Why is Opiate Addiction So Hard to Treat?

Okay, I’ll admit it: I experience much difficulty treating opiate dependence. From heroin to OxyContin to Kratom, opiate abuse is alive and flailing in this field.

What I more specifically have a difficult time treating are the behaviors associated with opiate withdrawal: lack of motivation, constant discomfort, and hopelessness, to name a few. What this looks like in a treatment setting is resistance to treatment (resulting in early termination of treatment), pervasive irritability and affective lability, constant behavioral disruptions within the milieu, and sensationalizing the drug despite the consequences that have accompanied the addiction.

…if I don’t feel that I can always successfully treat the behaviors associated with the withdrawal from opiates, the best I can do is try to understand some of the components that make treatment… so difficult.-Lindsay Kramer
I notice that when we have a band of opiate addicts on the unit, the staff is working exponentially harder to manage these patients and to keep everyone on track than in comparison to when the milieu is lacking of this demographic. It’s said that the squeaky wheel gets the grease when it comes to attention focused on patients in treatment, and unfortunately, we often spend arguably too much time attempting to motivate patients to surrender to recovery when these “wheels” aren’t even motivated to be squeaky in the first place.

As I teach my patients to shift their unpleasant feelings toward someone to having compassion toward their difficulties that are impacting the relationship, so I must do with regard to understanding why opiate addicts struggle within treatment settings and within their overall recoveries. Therefore, if I don’t feel that I can always successfully treat the behaviors associated with the withdrawal from opiates, the best I can do is try to understand some of the components that make treatment for these addicts so difficult.

Motivation

To say that an opiate addict in early recovery isn’t motivated is absolutely inaccurate. They are motivated; it’s just a matter of what they are motivated toward. Due to the fact that the language of neuroscience is as foreign to me as is Cantonese, I will attempt to regurgitate this information as concisely as possible so that other laypeople like myself can understand it:

Person takes opiates. Opiates release chemicals that bind to the opioid receptors and produce a euphoric feeling. The euphoric feeling is better than the brain expects, so it releases the neurotransmitter dopamine to reward the user for the opiate use, which also causes the user to feel good. Dopamine is released within the prefrontal cortex and the nucleus accumbens, which both play a role in behavior and motivation. More opiates equal more euphoria, which produces more dopamine, which creates a behavioral motivation to continue to use in order to achieve the same effect. It’s a vicious cycle of using to feel good, and the good feelings leading back to using.

Here’s where it becomes more complicated.

With greater opiate use, the brain creates more opioid receptors in order to adapt to the presence of opioids, which in turn are constantly active and require more of the opiates in order to fill these receptors just to reach that same euphoric state. This is called “receptor upregulation.” Empty receptors also cause discomfort, which signals pain to the user, further perpetuating the craving for greater use in order to return to the euphoric, better-feeling state. While this is occurring, the brain is also more frequently releasing dopamine as the reward for the increased use, which is a key motivator in this process and has been determined to also be released prior to the use itself in order to jumpstart motivation for continued intake. (Read more about that here.) Simultaneously, as the brain senses the overload of dopamine due to the opiate use, it stops naturally-producing dopamine in order to balance out this new dynamic, but still craves the dopamine that is released by the opiate use. What we have now is a conditioned overload of opioid and dopamine processes, which embodies the addictive elements of tolerance, dependence, and craving.

Motivation in recovery is present, but its gaze is in the wrong direction.-Lindsay Kramer

When the addict suddenly stops using opiates, all “feel good” chemical processes come to a screeching halt, signaling an overwhelming, life-or-death motivation for the supply of opiates for which the brain was dependent. Therefore, when a person is detoxing off opiates and is newly sober, the only intrinsic motivation that they have is to obtain more of the opiate, and their thoughts, feelings, and behaviors are all constantly aligned in this direction.

They aren’t naturally motivated for sobriety because such is the opposite of what is desired by these prominent parts of their brain. Motivation in recovery is present, but its gaze is in the wrong direction.

Discomfort

As one of my patients quipped after resisting my attempt to dig deeper with regard to his unresolved family conflict, “you know us heroin addicts; we really don’t like to feel pain.” When opiate addicts first experience sobriety, not only are they in a constant state of physiological discomfort, they also endure much psychological discomfort. As the addict is conditioned to seek pleasure, they have also learned to avoid pain at all costs. While the physiological discomfort may be managed by opiate maintenance and anti-craving drugs, resolving the internal struggle of the awareness of the consequences of continued use versus the undeniable craving of the drug is an entirely different battle.

…the one substance they feel is needed to survive is the very drug that will cause their ultimate downfall.-Lindsay Kramer

The addict must reconcile the notion that despite an insatiable drive toward the drug, such a substance has only caused tornado-like wreckage in one’s life and will continue to do so if the addict succumbs to the craving for more. I can only try to imagine how painful this dilemma must be, but I do witness how much discomfort this provides for the addict in recovery as they struggle to comprehend that the one substance they feel is needed to survive is the very drug that will cause their ultimate downfall.

In treatment, we have a saying: “if you’re not uncomfortable, you’re probably not doing it right.”

As clinicians, we know that if we don’t push our patients enough in treatment, they will not strive toward growth, insight, and change. On the converse, no one wants to voluntarily take on pain when they’re already uncomfortable; it’s like requiring a person to explain the Theory of Relativity while running a marathon with a broken leg. Therefore, the discomfort that patients experience in sobriety from opiates is only compounded and displaced onto the work attempting to be done toward the goal of achieving any success in the recovery process. With that, it seems that behavioral problems, resistance, and affective reactivity are just par for the course as the addict seeks to avoid any other discomfort associated with the recovery process.

Characteristics of Young Addicts

Taking my initial self-disclosure a step further, I have a really hard time with treating young opiate addicts. Being that the treatment center I work for is located in San Diego – a hotbed of opiate abuse in general – a decent slice of our admissions are designated to opiate addicts. Moreover, heroin addiction is the bulk of that demographic; more specifically, young, intravenous-use heroin addicts. While I understand that not all treatment centers encounter the demographic of middle class, Caucasian heroin addicts that are 18 to 35 years old and are IV users, I am blown away by how stable that population is within our detox and residential treatment center. But, I digress.

Due to the fact that the prefrontal cortex (PFC) is not fully matured until around age 25, a young adult will arguably struggle with risk taking, limited judgment, and impulse control, to name a few. Furthermore, it is regarded that individuals with addictive disorders also have abnormalities in the PFC, thus continuing to impact regulation of impulsive behaviors and judgment. When young people develop an addiction to opiates, not only are they already limited in this area of executive functioning, but the opiate use also conditions the brain to continuously override risk for the sake of reward, thus seeking pleasure and avoiding pain. The result is a young opiate addict with a programmed mentality of, “feel good now, consider the consequences later.”

The result is a young opiate addict with a programmed mentality of, ‘feel good now, consider the consequences later.’-Lindsay Kramer

Because of the fact that this demographic also possesses difficulty of foresight, they don’t seem to grasp the reality of the consequences associated with opiate addiction and continued use. They may witness their friends overdosing, but there still may be a strong disbelief that such would ever happen to them. Their youth limits them from connecting to and fully comprehending the consequences. One of my mentors used to say, “there are no successful heroin addicts in life. You either quit or you die.” Attempting to hammer this concept into a young heroin addict serves as a treatment roadblock because they aren’t as capable of concretely understanding it and they truly don’t want to connect with the pain involved in doing so.

Working with the Resistance in Treatment

I loathe concluding that overcoming the effects of opiate addiction just takes time, but this often is my best answer. Unfortunately, clear information regarding how long it takes the brain to “recover” from opiate addiction and return to its normally-functioning state was nowhere to be found in my extensive research, which I understand is due to differing factors of each individual addict. In my work, I’ve heard anything from six months, to a year, to many years, which is difficult to explain to a recovering addict and family members who very much desire a definitive timeline as to when they will reach that light at the end of their seemingly-boundless tunnel. In short, it does take time for the reward pathways to retrain themselves, for the addict to overcome the overwhelming craving to use, and for the motivation to be shifted away from continued use and toward a life devoid of the illusion of pleasure.

Finally, understand that no feeling, drug, or experience will compare to opiate use. It truly is one of the most difficult addictions to overcome because of that notion. Opiate abuse in America is appalling at the moment, and increasing our awareness of the undeniable addictive potential of this class of drugs by advocating for prevention over intervention will greatly reduce the need for an article of this nature in the future.

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