America’s deadly cult of abstinence
By: Andrew Katz
Tags: Loss, Methadone, Addiction, Grief, Opiods

An impossible ideal costs lives, prevents recovery & promotes teen pregnancies

On the morning of May 23rd, 2019 I went to wake my son, Aaron, who had surprised me by traveling from Charlotte, North Carolina to visit with his mother and me while I underwent treatment for cancer. He lay supine on our living room couch, still wearing jeans and a tee-shirt. Typical. His face was covered with mucus; bubbles of saliva formed around his mouth. I thought he must have been experiencing allergies from the change of locale. I paused, awaiting the reassuring rise and fall of his chest. When it didn’t come, I touched his jean-clad leg.

And I knew. He was dead. Had been for several hours.

Aaron, my son. © the author

There is so much horror in the world, but I can imagine nothing worse than finding my beautiful only child, my son, dead.

It was heroin.

The high-quality China white that permeated our neighborhood’s drug scene, and which he himself had sold to fund his habit while living with his mother and me a few years prior. After we confronted him, he made the transition to suboxone. Suboxone is buprenorphine, a potent narcotic agonist that works much like methadone—but is even more stable—in combination with naloxone.

Aaron’s life straightened out while on suboxone. He found work in some of the city’s finest restaurants, but eventually felt the need for a change of scene, because, after all, the stuff was still right there, under his nose. He decamped for Charlotte, North Carolina. After experiencing some difficulty finding a doctor to prescribe suboxone there, he weaned the dosage down and stopped taking it altogether.

He was abstinent, working hard in the city’s burgeoning fine-dining scene. I confirmed this during a visit I made earlier that year.

So, how did he get to be so careless? To throw away all of that hard-won sobriety for a transitory high?

Easy. A dope fiend can score nearly anywhere, but as I wrote, our neighborhood was special. Subreddits confirmed it. Surely he thought: off the wagon for a few days, then back home and back to work.

What’s the harm?

We fetishize abstinence.

It’s the 100%, sure-fire AIDS prevention; it forms the core of religious-based sex ed; it’s just-say-no; it’s the road to that size 00; it’s taking the Pledge. Who doesn’t admire the qualities of frugality, restraint and self-discipline abstinence demands?

Some years ago I took a job in a neighborhood methadone clinic. Our clients came by daily, seven days a week. Rather than hustle for the next fix, most of them worked at steady jobs, supported families and cared for their children. Along with dosing, staff responsibilities included meeting with each one on a regular basis to provide counseling, which consisted of, essentially, begging them to reduce their doses.

Can you do five milligrams next week?

Two-and-a-half?

How annoying that must have been!

Small wonder clients on my roster dodged our meetings. I was always behind in my documentation, in part because it really made no godly sense to urge lower doses for people who had managed to stabilize their lives on whatever quantity they and our medical director had worked out.

We had to pretend that abstinence was the only valid goal of methadone maintenance.

Generations of TV and film writers, who ought to know better from personal experience, portray the smallest dose of opioids making the user loopy and discombobulated. Drugs like methadone and buprenorphine have side effects, of course, the most common of which is constipation. Compare that to other drugs, especially psychotropics. In her memoir, An Unquiet Mind, Kay Redfield Jamison recounts taking up needlepoint because the lithium sulfate prescribed to treat her manic-depression left her unable to read or write. It took several years for the drug to be refined and the dose titrated correctly before her literacy returned.

It’s a good thing, too, because Jamison will be on lithium for the rest of her life.

Kay Redfield Jamison ©Robert Sherbow/The LIFE Images Collection via Getty Image

The physical syndrome of opioid withdrawal isn’t as dramatic or potentially life-threatening as those of, say, benzodiazepine tranquilizers or barbiturates, but the depression that ensues can be profound and long-lasting, and leave one vulnerable to relapse, or worse.

It didn’t occur to me that abstinence need not be the only goal of addiction treatment until one day I happened to cover a visit by Dr Vivek Murthy — America’s once and future Surgeon General — to Montefiore Medical Center’s Outpatient Substance Abuse Program. Accompanied by NYC First Lady Chirlane McCray, Dr Murthy spoke with several clients of the center’s methadone maintenance program. One, Walter Ginter, is the founding project director of MARS, Medication Assisted Recovery Services.

My history consists of periods of recovery, being drug-free,” Ginter told the audience, “only to relapse into full-fledged addiction. I realized I had more stability and consistency when using methadone than during periods when I clean and sober.

Walter Ginter (second from left) talks with Chirlane McCray (far left), US Surgeon General Vivek Murthy & NYC Commissioner of Health & Mental Hygiene Mary Bassatt inside Montefiore Medical Center (©the author)

Maybe by then it ought to have been obvious. Or no maybe about it. But still, there it was. Outright heresy. Addiction treatment might have other goals than eventual abstinence. In fact, abstinence might not be the ideal outcome for some people.

Why did that take so long to become evident?

Perhaps in part because addiction theory and treatment owe a great deal to the model created by Alcoholics Anonymous, and promulgated by the many other 12 Step programs that evolved in its wake. People who ran afoul of the legal system, but weren’t true Friends of Bill W, were often exposed to AA/NA/CA/GA by courts requiring attendance at meetings as part of sentencing, or as incentives to reduce fines and jail time. As such, even the most casual, resentful attendee was exposed to the cult of abstinence, which most 12 step programs preach with the passion of religious fervor.

When I called Ginter a few months later, I asked why he was on methadone rather than suboxone — in contrast to methadone, suboxone is a class III narcotic and can be dispensed in thirty-day quantities. The user need not appear in front of a clinic window every morning.

©the author

“I worry that at my age, I might need surgery or some other major intervention,” he told me. “And if I’m using suboxone the pain meds won’t work.” This last was in reference to the drug’s partial agonist quality, which means buprenorphine molecules bind to opiate receptors in the body, generally preventing other opioids from attaching. Methadone is more readily supplanted by standard opiates such as morphine, should the need arise.

Ginter and company are demonstrating new ways to cope with drug addiction. Ways that don’t necessarily lead to abstinence.

Progress is made, but slowly.

In 2015 Governor Andrew Cuomo signed into law a bill permitting addicts receiving medically assisted treatments [MAT] to enter judicial diversion programs, i.e. drug courts. Prior to that many judges demanded the defendant abstain entirely from any narcotic substance without regard to it having been prescribed by a physician treating addiction.

Robert Lepolszki was, like Aaron, a heroin addict who had, according to family and friends, finally turned his life around using MAT, which, in his case, consisted of daily dosing with methadone. While answering a felony charge from his time on heroin, however, the judge, Frank Gulotta, Jr. required Lepolszki cease taking methadone as a requirement for diversion, or face the full fury of the law.

They [methadone or Suboxone] are a crutch, Gulotta wrote. They are substitutes for drugs and drug cravings without enabling the participant to actually rid him or herself of the addiction.

Would Judge Gulotta demand paraplegics junk their wheelchairs or blind defendants surrender their seeing-eye dogs to city shelters because these are also crutches? Either way, his brand of tough love did enable Lepolszki to rid himself of his addiction: six months after appearing before the judge, Lepolszki died of a heroin overdose.

In response to a query from NBC New York regarding Lepolszki, Judge Gulotta expressed doubt that a defendant using methadone or Suboxone was even competent to enter a plea of guilty, a prerequisite of being sentenced to diversion.

Abstinence is an ideal that ignores very human needs.

A 2007 study published in Current Opinion in Obstetrics & Gynecology concludes in part: Abstinence-only policies violate the human rights of adolescents because they withhold potentially life-saving information on HIV and other sexually transmitted infections.1

A 2011 study by Kathrin Stanger-Hall and David Hall determined: … abstinence-only education as a state policy is ineffective in preventing teenage pregnancy and may actually be contributing to the high teenage pregnancy rates in the US.2

Abstinence didn’t kill my son. But it made him vulnerable to a lethal overdose.

What he, Robert Lepolszki, Walter Ginter and millions of others experienced is the reality that addiction, like diabetes, or hypertension, or manic-depression, is a lifelong process. It doesn’t go away simply because an addict stops using.

Alas, there are no similar drugs for those alcoholics who seek sobriety following 12 step principles. They must remain abstinent. It has a place, certainly. But what might work for some doesn’t necessarily work for all.

©the author

My beautiful son is gone. Forever. And there isn’t a damned thing I can do about it, but try to tell his story in the hope that some other parent or spouse or sibling doesn’t have to endure this unimaginable pain because of society’s unrealistic and utterly inhuman expectations.

1 https://journals.lww.com/co-obgyn/Abstract/2007/10000/Abstinence_and_abstinence_only_education.8.aspx

2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3194801/