institute Inc., n.d.).

Adventure and Wilderness Therapy

Adventure therapy is a method of combining healing exercises with outdoor activities.

Each activity is guided by a therapist, and the activities can take place individually or with a

group. One of the most popular methods of wilderness therapy is therapeutic camps. Therapeutic

camps date back to the 1800s, and have been used ever since. The point is to get away from their

everyday life and focus on the nature around them. This is important for addicts, as many of

them lead very stressful lifestyles (Learn Through Experience, n.d.)

Much like therapeutic camps, adventure therapy is meant to take the patient out of their

comfort zone and bring them somewhere outside of their normal life. Adventure therapy pushes

the patient to learn more about both their environment and themself. Leadership is one of the

main skills people take away from adventure therapy. There are many different kinds of

adventure therapy because different patients have different fears or interests. Some of the most

popular methods include rock climbing and ropes courses (Learn Through Experience, n.d.).

Art and Music Therapy

Art therapy has a heavy emphasis on self expression, and is popular throughout each age

group. The therapy is guided by a therapist, and it usually takes place one on one. One of the

main goals of art therapy is simply relaxation. There are three different types of art therapy,

including self-expressive art, art studio, and legacy projects. Self-expressive art and art studio are
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the more popular types, as they predominantly focus on how the patient is feeling in the moment.

Legacy projects, however, focus on memories. The style of art therapy that the patient chooses

really just depends on their background and the details of their addiction (Hope Healthcare, n.d.).

Like art therapy, music therapy focuses on relaxation. Patients, accompanied by a

therapist, listen to music, and oftentimes are encouraged to create their own. Many patients enjoy

writing songs and performing them to the therapist. Music has many physical effects on the brain

and releases endorphins when people hear music they enjoy. This is what causes the positive

symptoms like relaxation and contentedness. While the meetings with the therapist are critically

important to improving, patients are encouraged to listen and create music outside of therapy

sessions as well (Hope Healthcare, n.d.).

Virginia Efforts

The state of Virginia has taken several approaches to address opioid addiction in the

commonwealth. According to Tina Pullen, the Public Affairs Officer for the Norfolk Field

Office of the Federal Bureau of Investigation, Virginia is a leader in addressing the opioid

epidemic. From the Governor of Virginia, who is a pediatrician, to the Virginia Attorney General

and the United States Attorney, there is a strong sense of urgency at every level of government to

address the crisis T. Pullen, personal communication, November 2, 2018).

This is exemplified, for example, by Virginia’s initiative to spearhead statewide change

in education curriculum both at the K-12 level and in higher education. More emphasis has been

placed on education about opioids and the hazards associated with its use as opposed to focusing

on the traditional DARE program. Additionally, there has been an improved response capability

by the law enforcement and first responders community. Naloxone is more readily available and
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coordination in investigations and the responsibilities of the first person to respond to a scene

involving opioids are being handled in an unprecedented way. Also, the medical community in

Virginia has changed the way they treat pain and has led efforts to incorporate comprehensive

opioid education and training for medical and nursing students. Furthermore, the outreach groups

have engaged the faith-based community and initiated social media efforts to crowdsource

awareness and information sharing (T. Pullen, personal communication, November 2, 2018).

In the Coastal Plain region of Virginia, the Virginia Attorney General and the United

States Attorney for the Eastern District of Virginia teamed up in 2016 to form the Hampton

Roads Opioid Working Group. The Hampton Roads Opioid Working Group is a

community-based group of action oriented members who are dedicated to reducing the number

of opioid related deaths by addressing the demand side of the threat through community

awareness, medical community innovation and leadership, and through the support of service

based organizations and treatment facilities. The group is made up of members of the law

enforcement community, educators, medical professionals, peer recovery specialists, and

outreach coordinators. Since September 2016, it has met regularly to address all angles of the

epidemic (T. Pullen, personal communication, November 2, 2018).

Because of all of these changes, Virginia was able to report that opioid related deaths in

Hampton Roads went down 17% in 2017 (T. Pullen, personal communication, November 2,

2018).

United States Efforts

Drug Addiction Treatment Act of 2000

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The Drug Addiction Treatment Act of 2000 is the act that allowed certified doctors to

prescribe illegal drugs to opioid-dependent patients in order to combat addiction. This was a

major act because it popularized the prescription of Buprenorphine, and 18 years later, it is still a

top choice for physicians. Buprenorphine is so effective because it has a very low abuse rate due

to the presence of Naloxone within it (The National Alliance of Advocates for Buprenorphine

Treatment, n.d.). According to a study done by the United States Department of Health and

Human Sciences, Buprenorphine saw an 80% success rate in reducing opioid use (Substance

Abuse and Mental Health Administration, 2018).

The Support for Patients and Communities Act of 2018

In October 2018, President Donald Trump signed the Substance Use-Disorder Prevention

that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of

2018. The act mainly focuses on hospitals and state health programs, and its goal is to make

treatment more accessible throughout the United States. This legislation aims to encourage

hospitals to be more conservative when prescribing opioids for pain-relief by increasing the

number of prescription drug monitoring programs (PDMPs). In addition, the new law will

encourage identifying substance abuse by allowing doctors to look for symptoms at regular

wellness checkups. Hospitals have been encouraged to view the act in its entirety on order to

reach its full potential (The SUPPORT, 2018).

Federal Bureau of Investigation

In addition to outreach and education programs, the Federal Bureau of Investigation

addresses the supply of opioids by targeting the violent crime organizations that distribute

dangerous narcotics in the community. It is widely acknowledged in law enforcement that

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putting people in jail is not the only solution to the opioid epidemic. Because the epidemic is

rooted in drug abuse and addiction, the demand for the drugs needs to be addressed. They use a

task force model, which leverages the strengths of each of the local, state, and federal law

enforcement partners who work as a team to investigate violent street gangs and drug related

violence. These large FBI sponsored task forces can indict and prosecute using federal and state

laws. Their mission is different than the Drug Enforcement Administration in that they target

groups based on their level of violence, which is measured by the number murders, assaults, use

of weapons, etc. during a drug deal, not simply the distribution. That being said, violence and

distribution often go hand in hand, so the Bureau routinely partners with the Drug Enforcement

Administration (T. Pullen, personal communication, November 2, 2018).

The Federal Bureau of Investigation has used their national platform to shed light on the

dangers of opioid abuse through awareness initiatives such as their video ​Chasing the Dragon:

Life of an Opiate Addict ​(U.S. Department of Justice, n.d.)​.

Relapse

Addiction is so complex, and opioid addiction, especially, is really hard to get rid of for

good. Many people describe addicts as “once and addict, always an addict.” The initial use of

opioids causes a rush, a euphoria, and feeling of wellbeing that is very stimulating the the reward

and pleasure center in the brain, causing a physiological addiction. It is very powerful, and

begins to change the brain’s neurochemistry from the first use. Over time, that rush and euphoria

starts to fade. Users are always trying to recapture their first high, which is why they are

constantly increasing their dosage (American Addiction Centers, 2018).

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The danger comes when the brain realizes that its normal function is being blunted by the

drug, because it increases a number of receptors to include those that sense pain and those that

give you energy and motivation. The longer the drug is used, the more these receptors are

increased. At this point, the addict is in a situation where they depend on the drug to feel healthy.

When they don’t use opioids, those increased receptors are still active; the increased pain

receptors make the addict feel pain; the increased energy and motivation receptors make the

addict feel agitated, antsy, and shaky. Those biochemical changes take a long time to fully

recover, if ever (National Institute on Drug Abuse, 2015).

There is also a psychological component, which can be just as harmful for some addicts.

The things that led them to use opioids in the first place can remain such strong triggers for

relapse, such as friends, locations, romantic partners, other psychological diseases or disorders,

past trauma, stress, homelessness, joblessness; the list goes on. These can be reminders of why

they started in the first place, and make the addict feel the need to go back to the perceived safety

or comfort that the drug provided them (Psychology Today, n.d.).

Conclusion

The United States needs to break the stigma that surrounds addiction, particularly opioid

addiction. It affects all walks of life, no matter what race, religion, color, creed, sexual

orientation, or age. Some start use on the street, but the majority start using from legitimate

prescriptions, out of curiosity, or a desire to party. Suddenly, they are hooked and can’t stop.

Nobody starts with the desire to completely destroy their lives. These people have a disease, and

society needs to treat them the way society would treat somebody with any other disease such as

cancer or diabetes; people need to treat them with support and focused care.
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As a country, the United States needs to eliminate the supply of illicit drugs that are

entering the market. Similarly, hospitals and doctors need to be smarter and safer in their

prescribing of these drugs. Small amounts of the least potent opioid should be used for the

shortest time possible and only when absolutely needed. The United States needs to work on

developing better pain medications that are not opioids and that have little to no risk of

dependence.

The things needed to make treatment more accessible include money, training, education,

advertising, and access. The United States should focus on educating providers of treatment,

people with substance use disorder, and the general public. More advertising is needed because

treatment is useless if the user doesn’t know where to access it. Access loops back to money, as

well as geography. Posh treatment centers in exotic places don’t really do much good for people

who will never be able to get there. When, and only when, the United States takes responsibility

for the opioid epidemic, things will begin to get better.

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