hen my patient, Marcus, wakes up shaky, exhausted, and ashamed each morning, he wants to quit using heroin more than anything else in the world. But that’s not the Marcus who is making decisions a few hours later.
Like countless people with addictions I have met in my career as a clinician and researcher, Marcus (not his real name) makes repeated, sincere resolutions to stop his drug use only to have his future self return to it a month, a week, a day, even an hour later. People like him once had no way to project their current desire to recover forward in time, and so lived in fear of their future, unpredictable selves. Today, emerging developments in pharmacology can help them parlay transitory desires to stop using drugs into lasting recovery from addiction.
Many addicted people try to bind their future selves to a commitment to stop using drugs. Some move across the country to a place where they don’t know any dealers or fellow users. Others throw away all their drugs and injection equipment. According to Thomas de Quincey, author of “Confessions of an English Opium Eater,” poet Samuel Coleridge went so far as to hire strong men to follow him around and keep him out of opium dens, instructing them to ignore his future self’s protests if the drug-craving Coleridge-to-come countermanded his sober self’s earlier orders.
Such tactics are often thwarted by the future self of the addicted person who adopted them. Like other drugs to which people become addicted, opioids cause enduring adaptations in the brain that weaken self-control and increase the urge to use these drugs. In addition, many people with drug addictions inhabit social networks that provide repeated stimuli and opportunities to use drugs.
Decreased self-control, powerful cravings, tempting environments, and fluctuating motivations to change create the roller coaster of quit resolutions and subsequent relapses referenced in the old quip, “It’s easy to quit; I’ve done it a thousand times,” that has been attributed to Mark Twain, W.C. Fields, and others.
Various psychological interventions that bolster motivation to change can increase the likelihood that someone follows through on a resolution to stop taking a drug. So can pressure from friends, family, or the legal system. Modern pharmacology now offers a qualitatively different tool: formulations of effective medications that stay active in the body for weeks or months. These allow an addicted individual to leverage today’s desire to quit into an extended period without drugs.
Such medications include an injected form of naltrexone, a drug that blocks the action of opioids, which stays in the body for a month. Another is an implant that slowly releases a stable dose of the opioid substitute buprenorphine for up to six months. Other long-acting medications are in the development pipeline.
Long-acting medications are particularly useful for people who are headed into situations where they can’t depend on their future selves to maintain their recovery from addiction. The classic example is an individual leaving a rehab program, halfway house, or other treatment facility in which drugs weren’t available and recovery was strongly supported. On the day of discharge, the patient is full of hope and commitment to change, but also has doubts as to how his future self will fare in the coming environment of ready drug availability and greater stress. A long-acting medication lets this person in the easier situation bolster his future self in the harder one.
Long-acting medications raise intriguing ethical and philosophical questions that medicine has yet to resolve. If, for example, a patient with a buprenorphine implant comes to a physician and asks that it be removed so she can use drugs more easily, should the doctor refuse or respect her wish to rebel against the tyranny of her earlier, recovery-minded self? Can an opioid-addicted person leaving incarceration truly consent freely to a shot of extended-release naltrexone offered by prison staff that will constrain his own behavior for a month after his release, or is that an act of inhumane coercion?
We must wrestle with such questions. But regardless of how we answer them, we should not underestimate the profound therapeutic possibilities of medications whose effect endures long after opioid-addicted people take them. For a disorder whose defining features include ambivalence about change, unstable but powerful desires to use opioids, and difficulty with self-control, many of the treatments we offer people with addictions often fail because they require addicted people to decide and re-decide every challenging day to take a pill or attend an appointment. For such patients, medications that let them make a good decision that their future self can’t easily revoke are truly just what the doctor ordered.
Keith Humphreys, Ph.D., is professor of psychiatry at Stanford University School of Medicine and a career research scientist at the Palo Alto VA Health Care System. He served as senior drug policy adviser in the Obama White House. He has no past or current financial relationship with any manufacturer of medications for opioid addiction.