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What Science Says to Do If Your Loved One Has an Opioid Addiction (fivethirtyeight.com)
183 points by anythingnonidin 5 months ago | hide | past | web | favorite | 289 comments

OP here.

An interesting takeaway I had was the importance of community. Does anyone know any non-profits or startups working to increase people's sense of community at a mass scale? It seems this is missing from large parts of the western world and has many consequences.

> any non-profits ... working to increase people's sense of community at a mass scale

You're describing most religions that I'm aware of. Say what you will about their beliefs, but most of them (definitely not all) work hard to have an inclusive and supportive community.

> work hard to have an inclusive and supportive community.

With the condition that you abide by the rules. It's the assurance that everyone adheres to more-or-less the same values that glues the community together.

Also, if I may venture slightly off-topic, the modern western definition of "inclusive" seems to imply "without requiring people to adhere to anything", which is the opposite of what you need to build a community.

No shared set of values ("do whatever you want" does not really count as a value) means less trust and more suspicion.

Simplest example: group A values sexual restraint and have a philosophical framework that justifies why this value is necessary for the preservation of society, group B values sexual freedom and is dismissive of the philosophical framework of group A.

Members of group A will be extremely weary of members of group B, and will be concerned about how they might start influencing their children, for example. So they will avoid them. Vice versa, members of group B will be suspicious of group A members, because when you see people being suspicious and avoidant towards you, you tend to become suspicious of them as well.

> With the condition that you abide by the rules.

The rules are generally in place to protect the community from sociopaths and serve as the communities immune system.

What!? Religious rules are not "to protect the community from sociopaths." For example, eating pork is not sociopathic behavior and yet a large part of the world's religions forbid pork eating.

People who have problems with the religious community usually are for their arbitrary rules rather than they'd much rather be sociopaths.

(I'd make the argument they aren't particularly good about keeping sociopaths out anyways but that's another topic)

The parent commenter probably read this book: https://www.gitbook.com/book/hintjens/psychopathcode/details

I read it to. The thesis is basically that - societal norms are designed to make it easy for normal people to notice psychopaths and avoid them. The book is pretty convincing, I'd give it a look. I didn't notice too many numbers or studies quoted in it, though.

Presented without evidence though, parent commenter's statement may be hard to believe.

In a way, I buy that. However, the problem with many religious / community "rules of order" is that they too often are based more on tribal patterns and/or irrational logic instead of evidence.

Not only has that sometimes caused harm to harmless people "not in the tribe", but sometimes legitimate sociopaths have actually exploited "the rules and norms" to their end. (A particularly notorious example of the later that I can think of is Ted Bundy.)

Agreed with the idea that religion does foster a sense of community. If you can get that without the nasty tribalism side effects you sometimes see from it, it would work.

One aspect of a rule is that it serves as a test to highlight those who can't/won't follow it (a psychopath). But that's not the only function...

Very true, yeah.

By making adherence to arbitrary rules a pain in the ass, they discourage people with insincere motivations from hanging out with them. Only a very dedicated sociopath would follow all those rules just to fit in and earn their trust.

This isn't failproof of course. Sociopathic cult leaders are very dedicated.

Does group B have any sense of community? Offline, not Online.

Yes, there are strong, tight-knit, and supportive LGBT communities in several major cities, sometimes defining semi-public spaces like bars/clubs and even entire neighborhoods like the Castro (historically). Similarly around certain activist and (performing) arts groups on college campuses, where people who are a small minority in the general population (in a way that many consider inferior or immoral) make up an overwhelming majority of the membership of some student groups.

There aren't instituting "reverse" sexual morality either - straight people will be found among their membership rosters and friend groups - but they do create spaces that are particularly welcoming to non-straight people, and have large concentrations of them.

Depends. If they have their own set of values and rules (no matter how arbitrary) that don't include sexual restrictions, they might end up having their own sense of community.

If their lack of sexual rules is part of a bigger 'no rules or values needed' system, then I would really doubt that they can develop a pepper sense of community.

> non-profits or startups working to increase people's sense of community

This is non-profit territory, absolutely not startup territory. You can only build a classic VC-funded startup by promising that eventually you're going to extract value (usually monopoly profits!) from the community.

"Sense of community" is one of those things that's traditionally ranked well below profits and been destroyed in the search for profit.

Cynically: 'sense of community' gets destroyed in the search for profit when you're profiting from something else. If you're getting your profits from the community, you'll build it up just fine. Not necessarily in a healthy way, but at least in a persistent one.

Hell, I think you could convincingly argue that opening a new pub counts as founding a startup aimed at increasing people's sense of community. It doesn't have the unlimited scale of a tech startup, but it is a company that profits from offering a 'third place'. For that matter, plenty of churches have been run more like businesses than non-profits while still creating strong communities.

As long as the sense of community is profitable, it might do well with startups. That just hasn't been a common state of affairs lately.

A pub is a small business. A startup is distinct from a small business in that it seeks outsized returns through economies of scale, efficiency, etc. The funding model and the set of behaviors which are adaptive for founding or working in these kinds of businesses don't have much in common.

Much of the loss of community in America is small businesses getting destroyed in the market by successful startups (i.e. large corporations).

It reminds me of things Mother Teresa (who was at times a horrendous person, her Nobel acceptance speech is pretty disturbing and cruel) said about American/western society. She remarked that although a person in India might be radically more poor, even if they were starving in the street, they knew people would reach out to them and cared for them. In America, no matter how rich you are, you feel far more alone than that.

> (who was at times a horrendous person, her Nobel acceptance speech is pretty disturbing and cruel)

Wait what? Because she brought up abortion? https://www.nobelprize.org/nobel_prizes/peace/laureates/1979...

I don't know about the speech particularly, but I think Catholic notions about poverty and suffering bringing people closer to Christ rub some people the wrong way. At least that seems to be a lot of the motivation behind "Mother Teresa was awful" stuff I see.

Mother Teresa didn't know much about America.

She failed to realize that money might not buy happiness but it sure buys the kind of misery we all like.

I don't think I've ever seen someone starving in the street in the US. I totally disagree with the sentiment that Americans wouldn't help each other. There is a lack of community here and that would be a nice problem to solve, but we aren't heartless.

I've seen a couple of documentaries where KKK members were interviewed and the sense of purpose and community seemed to be the main thing they were all getting out of it.

I'm not saying the KKK is a good community group, but I will say there are a lot of people with less community than they offer.

Same things with gangs, if you read auto-biographies, this is a recurring theme.

It was Inside The KKK.


I don't think I've seen anything quite so darkly comic as their fire safety class before their cross burning ceremony, as their artificial-fiber robes are highly flammable.

Extremely interesting. Don't suppose you have a link?

Even better, visit voat.co and read for a few weeks. The white nationalists are all about family, community, and a collective. Well, a specifically white collective. It's very important to them and a frequent topic.

Of course, this means reading their posts which is not for the faint of heart. It's like most of them are missing something and are trying to find something to belong to. In a way, I feel more sorrow than anger towards them.

See my response to nothingnonidin.



Uh, well, maybe not a popular answer here, but that is one thing churches are really good at.

With churches, there are a few problems that are intellectually repellent, meaning they won't solve for certain personality types.


  1. artificial social heirarchy
  2. magical thinking
  3. group think
  4. rules without reason
Part of religion is often about imposing order on the irrational aspects of experience and reality, but there's a lot of centuries-old cruft and inertia behind the ones that exist.

When you take apart any given religion, and inspect individual parts, and place those parts within the context of a small, insular village, dispossessed of plumbing, medicine or indoor heating, any single part starts to make sense. But many are far, far away from that, and need not invest in superstition.

Morality is great, but in some cases morality without purpose translates to overbearing fear imposed with motive.

Mythology and folklore are good for illustrating practical principles and relationships between ideas, but some people refuse to consider whether the ant and the grasshopper never actually happened.

All this taken together, often tips the scales toward cognitive dissonance for some who think too deeply about bald facts. I don't have a solution to fix this, but I've seen what happens when smart people try to reimagine a modern religion that might fit current scenarios, and it's usually equally terrible.

Someone will eventually figure this modern community rationale problem out, but it's not something you can just fake or make up for its own sake. It's something that needs to (seem to) happen organically, on its own, and remain authentic. Sounds pretty difficult if you ask me.

> With churches, there are a few problems that are intellectually repellent, meaning they won't solve for certain personality types.

Unitarian Universalist churches are good for community and avoid most of these negatives in my experience.

Yeah, that seems to be a popular choice for lapsed religious people.

Yes, if you think the religion in question is ridiculous on its face and everyone who believes in it is an imbecile, obviously it's not going to work for you.

Shameless plug: I've been working on a service (www.campfire.care) to build peer support groups for any focus. Groups of 5-10 people with the same issue meet regularly via video and stay connected via chat. The idea is that we are fundamentally social creatures, and struggling with a challenge alone is unhealthy.

Campfire is not therapy or a replacement for therapy. But peer support can be powerful + inexpensive. And being part of a true peer group can provide a kind of value that professional mental health can't. You can't be friends with you therapist, and their job is not to truly empathize with you.

Would love any thoughts / feedback!

Did you consider appointing (renting out) a community lead for those groups? Maybe something along the lines of Über driver system? If a group has a natural leader - perfect. If not they can "rent" one to keep the momentum of the group going.

Yes - we've been trying a variety of different backgrounds for our "hosts."

The most exciting approach is to level up our members to lead groups with their challenge. They truly empathize and care about the group, which can make them more effective than a whole bunch of training. Plus, it reinforces that this is not a case where you are being treated for a mental health problem. This is a tight-knit community helping each other.


What's the main challenge for you as it relates to the product? i.e. are you limited on needing more customers / stronger product market fit, do you have insane product market fit and limited on hiring, etc?

Is this a for profit thing?

Thanks! Generally, I think the challenge for us is going to be the same as for many other consumer-ish mental health startups. The experience is really effective, but most people aren't looking for this specific approach to solve their problem. So building awareness is super valuable.

Our main goal is to help as many people as cost-effectively as we can. After thinking a lot about it, I think there's more evidence we can scale better as a for profit.

the cynical amongst us would respond that this need is being "filled" by FB and social media ... I for one hope that doesn't turn out to be true in the long term.

Using social media to fill the need of community is like using heroin to fill the need of happiness. It provides a pale facsimile of the real thing at a terrible price.

This need is actually being exacerbated by the likes of FB.

Facebook can definitely be a complement to real-life associations; I've used it to find some real-life events.

I see people claiming this all the time (or even that somehow Reddit is the new version of it), but it's just not right... it's not the same kind of community at all.

Your comment reminds me of this video: https://www.youtube.com/watch?v=ao8L-0nSYzg


> Consequently, do not try to use legal consequences as a way to help people you love, and if possible, bail them out if they get arrested for drug crimes. This doesn’t mean you shouldn’t hold them accountable, but do so in ways that are less likely to lead to lifelong problems. Meaningful employment is an important factor in recovery — and few things are more harmful to the chances of getting a good job than having a criminal record.

This is one area that's crying out for some kind of reform.

I've been thinking about similar things in the context of a basic income. If we were to just pass a law and guarantee a significant basic income I think it would have disastrous effects and fail miserably. A guaranteed income is a good goal, but before we do that we need to figure out how to replace meaningful employment with other meaningful activities. People need a purpose.

If we can alter our culture and separate a person's purpose from their employment, then we might be able to get to a Star Trek future. If I can get anything I want from a replicator in the wall, what are my incentives to still better myself and work towards something?

I think you are way over estimating the amount of meaningful work, as well as how many people with meaningful work would be on basic income. Most of the people on basic income would be people who were previously flipping burgers at McDonald's not directors as 80000 hours.

You have to think longer term. Eventually, there may be very few jobs done by people. Medicine, law, many fields of engineering, agriculture, and even film making and novel writing may be performed by machines at a level as good as or better than the best people.

But yeah, in the next decade it's burger flippers and delivery drivers.

To the extent those people have some sort of crisis it sounds more like anxiety over loss of status.

> I've been thinking about similar things in the context of a basic income. If we were to just pass a law and guarantee a significant basic income I think it would have disastrous effects and fail miserably. A guaranteed income is a good goal, but before we do that we need to figure out how to replace meaningful employment with other meaningful activities. People need a purpose.

I don't think so. I think people can find a purpose without us imposing one on them.

> If I can get anything I want from a replicator in the wall, what are my incentives to still better myself and work towards something?

Why do people get really good at chess when there is little extrinsic motivation in it? If some people just want to hang around, is that really a "problem" we need to address?

Does maintaining an opioid addiction count as a meaningful purpose? Who's to say it's not (as long as it doesn't harm anyone else)?

> I don't think so. I think people can find a purpose without us imposing one on them.

I didn't mean to say a purpose should be imposed. Today it kind of is. A purpose is often closely tied to a job and a job is pretty much required to survive.

I was trying to convey that we should look for more ways to help people find a purpose or whatever you want to call some activity that is meaningful and fulfilling to that individual and socially healthy.

> If some people just want to hang around, is that really a "problem" we need to address?

Maybe, maybe not. If they are hanging around because it's what they want to do and they are happy and healthy doing so, then I don't see a problem.

Well you said there shouldn't be a universal basic income because people wouldn't have a purpose without the job being imposed on them, which seems to take as its premise that people need to have some kind of purpose imposed on them. The big reason unemployed people feel purposeless is because we live in a society where everyone is supposed to have a job or else is a drain on society/shamefully failing to support their families/whatever else. In a world where there's no need to have a job to support yourself who's to say that's still the case? That's not to say there aren't other potential problems, but I'm not sure "purpose" is the real one.

> I'm not sure "purpose" is the real one

Purpose might not be the right word. I think people need meaningful lives.

Well, no, I think that's the right word to convey that. I don't see life as meaningful because of the amount of time I spent at my job really.

> reform. Agreed, drug problems need to be treated for what they ultimately are; issues of public health.

An addiction tries to replace a void in someone's life. Chances are big the environment of the addicted played a role in cerating the void.

That's not helpful at all. Yes, addiction is "filling" "something" "broken". Now what?

It is extremely helpful. It is very incovenient, to be sure, but it is very helpful. If you want people to not use drugs, then you have to provide them with a fulfilling life or the opportunity for such. If your desire is to operate a society that grinds people down, restricts them in ways that feel burdensome to them, insults them, and also does not have people using drugs? You might as well wish to fly. Because your wish is as realistic, and as worthy of ridicule.

It comes down to whether you want to stop people using drugs because you don't like that they get happy so easy, or whether you want people to stop using drugs of their own accord and have happy lives. If it's the second - help.

This is not true in the general sense. If I take a pill that my doctor prescribes, I run the risk of becoming addicted.

Now you put it on me and my happiness? Not helpful either.

Never mind people who get addicted after being prescribed medication for an injury, then? Never mind that the new generations of opioids were marketed as safer/less addicting when they probably were more addicting, and thus prescribed even more out of perception of their safety?

Althogh this has certainly become the narrative of late, TFA seems to discount this fairly strongly;

"To that point, pain treatment is not the most significant risk factor for addiction. Far greater risk comes from simply being young and from using alcohol and other recreational drugs heavily. Ninety percent of all drug addictions start in the teens — and 75 percent of prescription opioid misuse begins when (mainly young) people get pills from friends, family or dealers — not doctors. Opioids are rarely the first drug people misuse."

And whether or not it is the most, least, or somewhere in the middle, risk factor, makes no difference in treatment. The article is about effective treatment for that addict and TFA suggests medication. It does not suggest addressing addiction issues, except as mean to getting the addict into actual treatment.

Filling voids and seeking happiness aren't mentioned in TFA.

There's a difference between "is not the most significant factor" and "is not a factor at all". The latter is what's being implied by the comment chain I responded in.

I don't know that we can say that teenage substance abuse in parties is a symptom of some "void" either.

You focus on the actual problem rather than the previous false causes of addiction. In the past, we've blamed the addict's moral character and will power and, more recently, we've tried to look at addiction through a purely physiological lens where we believed we only needed to break the dependence. Guess what happened...most people relapsed or fell into some other self-destructive behavior. Human beings are just not able to live in a mostly-detached state.

Our improved understanding recognizes the need for human-to-human connection. We're realizing that substances are serving as substitutes for people who are lacking that genuine connection in their lives. Just removing the substance will create a void that will quickly get refilled, either by a relapse, another substance or something else that isn't productive.

And it's a mistake to think of this as solely a substance abuse problem. There are many other ways that people self-medicate. Television, the Internet and smartphones are all "relationships" that we lean on when we're not getting enough of the genuine kind that we crave. We like to blame this opioid epidemic on overprescription of these drugs, but we're making a huge mistake if we ignore everything about our society that has created so many human beings who are so detached from each other that they become addicted to these things.

Right. I get that and agree. The article is about the effective way to actually help with heroin addiction. The comment I replied to said, "An addiction tries to replace a void in someone's life. Chances are big the environment of the addicted played a role in cerating[sic] the void."

"Chances are" he's identified a vague cause? I'm not saying he's wrong, but that it doesn't help an addict to point that out. And again, the article is all about effectively helping the addict.

I don't think we disagree except for in the intent of my original comment.

Now you address the environmental factors that created the void in the first place, such that the drugs are no longer desirable. See: Rat Park.


Also, downvoted for needlessly confrontational pedantry.

I'm sorry you felt I was being confrontational. But I stand by it. Telling someone there is a reason for what they are going through, then saying, "now find it and fix it" is NOT helpful.

I sincerely believe that anyone that thinks pointing out the obvious to an addict will help has not actually done it. And I consider "It's something in your environment" to be obvious, true, and totally not actionable.

Furthermore, the idea that addiction is necessarily filling a void is, to be blunt, bullshit.


I didn't say any of that, addressing the context in which people become addicted is actionable and valuable, and I'm bowing out of this conversation.

I was replying to the second part of your comment, where you accused me of pedantry for some reason. I'm explaining to you why I commented that "it's the environment" wasn't helpful, in spite of your downvote.

peace out :)

I read this, as a recovering addict that went through my own hell mostly from alcoholism, and wondered where the "science" part was?

For instance this sentence "More than 13 percent of its participants died after treatment,1 mainly of overdoses that could potentially have been prevented with evidence-based care." The argument is that they "could" have been prevented but how do they really know that? How many people in general die of an overdose after X number of stays in a rehab? Through my own experiences going to rehab, I have known of many people who die. The fact is you can't predict which people will "get" it any better than you can predict if it will rain next month.

I also disagree with this notion that being on suboxone or methadone indefinitely is a legitimate solution. Like what? You're advocating to stay on a drug the rest of your life? That isn't recovery at all, it's a band-aid that will likely lead to relapse and promotes a perpetual notion of being sick.

I also disagree that their supposed evidence that CRAFT gets twice as many people into rehab has much relevance. How many of those people relapsed? How many of the people that didn't go to rehab ended up overdosing OR recovering? We don't get the whole picture so the "evidence" is mute.

They knock 12-step which is fine but it turns out that it works for millions of people.

There is no silver bullet here.

While I have mixed feeling about the "tough love" approach, I can tell you from personal experience that the only reason I'm not buried right now is because at a certain point the floor dropped out too low, my family and friends abandoned me, I lost everything for a moment, and the pain and horror reached a level that finally I had a change of psyche on my OWN and realized I wanted to get better.

In my own humble opinion the only "science" that matters on this subject are the opinions of those whom have lived it and recovered. Go survey the opiate addicts that didn't end up dead and find out what worked for them.

> In the U.K., researchers looked at data from more than 150,000 people treated for opioid addiction from 2005 to 2009 and found that those on buprenorphine or methadone had half the death rate compared with those who engaged in any type of abstinence-oriented treatment.

That's some pretty scary data. Half the death rate... that's a very significant number.

> You're advocating to stay on a drug the rest of your life?

Why not? It saves lives (hello insulin). And here's a telling bit from the article:

> When patients take a stable, regular and appropriate dose, maintenance medications don’t cause impairment, and the patient can work, love and drive. In essence, what maintenance does is replace addiction — which, remember, is defined as compulsive use despite consequences — with physiological dependence, which, as noted above, is not harmful in and of itself.

Here's the link with much more info about buprenorphine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293937/

Certainly it would be nice to have an effective solution that didn't require daily use... but we don't. What we have is a safe drug that cuts the death rate by half.

If there were 0 people who recovered from opiate addiction without being hooked on a maintenance drug for the rest of their lives then it'd have more credence. If you give an alcoholic xanax for the rest of their life because it affects the same area of the brain but they aren't drunk anymore, are they recovered?

Not to mention, that seems like a pretty horrible and bleak outlook to make people believe they can't make a full recovery without being medicated for the rest of their life.

Again, I've known many people who have taken these drugs and a large number of them relapse bad. In fact, from what I hear the withdrawl from suboxone is 10x worse than from heroin.

If someone replaces a drug that's doing them very serious harm with a drug that doesn't do them harm, I don't see the problem.[1] I take doctor prescribed medication daily that I could live without but it significantly increases my quality of life, I don't see a difference between me and a person who is on methadone but otherwise well in life - has job, money, clothes, friends, community, etc.

[1] Xanax has a lot of problems with long term use though, so Xanax, specifically, would likely not be a good candidate.

My MIL replaced alcohol and cocaine addictions with a coffee addiction. It's been over a decade and she doesn't seem to have any significant negative outcomes with the coffee and coffee is cheap and readily available almost everywhere. From what I see, I believe the coffee is more of a psychological crutch for her - but it's not harming her.

It's not always about recovery, but harm reduction.

best is the enemy of better, sometimes we can only do better and best is a pipe dream. I spent most of my life so far learning this.

And sometimes better is our best. I'm on Suboxone. I'm okay with that. Harm reduction is a good thing.

First of all, thank you for sharing your experience. It was insightful, and I completely agree with your criticism of the article.

I would like to make a small, and perhaps somewhat pedantic comment regarding your last statement:

>In my own humble opinion the only "science" that matters on this subject are the opinions of those whom have lived it and recovered. Go survey the opiate addicts that didn't end up dead and find out what worked for them.

There is a problem of silent evidence and survivor bias here. What is important is not what they did that led to their recovery, but what they did differently (or, more generally, what was different in their circumstances) from those that tried to recover, but didn't.

So, IMHO, what is needed is not _just_ the opinions of those that recovered, but a longitudinal study to identify which, out the many factors that were involved in the recovery process, have been the most instrumental.

> There is a problem of silent evidence and survivor bias here. What is important is not what they did that led to their recovery, but what they did differently (or, more generally, what was different in their circumstances) from those that tried to recover, but didn't.

That's assuming they did anything different at all. It could just be that there is not a one size fits all treatment for this problem, and part of the solution is to match the right treatment for each particular addict.

While I agree with your points about collecting empirical and unbiased data, I want to point out that when it comes to opioids, "Science" is moving the goal posts. They are measuring social acceptability of a subject while under the influence of doctor-prescribed dope, while ignoring the numerous addicts who maintain similar levels of social acceptability while using Street dope, then declaring their method a "success".

Yes, fair point. This is a common problem for social studies. One must keep in mind and be explicit about the population the study sample is drawn from; and very cautious about extrapolating the findings to other populations.

Not only what they did differently. It might be something they didn't do as well. Since data is laking any personal effort might be completely irrelevant and only the environment might make the difference. I presume there is a large personal effort involved but we don't know.

On survivorship bias: the B 17:s in 2nd world war that generally are used as the practical example of this principle had bullet holes exactly in those parts of the plane that were fine. The parts that had not taken a beating in the survived planes were the ones that needed more armourplating.

So, where are the psychological bullet holes in those who've not beaten addiction?

I have a couple of friends on methadone, they are cordial, relatively together and in a totally safer place than prior. I would rather that than the other so it's legitimate approach in my eyes, they have the rest of their lives to figure out when they can stop.

"Detoxifications and drug free modalities, although appealing to an understandable desire for recovery without medications, produces only 5-10% success rate. Methadone maintenance is associated with success rates ranging from 60 - 90%. The longer the people are in this modality the greater their chances are of achieving stable long-term abstinence."


> I have a couple of friends on methadone, they are cordial, relatively together and in a totally safer place than prior.

From my work with injecting drug users about a decade ago: None prefers methadone, they only take it because, when in a treatment program, they get it for free and unadulterated. When it comes to actually ceasing consumption, at least on the mindvox drug users list, the consensus seemed to be, that is is easier when first switching back to heroin.

Ask your friends whether it is the methadone as a substance that helped them or the decriminalization and steady supply they don't have to worry about. From experience, I bet on the latter.

We now have a methadone clinic in our local shopping center, right next to a large childcare facility. Since then, crime has gone way up. The grocery store now has armed guards.

This is not what a solution should look like.

>This is not what a solution should look like.

I'm not necessarily a supporter of suboxone / methadone / whatever , but this NIMBY rhetoric isn't helpful, either.

It's rare for the down-turn of an area to have one extraordinary cause.

I guess that the suggestion is that methadone clinics create crime where there otherwise wasn't -- but I don't see it that way in my community.

What I see these clinics provide is a centralization of potentially bad actors for authorities to keep tabs on while they seek guidance or pay court-ordered time to the system otherwise.

What's the alternative here? Cease these communal style clinics? If one believes in these treatment options whatsoever then it must be realized that cessation of these clinics would take that care option away from many people who may find legitimate use.

I don't have alternatives to the clinics , but I do have insight into what one should pay attention to when an area begins to struggle:

Income, education, and general upward mobility within society.

> It's rare for the down-turn of an area to have one extraordinary cause.

no it's not. he's talking about a single store. in my town it's the homeless shelter and halfway house that causes a 5 block radius around it to be a terrible place to live.

we're not talking about building more housing, or zoning for high density commercial/residential mixes, or building public transit, or eliminating cars from downtown cores, or building more bus routes, or bikeshares, or uber, or any number of things that people actually want. we're talking about methadone clinics and halfway houses next to where affluent people live.

if you pretend like it's hard to understand why people don't want those things in their residential/shopping neighborhoods, you're just going to alienate everyone you communicate with. you can't just invoke the magic 'nimby' and get people to change their minds. __they don't want these things next to where they live__.

> __they don't want these things next to where they live__.

Which is the precise definition of Not In My Back Yard...

yeah, and good luck convincing anyone, anywhere that building a methadone clinic in their back yard is a good idea.

here's another turn of phrase you might find handy: choose your battles.

why should it be a problem? in the UK, methadone is normally dispensed from a regular pharmacy, just like any other prescription you might get from your doctor. I wonder if what you are seeing is that the clinic has been placed in a neighbourhood that already had high crime/homelessness/etc. since that is where the addicts who need its services are? it just seems odd that a clinic would be placed in an affluent area, where property costs are probably high, and the service users have to travel to get there, but maybe it's an american thing?

I know some people complaining about the noise from child care in their neighborhood.

the methadone clinic near(ish) my house is a well known place to score dope.

the junkers have basically turned the nearest subway into hamsterdam.

McNulty: If Snot Boogie always stole the money, why'd you let him play?

Man On Stoop: Got to. This America, man

> they have the rest of their lives to figure out when they can stop.

The answer is: never.

Only if they get into a program that guarantees they will be detoxified in 6 months(or so). This is rare unfortunately because it needs the addict's consent, which is rarely given. They usually choose the "open-ended" program because it's easier.

They only use methadone because it's a legal(but controlled) drug. It's not that much better than heroin.

never and alive is just fine, methadone satiates the addiction though does not really deliver a 'high' anymore so these friends can fill their lives with more interesting things, at some point methadone might get de-prioritised, in the meantime, I support them with love and encouragement, they recognised they were in a situation and took intelligent pro-active steps to move their lives forward, I'm not them, I'm not inside their mind, I don't know how hard it is for them, I'm not here to judge.

No one is judging no one. And you should keep supporting them any way you can.

But I am just stating facts.

> at some point methadone might get de-prioritised

But that is wishful thinking, not reality. Open-ended programs do not work. Period.

By far most people in such programs relapse multiple times. You can't expect from the addict to kick the drug off out of sheer will and good intentions.

> took intelligent pro-active steps to move their lives forward

You don't understand addiction and how it works. It has nothing to with intelligence or logic. When someone chooses an open-ended program is because the people around them force them to take some action and they choose the easiest one.

Again, no one is judging and no one said those people do not need love, quite the opposite. But open-ended programs destroy their lives.

You're talking in absolutes, with no references, do you have any supporting evidence, did you read the linked article, I seem to some good science on my side.

"For opioid addiction itself, however, the best treatment is indefinite, possibly lifelong maintenance with either methadone or buprenorphine (Suboxone). That is the conclusion of every expert panel and systematic review that has considered the question — including the World Health Organization, the Institute of Medicine, the National Institute on Drug Abuse and the Office of National Drug Control Policy."


I'm talking with more than 20 years of experience being close to people who follow these treatments.

One has to wonder why would we not choose a treatment(3-12 months, depending on the person/situation) since it can demonstrably help people recover completely from opioids and instead choose life-long dependence on particular drugs.

Are these the same scientists that think prescribing Vicodin, as if it's aspirin, is a good thing?

> One has to wonder why would we not choose a treatment(3-12 months, depending on the person/situation) since it can demonstrably help people recover completely from opioids and instead choose life-long dependence on particular drugs.

Who cares? Nobody talks this way about a person who has to take heart medicine every day to survive, and not that many talk this way about me when I take Lexapro every day to not get depressed. What makes methadone so different?

> What makes methadone so different?

You can survive without it for starters. Not the case with heart medicine I guess?

If you saw people, with the same condition as yours, having a good quality of life without medicine wouldn't you not wonder if that could apply to you too?

In the case of drug addiction, I've seen many people successfully kicking off the habit in months and living a perfectly healthy life, as if almost nothing happened.

Life-long methadone users? Not so much. I can tell that people really think it's different from heroin but it's not really. It's just regulated. Think about it ;)

> I'm talking with more than 20 years of experience

Experience is valuable but for driving systematic changes, unreliable. Its too easy to color personal experience with bias of many kinds. That's the entire point of science, to eliminate those biases and document the underlying evidence to support a claim like: "Methadone does not work."

> That's the entire point of science

Challenge accepted :D

Scientific fact 1: methadone doesn't alleviate the addiction. It actually feeds it to the point that it increases the patient's tolerance at which point you have to increase the dosage.

Scientific fact 2: methadone doesn't provide the "high". Totally true. That's why the vast majority of patients seek it elsewhere(alcohol, cannabis, etc).

Scientific fact 3: Life-long methadone users have relapses more than once. Most clinics/doctors supporting methadone brush it off as "it's quite normal and logical".

Scientific fact 4: innumerable people have been able to kick off opioid addiction by following long-term(but not life-long) therapies.

General fact: You'd be hard pressed to find a drug, other than methadone, that has been so controversial in its usage.

More facts: these panels of "experts" don't provide evidence that long-term recovery doesn't work, but they opine that "hey, methadone is the best, true story.". Show me data, show me science ;)

Isn't it way too convenient for the drug industry? Has it ever happened before, I wonder?

Isn't it weird that heroin addiction in US has increased because of the gratuitous opioid prescriptions?


My read is that the science was principally this 'graph:

For opioid addiction itself, however, the best treatment is indefinite, possibly lifelong maintenance with either methadone or buprenorphine (Suboxone). That is the conclusion of every expert panel and systematic review that has considered the question — including the World Health Organization, the Institute of Medicine, the National Institute on Drug Abuse and the Office of National Drug Control Policy.

With four links in that last sentence.

Alcohol != opioid.

As I said in another comment, alcohol is an odd drug. It's mechanisms work very differently from opioids and needs very different behaviors and strategies to combat.

In my opinion you can't simply discard the debate as comparing apples to oranges... There are many similarities. It's a drug addiction at the end of the day.

Going cold turkey from heroin is unpleasant.

Going cold turkey from alcohol can be fatal.

So, we should give alcoholics naloxone?

Okay, so now we've established that alcohol and opiates do different things in the brain.

So, at this point, I'm going to ask you: "Why should you assume similarity rather than assuming difference?"

Just because viruses and bacteria are both harmful does not mean we should use antibiotics for both.

One of the most successful treatments for alcohol addiction is the Sinclair method which uses naltrexone and opioid blocker.

> Just because viruses and bacteria are both harmful does not mean we should use antibiotics for both

But getting rest and good nutrition will help the body fight both. So they work differently but some treatment is the same. Not unlike what gp was pointing out.

The issue with some of these therapies is more or less that they are defaults, not that the therapy itself is bad in itself.

12 Step programs for instance... well, they really don't have a great success rate. It seems like the success rate is around 5 to 10 percent for AA. (http://www.npr.org/2014/03/23/291405829/with-sobering-scienc...).

But for me, I think that the issue is less the program than it is the default option, often ordered by the courts. 12 step therapy probably does work with certain personalities. For others, it will do nothing, or maybe even make things worse.

This is probably the same for "tough love" type rehab programs. Some people would be okay with this. Others would react better with other options (your CBTs, BCTs, etc.)

I will say this from a "non-expert" perspective: suboxone honestly is what you want to do from a chemical perspective for opioids. Suboxone is a combination of a mild opiate (buprenorphine) and naloxone, a μ-opioid antagonist that's there mainly to prevent abuse.

For an addiction, chemically, moving to something milder seems like a great intermediate step, akin to some methods of getting off of nicotine (eg, slowly decreasing mg of patches etc). The nicotine patches don't work too well -- it seems like the effectiveness rate is only about 17% (http://www.mdedge.com/jfponline/article/60156/addiction-medi...). But this is a significant increase from placebo (another study -- https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0010505/ -- says 50-70% more likely).

Agree that there is no silver bullet; probably the best route out is a combination of something to handle the chemical side with some form of therapy to handle the other end. The type of therapy would probably have to heavily depend on the person, given that the therapy must be something the person is willing to commit to in order to work.

I think the saddest part of this article is perhaps the glancing statement it makes about how prison isn't a place of recovery and rehabilitation. The prison system here really is too focused on punishment and locking people up forever rather than helping them get back on their feet and being productive members of society

Unfortunately, the drug war and punishing users of non-sanctioned drugs is embedded deep in America's political and social DNA - but seeing how much has changed in some areas of drug policy especially with variations from state to state - I hold out some hope that we might see some changes there too - but I just wouldn't hold my breath.

It's not just America's DNA. Many countries around the world base their drug policy off of US drug policy.

The prison system is highly privatized. Prisons with more people in them make more money and have a higher return on investment. Prisons that have repeat visitors can out compete prisons that do not. Therefore, there is a selection towards not keeping an inmate out of prison in the future.

I hate how tinfoil hat-y this sounds, and I'm certainly no expert, so feel free to offer alternatives

The ACLU, using from the Bureau of Justice Statistics, says that "for-profit companies were responsible for approximately 7 percent of state prisoners and 18 percent of federal prisoners in 2015"

I don't think that count's as "highly" privatized. I personally think the incentives involved in the private prison system present major ethical issues, but I think we need to look at the incentives involved with the our legal system and governmental prisons, also.

They may be referring to a bit more than that. Most inmate supplies, from clothing to blankets to mattresses to hygiene supplies, comes from one company called Bob Barker - no affiliation with the TV personality. There are just a few companies that supply canteen/commissary services. Construction is done by just a few companies.

Things like that may be what they are referring to.

Yeah, fully privatized prisons are just the apotheosis of a broader issue.

While private prisons account for a relatively small percentage of total prisons in America, they're a multi-billion dollar industry, and they lobby for laws that affect all prison populations. So, in that sense, we do have a highly privatized prison system.

And it is highly privatized in the sense that the amount of privatization in that sector should probably be zero. When incarceration is a burden rather than a business, incentives exist to prevent crime and reduce recidivism. Otherwise, there are incentives to invent crimes that did not previously exist and turn ex-convicts into "repeat customers".

And it is highly privatized in the sense that the amount of privatization in that sector should probably be zero.

I could only agree more if you removed probably.

Also interesting and related: https://news.ycombinator.com/item?id=15241874

"Psychedelics Help Reduce Opioid Addiction, According to New Study"

Interesting, but I'm surprised it doesn't mention Iboga.

Have you also read "Abstinence Helps Reduce Opioid Addiction, According to New Study"?

Oh, is this like the "abstinence based sex education" that increases teenage pregnancy and STD rates?

No, I haven't read that one. Did you have some point to make by making up a fake study title?

Now that the opioid crisis is a problem for white people, science makes an appearance in the policy discussion.

Contrast to the crack epidemic in the 80s: fuck'em, throw them all in prison.

Edit to add: I wish the best of luck to those who have been caught up in this crisis: I'm rooting for you, and I hope every last one of you find the treatment you need. For those of us who aren't affected, it's time for some deep introspection about what we allow our politicians and (yes) our neighbors to get away with.

>Contrast to the crack cocaine epidemic in the 80s: fuck'em, throw them all in prison.

That's overly reductive to the point of being wrong. There was never a particularly strong feeling that crack addicts should be thrown in prison any more than other types of addicts. People were strongly in favor of throwing crack dealers in prison because they were turning neighborhoods into war zones as they fought for lucrative turf.

And it wasn't just white people, either. The strongest advocates you'll find of drug criminalization are black people who lived through the crack epidemic in the '80s.

crack vs cocaine sentencing doesn't agree with you. It was clearly making the "black" crime of crack possession worse than the "white" crime of coke possession.

Obama got a whole law passed in 2010 to address it!

Y'all realize that black legislators and community organizers pushed for and voted for those "racist" crack sentences? They were trying to save their own communities.

Edit: for the uninformed down voters: https://www.google.com/amp/amp.slate.com/articles/news_and_p...

That's a non-sequitur answer that also manages to concede the point of the comment upthread, which is that there has in fact been a retributive cast to drug policy for black people.

You make a good point.

That article doesn't support your point. The law being referenced here is the Anti-Drug Abuse Act of 1986, signed into law 8 years earlier by Reagan [1]. You are correct, though. The Black Congressional Congress and the majority of black congressmen at the time supported the ADAA, even helping draft it.

But, I still think that it would be wrong to assume that there was universal (or even majority) support among the black community. One confounder would be the media; studies have shown that public opinion about drug use and drug crime were/are directly related to media coverage [2]. With Reagan publicly saying drugs "are as much a threat to the United States as enemy planes and missiles", I think it's difficult to disentangle anyone's true personal feelings about the law from the sociopolitical influences that were present at the time.

The view of policing at the time was simply different. Some might have viewed the ADAA as a much more honest form of policing black communities, as opposed to the efforts undertaken in the 1960s and 1970s: stifling civil rights-related protests and other actions, along with actions by high-powered militarized SWAT teams being concentrated in poor black communities [3].

Even in retrospect, the issues are complex and unclear. Is it really difficult to believe that most people at the time, policymakers or not, were simply incapable of fathoming the results of the ADAA? It's clear that the imbalance in policing, partially as a result of the ADAA, has decimated the black community. Most of the damage, I would argue, is due to an ugly amalgamation of the rise of the prison industrial complex and the transparent willingness of policymakers to look past the needs of poor and minority communities in writing criminal law over the last 30 years.

[1] https://en.wikipedia.org/wiki/Anti-Drug_Abuse_Act_of_1986 [2] https://academic.oup.com/socpro/article/41/3/425/1671880/Set... [3] https://www.washingtonpost.com/news/wonk/wp/2016/05/02/ameri...

It's useful to remember the ADAA in the broader context of the 1980s push towards harsher federal sentencing across the board. It's not a coincidence that federal sentences were revised and federal parole abolished just a few years prior, or that the Willie Horton ad would run in the next Presidential election.

It's true that there was mainstream black support for anti-crime legislation, but that support wasn't distinctive. Blacks weren't leading the charge; they were just another part of it.

I see many of these discussions that focus on federal sentencing laws without considering that state laws and enforcement practices are far more important. State laws are varied and complicated - some states are far harsher than others. Yes the federal laws are and were unfair and stupid, but the large majority of prisoners and drug offenders are in state prisons.

John Pfaff has been on a lot of podcasts, he is the most insightful person on criminal justice that I have found. Surprisingly Vox has a good summary of his book.


Thanks for the link. I'm working on a post for my site about the recently deposed/pardoned Sheriff (Joseph Arpaio) and will probably quote something like this:

> Pfaff tries his hand at some of the messaging that will be needed here: He argues that incarceration is simply an ineffective way to combat crime, while it imposes all sorts of costs on individuals and society that likely outweigh its benefits.

Have you heard the theory that racism might be institutionalized?

I do not recollect with precision, but there is an article posted on HN few years ago, showing the 80s archives of New York Times, in it NYT was squarely arguing for harsher sentencing and so were African American civic leaders.

May be there is racism that is institutional, but the point is most people even those who are against harsher sentences today thought it was a remedy. We will be failing ourselves if we cannot examine that fact and simply hitch and re-assign every "fucked up" decision to racism.

> May be there is racism that is institutional, but the point is most people even those who are against harsher sentences today thought it was a remedy

I didn't. I thought it was racist back then. Many black leaders thought it was racist back then too

> May be there is racism that is institutional, but the point is most people even those who are against harsher sentences today thought it was a remedy.

That's exactly the irony of institutional racism: it's so rarely _consciously_ racist. It is often "colorblind".

Now that's just crazy talk.

Have you studied the crack epidemic or have you simply slurped up some recent liberal political journalism?

> studied the crack epidemic

Your bias is showing. Crack arrest spree is more accurate. I was politically active while it was happening, so no, this isn't a recent observation.

Can I just add how incredibly rude "slurped up some recent liberal political journalism" is? You should be ashamed of the way you talk to strangers on the Internet.


> So what you're saying is that black people can't be trusted to have their own opinions because of institutional racism? Words fail

No, I'm saying that you cannot make an appeal to authority. It is a logical fallacy. Just because some blacks were in favor does not mean it was not racist

If this were a group of white politicians and community leaders seeking tougher sentences for crimes occurring in their neighborhoods, I'm pretty sure we'd be hearing a debate on the merits of the proposal.

But because black politicians and community leaders came to the conclusion that tougher sentences for crack dealers are warranted based on their experience it must be because of institutional racism. It's like they've come to a conclusion you don't agree with so you feel free to dismiss their agency. Help me out here, because it's the only way I can read this.

You keep repeating this argument. Its premise is invalid. It was not in fact black politicians that raised the sentences for crack cocaine in relation to powder cocaine; it was the overwhelmingly white US federal legislature.

That's... completely irrelevant. The harsher sentences had wide support from black leaders and politicians.

It's obviously not completely irrelevant, as your argument depends on a causal link between black support for crack sentencing laws and the adoption of those laws. In fact, no such causality is established, and it is indeed unlikely, given that the laws were passed by an overwhelmingly white legislature in the grip of a nationwide (largely unjustified) freakout about crime.

John Pfaff's "Locked In" is a great source for the background on this stuff (Pfaff would be the first to say that drug sentencing laws are not the reason for mass incarceration in the US, but that's not the question at issue in this thread).

And white politicions supported harsher sentences in the past as well. Do they speak for us today? Did they speak for everyone back then? Last I checked you only needed a simple majority to get elected.

> If this were a group of white politicians... we'd be hearing a debate on the merits of the proposal.

You can't know that.

When was the last time white community leaders and politicians proposed a policy to address a problem in their own neighborhood and were accused of institutional racism?

And thus that's the trap that has been set: if you don't follow the recommendations of black leaders, you're a racist. If you follow the recommendations of black leaders, you're a racist.

Even a poorly powered AI in 1983 figured out the only way to win is to not play the game.

That's not at all what they said.

If you were around back in the 1980's, you'd realize it was because crack was labelled an "epidemic" and ended up on the nightly news often. "Something had to be done"

That wasn't happening with powdered cocaine.

That is the mechanism by which race-biased views of different drugs and crimes and other social problems operate.

Carl Hart has researched this[0]

I found his appearance on Joe Rogan's podcast (most recently #698) compelling


Crack vs powder sentencing isn't relevant. The violence was all on the crack side, which is what prompted the harsher sentences.

And yes, Obama got a law passed based on a lie. That happens all the time.

EDIT: Most people really don't care what you put into your body until you make them care, and that's what happened. You'd open up the paper and see another eight-year-old on the way to school got shot in the head because crack dealers were spraying bullets at each other again. That happens often enough and the public decides Something Must Be Done.

Personally, I thought a better solution would be to teach the crack dealers how to shoot, but nobody liked my idea.

No, the violence was not "all on the crack side":


Oh, yes, I see they've referenced a study that admits the violence was greater for crack but not if you "controlled" out the relevant variables.

Stupid statisticians with their stupid "controls".

I'll take this opportunity to point out that, right or wrong (obviously: I think you're wrong), you've contradicted your comment rooting this subthread. You began by saying there was never strong feeling that black crack users should be imprisoned, and find yourself here arguing that imprisoned black crack users somehow deserved it.

>Stupid statisticians with their stupid "controls".

I don't have access to the actual study, but the abstract very much reads like a study that came to the conclusion the authors wanted.

>You began by saying there was never strong feeling that black crack users should be imprisoned, and find yourself here arguing that imprisoned black crack users somehow deserved it.

Eh... no, I never said that second part. You might want to read through the thread again.

I would downvote you if I could.

I would laugh at you if I could.

Oh, wait. I can.

I will eat your billygoat.

to be fair when meth was ravaging poor/rural white people nobody really seemed to care much either. in fact it was something of a joke i.e. the "not even once" memes etc.

i think the real issue is opiates seem to be heavily affecting affluent suburban and urban people, who are predominantly white, and make up a huge amount of the tax base.

Doesn't the fact that the "not even once" ads existed in the public consciousness saliently enough to have a meme show that people did really seem to care?

well you could say the same thing about 'this is your brain on drugs' when crack was going around. that was also a PSA that entered into the public consciousness and then turned into a joke.

That 'this is your brain on drugs' thing with the egg and the skillet was heroin, not crack. I believe they did do a crack update later where the woman took the skillet afterward and destroyed the kitchen with it. To conflate humor and lampooning of those PSAs as not taking the actual drug issue seriously is not wise, though. Many people simply realize how useless, hyperbolic, and ultimately insulting those PSAs were.

If something is scary, you show the thing. You don't make up metaphors. Trainspotting and Requiem for a Dream most likely prevented more people from ever trying heroin than any government-sponsored PSA ever did.

There's an update to that ad: "This is your brain on drug policy".


Spoiler: same actress.

Sure, but one of these was paired with mass incarceration of a certain group of people, associated with laws that were struck down because of their disparity in sentencing. The other, not.

Never been to the States, but from half a world away and just by reading on reddit about it it all looked more like people were making fun of said meth-addicts, they (the redditors making the jokes) didn't seem to care that much about those meth addicts. This was all happening about 3-4 years ago, I'd say, and it's in very sharp contrast with the present-day opiate-related discussions which can get pretty personal. It's also interesting that the HN crowd has also joined the opiates conversation, I don't remember reading anything about the meth epidemic in the past on HN.

Class and race undeniably intersect in the US, so there's basis for both perspectives, imo

That's mostly wrong in that the opioid crisis overwhelmingly affects the rural white population, not urban.

Yeah, I think my initial comment missed that part of the equation. It isn't straight racism that's driving the differential response as it is indirect racism by way of inequality. The net effect ends up amounting to the same thing though, and ultimately that's what bothers me so much about it.

> fuck'em, throw them all in prison.

We've heard that before. There is a twist there though. A lot of that "tougher on drugs" legislation was pushed by the poor black community leaders because they saw what crack was doing to their children, young adults, whole families. Normally we'd all want to say it's the white man abusing their privilege in a sadistic manner but sometimes there are some subtleties involved.


Another interesting thing there is that CIA was probably involved:


Now on paper they "weren't" but given the article from Gary Webb and reading between the lines about what their own Inspector General said "...agency officers were not required to report allegations of drug trafficking involving non-employees, defined as paid and non-paid "assets"—pilots who ferried supplies to the contras, as well as contra officials and others.[49][50]..."

Imho i would guess it is more a markets thing than a racial thing. There probably wasn't a whole lot of money to be made in curing an epidemic to a poor minority in the 80s whereas the opioid crisis is hitting a larger middle class population

That doesn't make it any better. It's also not a simple A/B. Maybe society had to drag it through the aforementioned stages to reach a point of consciousness.

I don't really buy that though. Honestly, I think the problem is simply being on opioids for a week due to post surgery pain or similar is enough to hook people.

My write in ballot would include various forms of legalization and treatment. I've heard DMT can make people quit heroin over night. While a little radical, that's better than the alternatives.

Iboga can help people quit heroin overnight. And Kratom is a great 'maintenance therapy'

It wasn't a "markets thing". Crack hit black communities. Then, black leaders within those communities responded by passing tough laws.

No, that's not at all true. The Anti-Drug Abuse Act of 1986 was passed by an overwhelmingly white Congress and an overwhelmingly white Senate, and signed by overwhelmingly white Ronald Reagan.

This is the whole "dammed if you do, dammed if you don't".

Situation: Crack use climbs in black communities leading to major social problems.

Option A: Create tough laws to stop crack use. WRONG, YOU ARE RACIST (for singling out the black community).

Option B: Don't create tough laws. WRONG, YOU ARE RACIST (for not caring about the black community).

There are options other than "tough laws" for helping communities struggling with high rates of addiction.

Your breakdown of this situation makes it sound like you think it doesn't matter what you do, because someone will call you a racist no matter what. In other words, that accusations of racism are totally arbitrary. That's not true.

And the majority could just as easily have done the right thing and refused to pass the laws, while lending a helping hand and attempting to preserve these communities.

You're going through this thread and blaming victims for their misfortune. It is, to say the least, unedifying.

Ah, "blaming victims for their misfortune." You seem cool.

I hope you see that this is a problem? Why is our society incapable of doing the right thing when there is a market failure?

Because the moneyed interests have altogether too much power.

Really sad that this is the top comment here. How about instead of immediately making it a racial issue, maybe we consider that we've learned something from the crack epidemic of the 80s on how to better deal with such problems? Or we could also consider that the opioid problem is different because the source of such problems is pharmaceutical companies and the doctors prescribing them, rather than some illegal drug smuggling trade. I'm not saying any of these hypotheses are correct, just that immediately making this a race issue does absolutely no good.

I'd say it does the good of reminding us that where black communities face retributive drug policies, white communities tend instead to get therapeutic drug policy. That seems like an important detail, not an artificial concern.

I agree with your point but that feels like more of a class issue than a race issue, though of course race and class aren't independent unfortunately.

No, it's not. The opiate epidemic, like crack cocaine, is mostly a phenomenon of the lower class. But opiates involve white people and generate therapy, while crack involves black people and generates prison time.

You are "not saying any of these hypotheses are correct," but boy howdy are you really up on making sure he doesn't put forward one you don't like, yeah?

Saying "X is X" does not mean you are "making it X". If you think he's making it a racial issue, you might want to consider that it just might be actually a racial issue.

> but boy howdy are you really up on making sure he doesn't put forward one you don't like, yeah?

What? I made one comment. Not only was parent's comment only loosely relevant to the article itself, but they provided no evidence to support their position, all with an undertone of maliciousness. I'm willing to accept it's a racial issue if you present evidence that reasonably eliminates confounding factors like the ones I brought up. As for the opioid epidemic: I care about as much as I care about the crack epidemic, which is about as much as I can care without having anyone close to me be affected.

> Saying "X is X" does not mean you are "making it X". If you think he's making it a racial issue, you might want to consider that it just might be actually a racial issue.

They are "making it a racial issue" because the article is about how to best help someone with an opioid addiction, not why people write so many articles about opioid addiction, or why so many people care about opioid addiction, or why the method of dealing with the opioid epidemic seems different than that of the crack epidemic. Parent's comment is, again, only marginally relevant to the content of the article.

Given that justice reform for low level drug offenders has gone precisely nowhere in the last 30 years, I'm thinking we haven't really learned anything from the epidemic in the 80s.

I'll let you fill in the blanks: If the 80s epidemic and the current opioid crisis are experiments and the sentencing scheme remains identical, what is the independent variable?

- Ease of obtaining opioids compared to crack as a member of the middle class. - Ease of becoming addicted to opioids when the original intent of use was medical, rather than recreational - Arguably larger reach of opioid epidemic, specifically that it is less isolated to a few geographical areas - Socioeconomic class of people that are affected - More accepting/understanding of addiction and drug use in general, even if the laws yet aren't

I would say on the one side that there is still little science in our current policies around drugs and on the other side I would say that many dedicated individuals and organizations like the Drug Policy Alliance have spent immense amounts of energy and money on attempting to get drug policy to reflect science.

Not to argue that there wasn't and still is racial inequality when it comes to drug enforcement, but how advanced was our understanding on how to treat opiate abuse even by the 1980s? To make things clear, I'm curious about the history of treatment methods involved with addiction. Not about excusing bad policy.

I don't know much about the subject but when I try to do a bunch of cursory searches, most of what I find are histories on alcoholism and the variety of treatment methods. As far as I know, before the crack cocaine epidemic, I don't think people really understood just how pernicious the problem of opiate addiction was. Doesn't excuse mass incarceration of black people, but I'm not sure people had any idea on how to actually approach the problem back then. I'm not sure we have a good approach even now.

It's also worth noting how small the problem with cocaine and other opiates was in the past. The crack cocaine epidemic was probably the first time the nation as a whole had to learn what this stuff actually was.

> I don't know much about the subject but when I try to do a bunch of cursory searches, most of what I find are histories on alcoholism and the variety of treatment methods.

And alcohol is a very strange drug. It doesn't quite work like others. For example, if you block the high, most people quit wanting opioids. That doesn't seem to be true of alcohol. In addition, drying you out from alcohol seems to actually damage the impulse control centers in your brain, so avoiding relapse is much more important. etc.

> It's also worth noting how small the problem with cocaine and other opiates was in the past. The crack cocaine epidemic was probably the first time the nation as a whole had to learn what this stuff actually was.

I think the real issue is that modern production methods at that point started making far more potent drugs.

Cocaine isn't an opioid.

Wow. At the time I'm writing, there are 11 other responses, and they're all unconvinced/opposed/offended regarding the parent comment. I'm embarrassed by the deliberate ignorance on display.

Race was and is a key factor in American politics, and in politics everywhere. (I don't know anything about politics in, say, Cambodia, but I can tell you race is a key factor.) The civil rights movement, 20 years before crack was a political issue, faced such powerful opposition that it reversed the polarity of US political parties (causing the former Confederate states to flip to R from D).

In this light, sibling responses to the tune of "why do you have to make it about race" or "seems like it was more about X" read as worse than ignorant. You'd have to be willful to be this ignorant about politics.

My 2c: Parent comment is so obvious it is inane. But apparently I'm in the wrong here.

How about this? Instead of saying that it's so obvious and that people are "deliberate" in their ignorance, you present some data that support the hypothesis that this is a racial issue.

I'm not saying you're wrong. But turning this into a platform for calling out racial inequality is probably just asking for backlash. Yes, in the future we can apply science more equally to all regardless of race. Yes, we failed in this area in the past. But does that somehow invalidate science, or this research? No.

I think we will find that suburban white folk are backlash-proof. And a good thing too, because they need all the help they can get.

That doesn't mean I'm not allowed to feel regret for society's past (and indeed ongoing) failures.

>That doesn't mean I'm not allowed to feel regret for society's past (and indeed ongoing) failures.

Agreed. And there is no reconciliation for the damage that has been done (and continues to be done). Politicians don't take this seriously enough. It won't be enough just to reform drug policy. It won't be enough just to free people who were wronged by the system. It's going to take society changing heart and supporting people who have been hurt for years. And the people who were hurt trusting a society that threw them and their family away...

I would agree about it being racism, more like classism.

> Now that the opioid crisis is a problem for white people

a lot more people die from opiods than crack. most crack users are white.

Interesting, I hadn't thought of it that way. I wonder if white people are the only racial group that demonstrate some kind of a preference for other members of their racial group, and if not, what the implications would be if one racial group stopped having such a preference and other racial groups did not follow suit.

That reads like a barely veiled attempt to justify racism as something that "everyone does".

Because it's well-known that stereotyping works on everyone. And yes, black people can be racist against whites, or also against other blacks.

But that doesn't justify anything. In the particular case of the US, it also ignores that white (men) overwhelmingly control the levers of power, answering your question with a resounding "nothing bad".

I assure you I'm not trying to justify anything. I'm just speculating on the consequences of people behaving in certain ways.

Would you agree that white men have lost at least some of their control over the levers of power as you call them since the founding of this country when they had total control? Would you agree that it's perfectly possible for white men to lose even more of that power, perhaps even to the point where they are no longer the dominant political force, especially given the changes in demographics in the United States, and especially if white men display a low level of preference for members of their own race? Do you agree that is an outcome which many people consider to be extremely desirable and which many people are working toward achieving?

Assuming that other racial groups also show some preference for members of their own group, what do you expect would be the consequence to white people of this choice to show a low level of preference for other members of their own racial group?

If there were one article this year I could force my family to process adequately, it's this one. Addiction is still seen in our group as a failure of character -- not raised right, not religious enough, not following the right path. This kind of advice is seen as 'soft', and that's a shame.

I would also recommend listening to an NPR podcast "The Fix" by RadioLab: http://www.radiolab.org/story/addiction/

While the description talks about taking a pill to solve your addiction problems (some very interesting insights into the latest research at that time 2015 and also many absurd regulatory hurdles), it's the interviews with researchers and addicts that are truly eye opening - and address many of the issues you mention. After listening to it I personally will never reduce someone who has an addiction to failure of character.

In the words of Neal Stephenson, they are '[opiate]-seeky.' They have a tendency dug in at the neurological level to seek opiates, even if they aren't doing so at the moment. The distinction offered by Stephenson is that '*-seeky' is an adjective that modifies an individual, rather than a noun such as 'addict' which overshadows and eclipses an individual.

One of my passengers tried Naltrexone to get her drinking under control, maybe a dozen years ago. While on that drug, she couldn't drink enough to make all her problems go away so she discontinued it. I met her after her third DUI & almost 2 years in prison...

Addiction is multi-faceted.

Thx for the radiolab link.

I do not agree with much of what is stated in this article, nor do I feel that this article represents "what science says" should be done if a loved one has opioid addiction (although it really goes into addiction as a general topic). Treating someone with addiction is a remarkably nuanced and challenging situation, and the author tries to present certain treatment options as not worth doing based on science, when their own citations do not back up those claims.

As someone who has had a loved one go through addiction, and ultimately die from that addiction, I find the binary nature of a lot of this self-described "evidence based guide" dangerously black and white. Proclaiming that abstinence based programs "have not been found to be effective" is total nonsense. What the study found in GB was that psychological only based treatment is less effective at preventing death than replacement therapy, on average. For many, replacement therapy may very well be the best option. For other, abstinence programs may give them an opportunity to fully reclaim their life. How about we empower medical professionals with the ability to treat the disease with a number of weapons, rather than creating this false dichotomy, which is not represented in the data. This guide would potentially discourage someone, or a family member, from choosing a very viable option for treatment, by overstating results.

While I'm not a medical professional, the best example I can think of is with how we treat depression. For some people, active psychotherapy is the best treatment option. For others, a regime of anti-depressants is sufficient treatment. For others, a combination of both is the optimum treatment option. What we don't do, as scientists, is say, "Option 2 has a 30% better outcome, thus we only will treat depression with option 2." That's just absolute junk. What it means is that we will look at what cohorts tend to respond best to option 1, 2, and 3, and understand why, so we can choose a treatment option that makes sense for that individual, without having to try 1, 2, and 3. It doesn't mean that we just toss out the other options wholesale.

The 538 politics podcast does a, "Good use of polling" and "bad use of polling" intro during many of their podcasts. This article would clearly fall under the category of "bad use of polling". I hope to see better out of 538 in the future on these topics.

In short, the published science says to addict the patient to methadone or suboxone instead of whatever they are on, for a lifetime of perpetual treatment.

Actual drug users are likely to recommend using kratom to alleviate withdrawal symptoms and ibogaine (or another powerful hallucinogen) to permanently remove the addiction.

"Science" does not recommend this, because politics has made the hallucinogens--and research into their therapeutic uses--at least as illegal as the opioids that cause all the problems. As someone with an opioid addiction is likely already routinely breaking some rather serious laws, and frequently courting sudden death by overdoses or adulterants, it may be worth trying the single dose of ibogaine before choosing the lifelong maintenance therapy.

Interesting question: The replacing opioid addiction with maintenance drugs... I could understand that drug being an okay interim solution, but in the end the person still needs to go through withdrawal, the drug just replaces withdrawal with another drug.

Withdrawal is hard. Yes. But at least the person is in the right mindset to go through it once they are off the compulsory addiction, even if it takes a year to get to that point.

As kchoudhu points out and many have pointed out to me before this article, certainly once a bunch of white kids have this problem, suddenly they are "victims" not "criminals". Yet we have destroyed so many lives between the 80s and now, especially with the mandatory minimums and such.

Maintenance drugs are usually legal and tend to have less side-effects. This allows the addicted to focus on the underlying issue and then, once that is solved go through withdrawal. There has been a fairly interesting experiment in northern Germany a few years ago that handed out medical grade heroin to heavily addicted people. The results were pretty good, people were highly functional. Often the side effects of the addiction- having to organize drugs (and money for drugs), infections from used needles, additives in the drugs, breakdown of the social support network etc. are much worse than the actual drug. Giving substitutes, even allowing legal access to drugs helps removing those hindrances. Drug policy is just weird.

Why? The problems with addiction - specifically opioid addiction - is that it causes negative, destructive behavior. This isn't a consequence of having a physical dependence we are all physically dependent on things after all.

No, it does not cause negative, destructive behavior. It causes you to lie down and feel good. And it also causes constipation. And, if your supply is interrupted, withdrawal symptoms. The rest is caused primarily by the laws and social environment. Having to interact with criminals? Getting uncertain doses? Overdosing? Those things are because it is illegal, not because it's an opiate.

"Negative distractive behavior" can also include things like "spending so much money on drugs you can't afford basic living expenses," "destroying relationships with your friends/family," "being unable to take care of your children," "getting fired from your job," "not being able to take care of your basic commitment," "'lying down' while driving," etc., etc.

Addiction by definition does cause negative destructive behavior. That's part of the definition. What you're describing is a combination of the psychoactive effects of it and its withdrawal symptoms.

I do agree with you, however. People become addicts due to how our society has criminalized and deregulated drug manufacture and sale and made it extremely hard to teach people how to do properly.

The withdrawals do lead to destructive behavior.

> Withdrawal is hard.

Just to emphasize that:

Before my SO started working in a hospital, I had no idea that people going through alcohol withdrawal can end up in the ICU. They're ending up in an ICU because of the withdrawal, not the alcohol... That was really surprising to me.

Alcohol is one of the only substances on the planet that can cause you to straight up die from withdrawal alone. Deaths from opiate withdrawal are secondary, usually from falling during a seizure. But with alcohol, your heart can simply stop or your brain have a massive stroke from the withdrawal. We think it harmless because its legal, but alcohol is radically dangerous from an addiction standpoint.

That's interesting and makes alcohol sound pretty menacing. I should read more about it. It definitely sounds like seizures and heart issues come up the most. Plus their livers are shot, so toxicity of normally benign treatments is a concern.

Also interesting that, in the very wealthy area we're in, outside of infants and the elderly, middle-aged white men going through alcohol withdrawal are the most common ICU patients.

(sorry for derailing discussion away from opioid addiction)

FWIW, you can die from alcohol withdrawal well before your liver is shot. Also, you don't need to have been drinking for decades; you can get yourself in that pickle in months, not years.

Alcohol and benzodiazepines are the only ones, IIRC. In 2014, Xanax killed more people than fentanyl, morphine, and meth (https://www.usnews.com/news/articles/2016-12-20/heroin-cocai...)

My cousin is a pharmacist... During her training she found out "sometimes if you have an old drunk, you prescribe him alcohol, because the withdrawal will likely kill him"

Withdrawal is stupid and unnecessary. You don't go through withdrawal if your doctor were to say 'ok, you are no longer injured, but your medication is one which has dependence as a side effect. Here is your 12 month schedule for reducing your dosage very gradually.'

I'm physically dependent on caffeine. Why bother fixing that when it is cheap legal and available?

In case you're looking for a sincere answer: being physically dependent on any otherwise unnecessary drug is a drag. You constantly have to seek it out to feel better. Even though caffeine is easily obtainable, I still have found it to be inconvenient when I've been at high levels of consumption. Plus, it does have health effects. It may not be so, but you'll likely feel a lot better without it.

I've gone cold turkey on caffeine a couple of times (takes me about a week of headaches, I'm not an especially heavy user), mainly because I was making hot drinks to avoid work out of boredom, so switched to ginger teas and such like.

Anyway, there doesn't appear to be consensus on whether coffee/tea drinking in moderate amounts is good or bad, but I've seen more suggestions that it's beneficial than otherwise. Any input to that?

No you aren't. Caffeine "withdrawals" are trivial and not life threatening at all.

Opiate withdrawal is generally not life threatening either.

    > but in the end the person still
    > needs to go through withdrawal

I'm not sure it is a race issue. Times were different. People are now accepting that drug consumption doesn't make you a criminal.

At some point Britain thought that wealthy highly-educated people were incapable of being criminals, until time proved them wrong. Science is always evolving.

In a fair system, black and white defendants who score the same number of points under this formula would spend the same time beyond bars. But The Herald-Tribune found that judges disregard the guidelines, sentencing black defendants to longer prison terms in 60 percent of felony cases, 68 percent of serious, first-degree crimes and 45 percent of burglaries. In third-degree felony cases — the least serious and broadest class of felonies — white Florida judges sentenced black defendants to 20 percent more prison time than white defendants.

The war on drugs weighs particularly heavily on black defendants. The police target their neighborhoods, herding people into a court system where judges are demonstrably harder on black offenders. The report found that nearly half of the counties in Florida sentenced African-Americans convicted of felony drug possession to more than double the jail time of whites — even when their backgrounds were the same.

This may just be a Florida problem, but I doubt it.


I'd like to see a control for the amount of money spent on legal defense. The anecdote in that report itself suggests that it's the skill level of the defense attorney which is most likely a dominant factor.

From someone I know with personal experience, after they were charged with possession with intent to distribute due to growing pot, they had 3 choices. Go to jail, spend $X on an attorney who would get them probation, or spend 10 * $X on an attorney who would get them off. Both attorneys had perfect records, n>100, at their respective objective.

I'd like to see a control for the amount of money spent on legal defense.

So, then, why would black people spend less money on legal defense?

People spend as much money on legal defense as they can possibly afford, obviously. But that doesn't make the system racist.

So, black people have less money to spend on legal defense, because . . . ? And, do you think that the people in charge of the system don't know that black people have less money to spend on legal defense? Do you think they're unaware of the history of slavery -> convict leasing -> our modern prison system?

Male vs Women rape statistics seem to denote the same thing, 10% difference, 18% difference, -5% difference. How many cases did the study cover? Looks to be about 300 given the dataset from the website.

300 is a small statistic.

10% of 300 is even smaller.

Science is hard.

I would agree with this perspective. Over the last few decades there has definitely been a change in how people view addiction and more importantly how to address it. Harm reduction has much more traction then 20 years ago.

1. I haven't read the article. Why--because for myself, all the talk makes the problem worse.

2. For myself, going on generic bupenorpine, and tapering off was not that bad. I took a year to taper off. I probally could have tapeed off the opioids if I was given a chance. The problem is most Doctors just cut you off. Completely ridiculous, especially if the patient is a serious individual. (I got lucky to find a doctor to prescribe bupenorpine without driving me crazy with endless office visits. I also just happened to be given the drug for another disorder.)

3. The generic bupenopine is still pricey. I don't quite get it, other than most Dr's don't trust their patients to not abuse opioids, so there isn't a huge demand for generic Subutex? There are still some sensible people who just want to stop the original addiction. On the other hand, I wouldn't be schocked if the price of generic Subutex is the result of some shenanigans.

4. Most people will be given Suboxone, that has Naloxone in it. It makes doctors feel safe, and that's what was taught in the course they had to take in order to prescribe/treat. Crazy again. (I felt Nalaxone just raised the price of the drug, but some of you will need an opoid antagonist in your treatment, especially if street drugs are easily available, or you don't have not much self control.)

4. My point is if you Taper off, all the drama is spared. My story will never be on Lifetime.

5. It's still a pain in the ass with the Dr. visits, and getting scripts though.

6. I can offer this, if you want to stop, Taper off. Yes--I know it's just not that easy. The system we currently have makes getting off difficult. Again crazy?

7. Stay away from all the support group sites. They just scared the hell out of me, especially the ones on the internet.

8. If you are addicted to anything, most of you can successfully taper off yourself. Very few of you need the drama, and expense of a rehab. Again--the system is so rediculious, we are forced into going to the rehabs, just to get the opportunity to taper off. Again crazy.

9. We have a crisis. It's not giving addicted people the easy/cheap way to Taper off the most controlled substances. It's no wonder people turn to the streets to feed their cravings.

Annoying how this 538 article immediately bemoans the lack of regulation -- as if the only solution is to grow the government and pass more laws.

What science says nothing about because of the DEA's inane scheduling: hallucinogens.

Yes, Ibogaine is literally 10x more effective than Methadone. It's risky if you've weakened your heart with stimulants though.


The "science" on treating Opioid addictions at this point would just be reaffirming what we already know with mountains of "anecdotal" evidence. You want to solve the Opoid problem? Legalize Ibogane, DMT, Psilocybin, and MDMA, it is that simple.

Hands down, Naltrexone is the only thing that helped my loved ones with alcohol addiction. Please look into it and watch "one pill" documentary. You have a choice other than AA meetings.

Great article, but if your loved one has an opioid addiction and wants to quit without suffering the devastating withdrawal, I would strongly recommend investigating kratom. It is a non-opiate tree which grows primarily in Thailand and similar regions. It contains an alkaloid called mitragynine. This alkaloid is a selective opioid receptor agonist. Specifically, research shows that it is an agonist to several opioid receptors but particularly an antagonist of the receptor which causes respiratory system depression, and is thought responsible for the primary addictive nature of most opiates and synthetic opioids.

It is legal in most of the US (I believe there are 1 or 2 states which have banned it, it has a long history by now in US law. A year or so ago the DEA announced to Congress the intention to schedule it (ban it) under their 'emergency' powers (which is bullshit since there are no deaths from it, and it remains mostly unknown, those 'emergency' powers are simply abused). After that announcement, they were required to consult research and doctors, along with opening a public comment period. Afterward they withdrew their intent to schedule it. So, for now, it remains legal.

Its effect upon a person with no opioid dependence is at low doses similar to caffeine without the 'jittery' part and without the crash afterward. In larger doses it has mild analgesic and sedative properties. I've taken Vicodin after I had my wisdom teeth removed, and have also tried kratom, and not even in large amounts have I ever experienced it giving any sort of similar 'high'. It is mildly habit-forming of itself, but very mildly compared to opiates. Withdrawal after extensive use might consist of having the sniffles and feeling a bit restless for a day or two. With tapering dosages down rather than sudden cessation, nothing is likely to be noticed.

Reportedly, kratom ameliorates most, if not all, withdrawal symptoms from things like Oxycontin, heroin, etc. Expecting people to go through withdrawal is inhumane and stupid. We can deal with it without the suffering. Kratom can be gotten online from multitudes of vendors. Please steer clear of the "legal high" and 'weed shop' variety of places. In addition to being radically overpriced, their association does active harm to the community of people who use kratom reasonably. Stay away from extracts and concentrated forms (although those seem to have mostly gone away from most outlets, they were big for awhile and were bordering on dangerous) and just get simple crushed leaves. If you or a loved one wants to quit, kratom will let you do so without ruining your life.

If your loved one does not want to quit, because doing so would expose them to the full pain (emotional, physical, OR psychological) of a life they hate and which they feel traps them... your problem and theirs is not the drug.

Thank you for your detailed and educating post. I came into the comments here after Ctrl+F "kratom" on the article and finding no results. Kratom is life saving for opioid/opiate addictions, but as well as for chronic pain. My wife has been in constant chronic pain for the past few years, to the point of mostly being bedridden the entire day and not working. But doctors haven't found anything wrong with her. Perhaps it is a rare autoimmune disorder, but it remains yet undiagnosed. In the meanwhile, we're grateful to have discovered kratom, where with it she can actually get through the day nearly normally.

I am very lucky myself, as I have mostly watched kratoms story from the sidelines. I've never had an opiate addiction and I don't have any chronic pain or anything like that. I tried it originally just out of curiosity after reading some of the research, and still occasionally use it in small doses for the energizing effect. I don't find larger doses useful to me personally. But I've encountered many people that have had their lives saved due to kratom, and witnessing the way some politicians and authoritarians just so rabidly pursue anything because it's LIKE something else is disturbing. Milk has opioid receptor agonists in it. And we give milk to babies. The opioid receptors in our brains are not there as some sort of evolutionary boobytrap to enslave us to poppy plants. And there are a variety of different receptors to boot, with them not being equal.

I often do not mention kratom in public forums intentionally. It's odd. I do not hold my tongue about hardly anything, I am very talkative. But I am always afraid that one message about kratom will get read by a busybody with an axe to grind and they'll spearhead a movement to have it banned. I am glad to have seen the multiple places around the country where states tried to ban it but were met with both doctors and police stepping up and telling them "this is not a problem. Stop trying to make it one for your own aggrandizement."

But when I come across someone who deals with addicts, I always try to explain it as best I can.

Yeah, you do make a great point about when to mention something or not.

I’ll chime in anecdotally in favour of kratom as well. It has helped save multiple people I know from opiate addiction, and has helped me and others I know with chronic pain, anxiety, and perhaps most importantly, avoiding alcohol abuse.

It’s not a wonder-drug, and it needs to be respected and taken in moderation because it is habit-forming. But I believe that it’s one of the best underused tools we have for helping victims of addiction.

Kratom is fine and all but I'd hardly describe the high as "mild". I'll take it once every few months but not more often than that primarily because it feels way too nice (much of the reason why I've not gone beyond dabbling in opiates).

It should go without stating that I very much support keeping it legal and available, especially to people who are addicted to opiates.

Kratom tolerance builds insanely fast. It is extremely mild for 99% of people if used daily by the 4th or 5th day.

The only way to continue to get the effect you experience, is by following your protocol and taking months in between uses to reset.

Please note that kratom extracts are also extremely addictive and you can end up in largely the same situation as an opiate addict (minus the needles) if you go too far.

Many, probably most, opiate addicts don't use needles. Oral and intranasal are the two most common routes.

> evidence-based medicine

non-evidence based medicine that uses the made-up-on-the-spot holistic approach is upheld by the idea that there is no scientific method available because it is about the body as a whole.

I think that rebuttal is reductionist and that there could be a method that is applicable to that form of treatment.

does anybody have thoughts on that?

posting my response above but I am with you...

Sympathetic support I'd fine for people interested in kicking a habit. But when the addict doesn't want to quit? What then?

Nothing about NAD therapy? Sadly, it's an underutilized treatment for opioid addiction.

"Science"'s answer to opioid addiction: prescribe opioids, declare addict cured.

PS I'm not an advocate of treatment because they also employ shortcuts to "recovery".


Fun fact: The current standard within the US is AA/NA.

AA and NA are not only wholly unscientific, being invented of whole cloth by a layperson in the early 20th century (for context, lobotomy was a totally accepted psychological treatment for decades after 1935). There was no science whatsoever involved in AA, and indeed Alcoholics Anonymous actively resists any data collection about the efficacy of its techniques whatsoever.

It's main advantages from a US perspective are a) it's free. The costs are borne mostly in the form of churches providing basements and meeting rooms. and b) it's super churchy. We love churchy stuff around here.

So basically we kicked addiction under the rug for the entire 20th century in favor of religious hokum that refuses any objective evaluation of its efficacy, or changing its methods.

I should say, for the record, that there's a lot of people that have been helped by AA and NA, and there's indisputably good work being done there. But it's not perfect and categorically refuses to get better, and its longevity is IMHO more a result of our collective refusal to take the problem of addiction seriously in the US than anything else.

The only way to fairly evaluate a program is on the difference between it and a control intervention of some sort. Like, you can't just claim that the best students must have had the best teachers. A fair chunk of data supports the claim that people have gotten sober while in AA, which is significantly different than the claim that AA helps people. Unless you've got comparisons with control groups, "good work being done there" is disputable.

AA is all volunteer, run by people who are doing their level best to help with a monstrously difficult problem, with demonstrable success. I do think they got some things right. I don't think their work is finished, and they do need to examine their methods and the efficacy of the same.

Oh, I completely agree. I don't think AA is run by bad people or anything - my disagreement is with the level of institutional support given to AA. Decisions come with opportunity costs, and the cold logic of prioritization means that sometimes the best thing to do is to give less money to "people who are doing their level best to help with a monstrously difficult problem, with demonstrable success".

>refuses any objective evaluation of its efficacy, or changing its methods.

The reason AA works is it refuses to change. It refuses to follow fads. It makes it imperfect but also makes it very resistant to politics.

> actively resists any data collection about the efficacy of its techniques whatsoever.

Because it's Anonymous. This is part of what it is. Sucks, but that's what it is. It's an important part.

> it's super churchy.

True, it's full of atheists though, I'd be interested to see if it has more atheists than the general population. But true it does use a cult model for positive change.

> There was no science whatsoever involved in AA

But there is solid science that backs AA. Even if it was started without a scientific underlying idea.

People love to bag out AA, but as your last line says it is working for some people, studies back this.

In a future utopia where healthcare is free and drug abuse is treated appropriately there might be better but we can't toss out one of the best treatments while we wait.

The article is about family (Nar-Anon) and opioids (NA) so my comment is all a bit OT.

But let's take CRAFT from the article, without the culty bit of Al-Anon/Nar-Anon, which CRAFT removes, can it be self sustainable across the world? If not, then is it really a better cure.

> Because it's Anonymous. This is part of what it is. Sucks, but that's what it is. It's an important part.

Dude, there is no reason you can't collect medical data responsibly and with respect to privacy. Cmon man. We do a whole lot of this, all over the place. They can, they just won't.

> But there is solid science that backs AA. Even if it was started without a scientific underlying idea. > People love to bag out AA, but as your last line says it is working for some people, studies back this.

It would be untrue and unfair to say that there's nothing to AA. It's been successful, but how successful? Compared to what? IMHO, the greatest aspect of its success is its ability to let people off the hook. This is just a way for politicians to throw some 'thoughts and prayers' at a hard problem and call it good.

It's not good. It's not all bad, but you start digging into the social science research and there's a lot of progress that's been made since the 30's that AA just won't touch. AA isn't working for a whole lot of people.

But it's cheap and it doesn't trigger certain populations within our democratic society, so it's gone on and on. I think we're running out of road here, but... well, we'll have to see.

Got any better suggestions? Genuinely interested, not sarcasm. (Mostly.)

I've seen a lot of headlines about studies of psychedelic drugs and compounds having a positive impact on addicts.

There are a ton of articles out there, most seem like clickbait, but there are studies that have been done such as this one [1] which say that LSD has had a positive impact on alcohol abuse. I'm not saying this is the cure, but I do think further studies could prove beneficial.

Edit: Added pdf of paper [2].

[1] http://journals.sagepub.com/doi/abs/10.1177/0269881112439253

[2] https://www.ntnu.edu/documents/139226/8932977/JOP439253.pdf

It's happening, it's just happening slowly.

Point of fact, addiction is a disease and must be treated like a disease. This is pretty mainstream and not really all that controversial. The issue we're working through, glacially, is that in the US healthcare is for-profit and junkies are not profitable. So we just.... throw those people in the garbage. I think that's both immoral and economically wasteful. I know former junkies. Personally. And they're not garbage-- they have value and if you can get them well, they want to live a productive life.

The plain fact of the matter is that there's no business case for treating these folks-- the government is going to do it or nobody is going to do it. And the status quo is "Fuck it, send them to church. I'm not paying for a bunch of crackheads to get clean. They need to find jesus." Which is another way of saying "Let them eat thoughts and prayers."

While I appreciate the "US healthcare sux!!" sentiment, that's a pretty naive viewpoint that underestimates the difficulty of the situation imo. Are there other non "for profit" healthcare countries that have substantially better results in this area?

Not the poster you're replying to, but I'd say mindfulness and meditation. Learning to look inward can be an incredibly powerful tool for dealing with issues like substance abuse.

I think those things have a lot of value but quite a challenge for the kind of person who struggles with addiction to make the leap to having the kind of mindset that would benefit from them.

The OP suggested CRAFT and methadone are proven approaches. You could read the whole article it's informative and not that long.

Will do, thanks.

actively resists any data collection

What an overly dramatic way to restate that these orgs are anonymous.

collective refusal to take the problem of addiction seriously

Incorrect. The church, particularly Jesus, does take it seriously. Addictive and destructive behavior patterns are called sin, but because this "progressive" society continues to water down right vs. wrong and tread down a path of moral relativism (that's just like your opinion, man!), it has reaped exactly what it has sown - a lukewarm and ineffectual stance towards active repentance from sin, including the desire to help others in that process.

What have you personally been doing to take things more seriously?

My understanding is that Jesus suggested helping sinners stop being sinners, not shaming them for being sinners. And "progressive" society is all about that - helping those that have failed.

Evaluating the performance of our current approach is very much "taking it seriously". This is what the OP is suggesting.

I don't think he's advocating shaming people with problems. I think he's just pointing out that the way our culture acts like obvious sin is hunky dory is a real problem.

Thanks, glad to see someone stand up for Jesus on HN. People act like religion is stupid here, but you make a great point to the contrary. If everything truly is relative and all that matters is what you want, why is opioid addiction a problem if that's what you want?

There is good and there is evil. The attempt to deny it, as you correctly say, causes huge problems. Like how we tell school children that they are no more than evolved animals, then wonder about why they go shooting people then take their own life.

Slight issue: I don’t think opioid addicts want to be addicts. When an externally introduced chemical is hijacking your neurochemistry and making you feel some of the worst pain imaginable when it’s not there anymore, wanting the pain to stop is the most natural desire - it just happens that more of the chemical is the fastest way to do so.

There’s also the fact that it’s objectively destructive, simultaneously to society, personal relationships, and the addict. No need to even invoke philosophical good and evil there.

And I say this as a religious person myself.

> When a family member, spouse or other loved one develops an opioid addiction — whether to pain relievers like Vicodin or to heroin — few people know what to do. Faced with someone who appears to be driving heedlessly into the abyss, families often fight, freeze or flee, unable to figure out how to help.

OK, if someone wants to be an opioid addict, why not just let them? The "driving heedlessly into the abyss" aspect seems mainly due to opioids being illegal and expensive. I mean, do we use such language about diabetics? Do we expect them to manage their diabetes through diet alone?

I'm not aware of solid evidence for health risks associated with chronic opioid use alone. Excluding opioid addiction, I mean. But please do share.

A lot of people are dying from overdoses.


People are dying of overdoses because opioids aren't available legally, with regulated strength and purity, and at reasonable prices. If opiods with regulated strength and purity were as readily available as liquor, few people would be overdosing. In parts of the Middle East, where alcohol isn't available legally, methanol poisoning isn't uncommon.

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