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 14^th 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.

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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

Tags: 12-step programs, abstinence-based drug treatment, addiction, alcoholism, Buprenorphine, Drug and Alcohol Treatment, drug overdose, drugs, harm reduction, heroin, Opioids, public health, Rx opiates, suboxone, War on Drugs