“A crisis is a terrible thing to waste,” is a phrase coined by Stanford economist Paul Romer. Politicians are always in search of new crises to address—new fires to put out—with rapid and decisive action. In their passion to appear heroic to their constituents they often act in haste, not taking the time to develop a deep and nuanced understanding of the issue at hand, insensitive to the notion that their actions might actually exacerbate the crisis.
An example of that lack of understanding was made apparent in a press release by the office of House Majority Whip Steve Scalise (R-LA) on June 22 supporting legislation that packages together over 70 bills (H.R.6) aimed at addressing the opioid (now mostly heroin and fentanyl) overdose crisis. The bills mostly double down on the same feckless—often deleterious—policies that government is already using to address the crisis. The release stated, “Whip Scalise highlighted a Slidell, Louisiana family whose son was born addicted to opioids, a syndrome called NAS, as a result of his mother's battle with addiction.”
The press release quoted Representative Scalise:
I highlight Kemper, a young boy from my district in Slidell, Louisiana. He was born addicted to opioids because his mother, while she was pregnant, was addicted to opioids herself…this example highlights something the Centers for Disease Control has noted. That is once every 25 minutes in America a baby is born addicted to opioids. Once every 25 minutes. That's how widespread it is, just for babies that are born.
Before crowing that the “House Takes Action to Combat the Opioid Crisis,” as the press release was titled, Representative Scalise should get his science right. No baby is ever born addicted to opioids. As medical science has known for years, there is a difference between addiction and physical dependence—on a molecular level. Drs. Nora Volkow and Thomas McLellan of the National Institute on Drug Abuse pointed out in a 2016 article in the New England Journal of Medicine that addiction is a disease, and “genetic vulnerability accounts for at least 35 to 40% of the risk associated with addiction.” Addiction features compulsive drug use in spite of harmful, self-destructive consequences.
Physical dependence, on the other hand, is very different. As with many other classes of drugs, including antidepressants like Prozac or Lexapro, long-term use of opioids is associated with the development of a physical dependence on the drug. Abruptly stopping the drug can lead to severe withdrawal symptoms. A physically dependent patient needs the drug in order to function while avoiding withdrawal. Dependence is addressed by gradually reducing the dosage of the drug over a safe time frame. Once the dependence is overcome, such a patient will not have a compulsion to resume the drug.
NAS stands for Neonatal Abstinence Syndrome, a withdrawal syndrome resulting from physical dependence developed by the fetus due to the transplacental transmission of drugs being used by the mother during pregnancy. A combination of gradual opioid tapering with soothing and supportive measures resolves cases of NAS due to opioids.
In addition to opioids, cocaine can cause neonatal withdrawal syndrome, and alcohol has been long known to be a cause. In fact, much worse than NAS, Fetal Alcohol Spectrum Disorders (FASD) include head and face deformities, heart defects, and cognitive disabilities (none of which are sequelae in opioid-dependent newborns).
The distinction between addiction and physical dependence is important for a number of reasons. Because many people see addiction as a vice rather than a disease, stigmatizing a baby as being “addicted” can result in their growing up being seen and raised as manipulative and “bad.” Unlike babies born with fetal alcohol syndrome, these babies usually grow up to be normal, healthy children. It has also led some to advocate for the forced treatment of opioid-dependent pregnant women, a violation of their right to informed consent, considered an ethical violation by addiction specialists and medical ethicists alike.
The distinction is also important because the tendency of politicians and many in the media to use the words “addiction” and “physical dependence” interchangeably can conflate the two distinct conditions and feed the sense of urgency about the opioid overdose problem. This leads to policies that are not evidence-based and have unintended consequences.
For example, multiple Cochrane systematic studies of chronic non-cancer pain patients on long term opioids have shown an addiction rate of roughly 1 percent. And a January 2018 study of 568,000 patients prescribed opioids for acute post-surgical pain found a total “misuse” rate of 0.6 percent. While it is true that most heroin addicts began their opioid abuse with diverted prescription opioids, as cheaper heroin and fentanyl have flooded the market in response to the cutback in prescription opioids, more and more non-medical users are beginning with heroin. A recent study found that 33 percent of heroin addicts entering rehab in 2015 reported their gateway drug was heroin. Yet, the government’s continued clamp-down on the manufacture and prescription of opioids causes many patients—including those in hospitals—to suffer needlessly, while the overdose rate continues to surge.
The overdose crisis will only be properly addressed once it is widely understood that it is primarily due to non-medical users accessing illicit drugs in a booming black market fueled by drug prohibition. Until then, members of Congress would be well-advised to stop the hysterical rhetoric and learn some science.