On a Tuesday morning last month, Dr. Jonathan Avery welcomed me into his office for a demonstration of how to use naloxone (better known by its brand name, Narcan) to reverse an opioid overdose. Although the drug has no major adverse effects, until later this year, New York State requires people to get some training before they can administer it. Dr. Avery, the vice chair for addiction psychiatry at Weill Cornell Medicine, had conducted many such trainings, and in his office that day he got right to it. He held up a small white plastic squeeze bottle, pressed the release button and watched as a tiny mist of Narcan burst from the nozzle. “That’s it,” he said.
The F.D.A. recently approved Narcan for over-the-counter purchase, an important step in making it accessible to those who might need it or be in a position to give it to someone who’s overdosing.
Still, the drug has yet to become a standard part of the public’s tool kit. It’s not something you can count on every store and restaurant to have on hand, and I don’t know how many subway cars you’d have to walk through before you found someone with a dose in a backpack. Why, I wanted to know, should something that could save a life remain out of reach?
Dr. Avery, whose research is in negative attitudes toward addiction, says it’s because legal and regulatory issues were only part of the problem. The bigger obstacle is stigma — the tendency to view addiction as a moral failing, a deficiency of character. It shapes the language we use to talk about addiction and the responses we think are appropriate. In a 2010 randomized study, respondents were more likely to agree that a person should be punished for drug use when they were described as a “substance abuser” than when they were described as someone with a “substance use disorder.”
The stigma of addiction is so strong, Dr. Avery said, that it’s even visible in arenas that should be the safest for people who need treatment. He has found that the attitude of medical providers toward addiction is worse than toward any other psychiatric condition. “Doctors aren’t special,” he noted. “In fact, we’re more likely to struggle with addiction than our age-matched peers.”
That’s particularly appalling given that the opioid crisis has been driven heavily by painkillers that were originally prescribed in a clinical setting. Patients dealing with chronic pain have few other options for treatment; insurance often pays for OxyContin, but not physical therapy and other less risky interventions. For many who are addicted to opioids, the alternative is often to live with debilitating pain. It is certainly not a character deficiency to want to not suffer.
Fighting addiction by stigmatizing those who use drugs is the same logic as fighting out-of-wedlock sexual activity with abstinence-only sex education, abortion bans and high barriers to obtaining contraception. And it’s the same mind-set that believes if a teenager does have sex before marriage, it is acceptable to punish her with unwanted parenthood. As a deterrent it’s cruel, and by the way, it doesn’t work.
I first met Dr. Avery last year because I thought I was drinking too much when I was out socially. I had read about Naltrexone, a drug that curbs cravings for alcohol, among other substances, by short-circuiting the mechanisms in your brain that make you want to have one drink, and then another. Until I found him, I had trouble finding a psychiatrist who was even familiar with it; one who had never heard of it suggested that it might lead me to drink more. Naltrexone works for me, and would for a lot of people — many of whom would never opt for total abstinence or need an intermediate step to quitting altogether. That’s the idea behind the harm-reduction approach to addiction: Forget all-or-nothing demands and focus instead on what’s actually going to help.
Dr. Avery and I grew up during the Just Say No era. We were bombarded with overwhelmingly negative images of addiction. He remembers police officers with drug dogs going to his school to make scary presentations. I remember my fifth grade teacher making us memorize street names for obscure drugs and reciting horror stories about even casual use of marijuana. “I think we’ve run the experiment of shaming people, imprisoning people, punishing people for their addiction,” Dr. Avery said. “That doesn’t help.”
What’s fascinating to me is that Narcan does help — even if it isn’t actually administered. At Weill Cornell, Dr. Avery found that simply training emergency room providers in how to use Narcan and having them keep it on hand changed their attitudes toward people who might need it. A 2019 study found the same thing: In a survey of primary care trainees, 33 percent of primary care trainees initially agreed with the statement “Increased public access to naloxone will increase risky opioid use.” After they were trained on how to administer Narcan, that number fell by more than half. Perhaps more striking, almost a third initially said they did not agree with the statement “I would feel comfortable having opioid-dependent patients come to my practice.” After Narcan training, that number fell to zero.
Training alone — just handling Narcan, learning how it works — was able to shift attitudes, and that results in better outcomes for patients. “If you can keep people alive,” Dr. Avery said, “hopefully, you can get them into treatment.”
I took home a Narcan kit and am planning to buy an extra one to keep in my bag. I’d be surprised if I ever end up using it on anyone, but it’s a small step that we can all take toward accepting addiction as a tangible part of the world rather than a faraway abstraction. And there is very good reason to think that even this small step can shift attitudes and help people with addictions get the care they need. Instead of punishing people, I’d rather help give them an opportunity to get better.