The Dead Are Always Drug-Free: Why An Abstinence-Only Approach Will Never End The Heroin Epidemic

Heroin is not alcohol. This might seem like a fairly obvious and even ridiculous point to make, but there are so many people in our courts, our governments, our treatment centers and our recovery communities who don’t seem to grasp this concept that I can assure you that I’m not trying to be facetious. In fact, this seemingly self-evident statement has been so roundly glossed over in our efforts to fight back against the opioid epidemic of the last several years, that I believe it bears repeating. Heroin is not alcohol.

Naturally, when I say that heroin is not alcohol, I don’t mean that there are treatment professionals and politicians and people recovering from substance use disorders who literally can’t tell the difference between a bottle of alcohol and a baggy of heroin. One is currently legal in the United States, while the other is illegal. One is a fine powder or a vaporisable solid that is usually injected, snorted or smoked, the other is a liquid that is almost exclusively imbibed. One has a multi-billion dollar a year advertising behemoth selling it to the general public and the other has the US government spend $100 billion a year in a failed attempt to wipe it from the market. I could go on, but somehow I have the idea you’re not having any trouble determining which substance is which in the examples above. No, the main problem with the conflation of heroin and alcohol doesn’t lie within our understanding of what they look like or how society views them, but in how they effect us and how we recover from having abused them.

It shouldn’t come as much of a surprise to anyone even tangentially associated with the worlds of addiction, alcoholism and recovery that recent research has shown alcohol and heroin to be the 2 most harmful drugs on the planet (with cocaine/crack coming in a close third). The definition of what constitutes harm and how to quantify it differs from study to study, but, broadly speaking, that harm can be split in two types: harm that effects the user and harm that effects others. In David J Nutt’s pioneering study, heroin, crack cocaine and methamphetamine were all crowded at the top of the leaderboard for harm to the user, while alcohol was the runaway winner in causing harm to others, with a score that was more than double that of the next drug (heroin).


A chart showing the different ways specific drugs can cause harm.

This dichotomy between harm to user and harm to others is certainly useful, but if you delve deeper into the data, more revealing patterns about the way individual drugs cause harm begin to emerge. For instance, the study showed that the areas in which alcohol caused more harm than any other drug were economic cost, injuries and family adversities. At the same time, the study found that heroin was the most harmful drug with regards to drug-specific mortality and crime and was tied with tobacco for the most harmful drug when it came to drug-related mortality. All of this isn’t to say that drug specific mortality isn’t an issue concerning alcohol abuse or that heroin abuse doesn’t produce hardships for the user’s family members. It is simply to illustrate that these two very dangerous drugs are dangerous in distinct ways that require different sorts of interventions to ameliorate.

I bring this up because we, as a nation, have to have an honest conversation about substance abuse that goes beyond acknowledging the tragedy of the dead and those who have suffered from the mendacious war on drugs to looking at the ways in which our current approaches to treating drug addiction in this country are failing us. Beginning with the introduction and mass dispensing of the opioid pain reliever OxyContin by Purdue Pharma in the mid-90s, a series of events took place in the United States that have turned prescription opiate and heroin abuse into public health emergencies that kill enough people on their own to clock in as the 14th leading cause of death in America. There isn’t enough time to go into those events right now in specific, suffice it to say that there hasn’t been a year in this millennium’s infancy that drug overdose deaths in the US haven’t been worse than the year before.


When I got sober in the spring of 2009, the hammer had yet to drop on America’s opiate crisis. At that point it was obvious that we had a pretty big problem on our hands with prescription drug abuse, but the rise of overdoses from prescription opiates was so steady and so gradual that it never really raised alarm in proportion to the severity of the threat it posed. Based on the numbers available at the time, Rx opioid abuse seemed like it was more or less a regional problem. Certain states, like West Virginia, New Mexico and Utah, had seen their overdose death rates from Rx opioids skyrocket in recent years, but the latest data showed a national average of 4.6 overdose deaths per 100,000 people—a threefold increase over the overdose death rate from 2000 to 2006 that was troubling, but not so much so that it broke onto page A1 of the national papers. With Rx opiates,it was a like we were being boiled alive in a hot tub that was increasing in temperature by fractions of a degree every couple minutes. We couldn’t necessarily feel the hot tub getting hotter, but before we knew it there were first degree burns all over our body. The heroin epidemic has been less subtle.

If the Rx opioid epidemic was like being slowly scalded in a hot tub, the heroin epidemic has been akin to having a vat of boiling hot oil dumped over our heads at irregular intervals. We had no way of knowing it at the time, but 2010 was the year that the Rx opiate-centric first phase of the overdose crisis ended and the second phase driven by heroin began. After 15 years of profligate dispensing of Rx drugs by pharmaceutical companies and medical professionals, all of the conditions were right for a heroin epidemic of unprecedented proportions.

By 2010, the sheer size of the Rx opioid using population in America combined with significant rises in drug costs (ironically, caused in part by the government’s increased emphasis on shutting down pill mills) and the influx of cheap, pure heroin from Latin America primed the pump for the heroin crisis we have today. From 2010 to 2014, the number of heroin overdose deaths increased by 348%, rising from 3,036 deaths to 10,574 deaths over the course of 5 years. To give you an idea of the obscenely steep nature of that sort of growth, Rx drug overdose deaths increased 342% over 15 years from 1999 to 2014, meaning that heroin overdose death rates in America are growing 3x faster than they did for Rx pills.

In a word, this heroin epidemic is overwhelming. It’s overwhelming our treatment centers and our courts. It’s overwhelming our recovery support groups and our providers of medication assisted treatment. It’s even overwhelming our funeral homes and our cemeteries. Personally, I have never seen anything like it. When I first got sober, an overdose death was a shocking and horrific tragedy that would sporadically remind me of the fragility of life and the importance of staying active in recovery. Today, it’s still as tragic as it was 7 years ago, but any pretense of shock or surprise has been replaced by a numbness that covers my heart like a thick callus and can only be breeched when the dead man or woman in question is someone with whom I felt close. The stories behind their deaths are as heartbreaking as they are predictable, with the most oft repeated story being that of the man or woman who goes to treatment, detoxes and gets a few months of clean time before relapsing and overdosing on their first night out.


A photo taken at the 10th annual Harm Reduction Conference showing a woman advocating for access to Naloxone.

Abstinence isn’t always everything and, in some cases, it’s not the right thing for someone with a substance use disorder. If an alcoholic goes into a treatment center for 28 days or gets a few months of sobriety in Alcoholics Anonymous and then slips up and goes back out to drink, the odds that that person dies that night are very slim. If they continue to drink alcoholically, those odds certainly go up, as does the potential damage to relationships with family, friends, partners, employers and strangers, but the physical risks of them drinking again are more long term than they are immediate. If a heroin addict does the same thing, he or she will be lucky to live long enough to see any of the long term physical risks that come with relapse.

I know plenty of people who have found relief from heroin addiction within the rooms of 12-step groups and through abstinence based treatment centers, but I have known just as many who only managed to find their way to an early grave. We need to acknowledge that heroin is not alcohol and that the treatment approaches we take towards the 2 substances need to be tailored to the potential harm they can cause. A recovering alcoholic can relapse every few months and still greatly increase the overall quality of his life while incurring significantly less risk than if he had never stopped drinking. A recovering heroin addict cannot. All I am asking for is for treatment professionals, policymakers, recovery communities and the the courts to keep in mind that a person’s life cannot be improved if that person is dead. All options should be on the table if they have the potential to improve the health and wellbeing of someone with an opiate addiction, including Medication Assisted Treatment, the increased distribution of life-saving drugs like Naloxone and access to supervised injection facilities. There is nothing that says that someone on Suboxone can’t work a great program of recovery, nor is there anything that supports the notion that a brief stint of sobriety followed by an overdose is better than using harm reduction techniques to make an addict’s use less dangerous. We need to start meeting heroin addicts where they are, even if that’s not the place we want them to be. Who knows? If we do that, they might eventually find their way to where we want them to end up and actually stay there.

Update: As I was editing this article, The White House announced that they would be proposing a rule change that would double the restrictive limit on doctors for prescribing buprenorphine from 100 patients per doctor to 200 patients, potentially allowing tens of thousands of Americans with opioid addictions access to the medication assisted treatment they need.

Categories: Addiction, Drug News, Public Health, Uncategorized

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8 replies

  1. Excellent article. Wish it would be published broadly.

  2. Drew, thank you. for this. I appreciate seeing the data on drug harm. And “a person’s life cannot be improved if that person is dead” is the heart of the work.

  3. My best friend is in a Suboxon clinic in Alaska for heroine addiction. She’s been heroine free for 5 years, but now is a slave to the Suboxon. She can’t even go on vacation out of state to come visit me in Indiana or her fiancées family in Texas because the clinic director won’t allow it. She had tried for a couple of years to start titrating down at home, but again, the clinic director won’t allow it. She had never relapsed not had she ever had a dirty UA. While there are others in the program continually using, giving dirty UAs, and over dosing while in treatment. She has to be at the clinic at 5 am, before she had to get her kids ready for the day for school, and if she is late,she can’t get her dose after 8 am. not only does she have to adhere to a meticulous time schedule, there are some nursing staff members at her clinic who are rude, condescending, and feel they are superior because of who they are helping to treat.
    There is a HUGE problem because she has the advantages of having the help at her disposal, yet, the staff make it unbearable and make the patience worse for getting to get better.
    My best friend got addicted to heroine by her ex, and was even using while she was pregnant with her daughter. She is sick a badass because she got clean from heroine, but is now a slave to Suboxon. She just traded one for another. How is that even helping her to be sober?

    • From what you’ve been saying, it sounds like your friend is on methadone and not Suboxone. Most methadone clinics require their clients to show up at a certain time each day for their daily “dose”, which is either a liquid or a pill. Based on what state you’re in and the clinic you go to, they may allow anywhere up to a week’s worth of doses to be handed to the patient after months or years of exemplary behavior. If your friend is on Suboxone, she would be seeing a medical doctor, often in private practice, but sometimes in association with a treatment facility. Suboxone is a sublingual tab (strip that dissolves under the tongue) and, while the doctor will normally want to see the client multiple times during the first week or two–and acknowledging that a lot of this is at the doctor’s discretion–most clients will wind up getting prescriptions for weeks and even months at a time once they’re on a maintenance dose. A lot of people on Suboxone will taper down and, in many of cases, completely off of Suboxone over a period of time. There is no reason why your friend shouldn’t be allowed to travel on Suboxone, if that is indeed what she is one.

      • Drew thank you very much for this excellent article. I feel that I am obligated to chime in as well because I have 2 years in recovery from heroin. I had tried every medication-assisted treatment possible and it wasn’t enough for me to get clean- I simply wasn’t ready. Going to prison is what worked for me. It took something so drastic as that for me to beat my addiction. And I’d like to add that it was not easy- I was given no treatment for my addiction during my incarceration. I feel that I rehabilitated myself, but I am now active in a recovery program to help maintain my sobriety.

        SassaFrass, I also think that your friend is attending a methadone clinic. Although I will say that the clinic I went to treated with Suboxone as well. And Drew is correct, they offer take-home medication for clients in good standing with the treatment center. The only thing I’d like to add is that any ethical doctor or treatment center would set up a plan with your friend to taper off the medication within a certain amount of time. The goal of any good treatment program is for the patient to live life without any medication, therefore there is no need to “trade one drug for another”.

      • Medication assisted treatment is a technique, a health practice, not a moral issue. It may be for a lifetime. It really depends on the person, and what is learned about the person’s situation over time. Nobody needs a plan to stop whatever technique is keeping them alive. I have a vague desire to end my diabetes, and stop taking insulin, but I can’t sustain the effort. Is that optimal? No, but I don’t fret over my lack of willpower, self control or whatever. It is the same with MAT. Addiction, like diabetes, never goes away. What’s important is having a life, staying safe and as healthy as possible.

        I am happy for anyone who gets their life back together using any legitimate technique, and I would like to see less shaming and more support of people who are willing to do what their doctor says.

        I wish the methadone experience was better, but it’s like anything else. Some clinics have indifferent staff, management problems and poor service. Others offer more options and can adapt better to what people want to do.And there may be other factors behind the scenes. Probation and parole restrict travel and complicate things.

    • If you go to a private doctor it cost $150 for his/her visit. If you go through a program it’s free and you have to attend meetings and go once a day to get your sub just like ppl on methadone do. I learned this from my niece..

  4. Thank you for sharing this. My son is dead because the rehab he was required to attend took him off of suboxone because they were a drug free treatment center. Four months later he overdosed on one bag of heroin that was heavily laced with fentanyl. He should never have been taken off of the maintenance we worked so hard to get him on. We waited for the opening at the Dr’s office and he was heroin free for almost a year. Probation office required him to go through a rehab program which would have been fine had they left him on the maintenance that had worked for the past year. Rehabs need to change how they operate.

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