After years of misery and upheaval in the midst of addiction, Leland Plew appeared to be in a stable place.
He had gone through a recovery program for his heroin addiction, spending 90 days among other people struggling with the same issues as he was. After he left that program, he had secured a job at Buchanan Hauling and Rigging, where his father worked. He was going to regular recovery meetings and staying away from the people who he’d hung around when he was using.
For the first time, it seemed to his parents, David and Susan Plew, that he may have overcome his addiction.
But just as their lives seemed to stabilize, he relapsed. On July 13, 2014, he died from a heroin overdose in his parent’s Center Grove area home.
Leland Plew’s story is an increasingly common one. Addiction recovery is not a straight-line process. People who have received treatment for drug use disorder have a 40 to 60 percent of relapse.
In opioid addiction, the chances of relapse are even higher — up to 90 percent in the first year, according to some studies. The drugs change the biology of the brain, which makes it more difficult to break away.
“It can take up to three years for the brain to go back to pre-drug use,” David Plew said. “No wonder it’s so difficult for people with addictions to stop. Anything can trigger it: a song, a place, certain people, a smell. It triggers the brain to remember one time you felt really good, and they have that in the back of their mind.”
Addiction is officially recognized as a brain disease, a chronic, relapsing condition in which a person compulsively seeks out and uses drugs despite continued harmful consequences, according to the American Society of Addiction Medicine.
That means the potential for relapse is an ever-present risk in all types of addiction. According to the “Addiction in America: Surgeon General’s Report on Alcohol, Drugs, and Health,” it can take as long as eight or nine years after a person first seeks formal help to achieve sustained recovery.
The report found that even people who have one or two years of sobriety are still at risk. It could take up to five years before the risk of relapse drops below 15 percent.
Research into opioid addiction and relapse is even more alarming. According to a study published in the Irish Medical Journal in 2010, 91 percent of patients who had entered an inpatient addiction treatment program for opioid addiction relapsed within three years.
Of that group, 59 percent relapsed within one week.
A study conducted by Dr. David Fiellin of Yale University School of Medicine revealed that relapse rates for those with opioid addiction approaches 90 percent by six months.
As the drugs are used over and over, the substances can change the structure of the brain and how it works.
“Self control almost isn’t even part of the story once it gets to that point of serious, long-term use. It’s not like you can use willpower to overcome it,” said Dr. Leslie Hulvershorn, a psychiatrist and medical director of the Indiana Family and Social Services Administration Division of Mental Health and Addiction.
Normally, the brain releases chemicals called dopamine to reward behavior that is beneficial from a survival perspective. Reproduction, eating, socializing with other people — all these types of activities release small amounts of dopamine that makes people feel good, and encourages them to repeat that behavior, Hulvershorn said.
Opioids take that natural process to extreme levels.
“The brain is designed so that people can feel good sometimes,” Hulvershorn said. “There’s a whole system in place for this reward circuitry. It so happens that opioids activate that circuitry in a way that’s really different than normal things that feel good. They hijack that circuitry.”
Initially, people take opioids to get high or feel relaxed. But every time someone takes an opioid, it changes the brain’s circuitry more and more, Hulvershorn said. The normal activities that used to be enjoyable, such as your favorite meal or seeing your favorite band in concert, no longer make a person feel good, Hulvershorn said.
As those pathways are changed and the normal function of the brain altered, people no longer feel as good when they take drugs. Instead, they use simply to avoid withdrawal symptoms such as irritability, cramps, nausea and vomiting.
“Withdrawal takes over that person’s life. They’re battling the fact that they no longer feeling good normally because their reward circuitry is damaged, and they’re having these horrible sick feelings all day, every day,” she said.
The drugs shape the brain’s memory center, inhibitions and motivational systems, essentially hijacking the entire function of the brain to focus on the next hit.
“It really focuses on stimulating the drive on use. It’s an insidious thing,” said Kim Manlove, a recovery coach with Fairbanks, an Indianapolis alcohol and drug treatment center.
With the high rate of relapse comes an increased chance of overdose and death. In 2016, more than 50,000 people died from overdoses of heroin and other opioids, according to the National Institute on Drug Abuse.
After someone stops using opioids during the recovery process, their tolerance for those drugs goes down.
Where the brain had been able to handle a certain dosage during the height of their use, now that same amount produces a much greater effect, Hulvershorn said.
Because opioids impact the part of the brain that is also involved in important life functions such as breathing, you breathe less and less often.
“Eventually, you breathe so rarely that your brain doesn’t get enough oxygen, and your heart doesn’t get enough oxygen, and you die,” she said. “It doesn’t take much for that to start happening.”
The strength of different types of opioids also are all different, Hulvershorn said. A drug such as heroin is similar but slightly more powerful to morphine, the drug that it is made from.
Fentanyl, a prescription pain reliever, is 50 to 100 times more powerful than morphine. Another drug derived from fentanyl, called carfentanil, is 10,000 times more potent than morphine.
Those different strengths make them more lethal, Hulvershorn said.
Reducing the risk of relapse and thus of overdose requires a multi-faceted approach to addiction, Manlove said.
Breaking through those intense cravings and helping people repair their changed brains so that they don’t need to go back to the drugs requires extensive long-term treatment, counseling and support.
Part of the reason that U.S. is seeing such a crisis with opioids is that historically, the treatment model has been on short-term inpatient care, Manlove said.
They go to detox, they quit the drug and they receive some short education about addiction. If you don’t treat addiction like a chronic disease, then it becomes more likely that they relapse, Manlove said.
Medication-assisted treatment is the pillar of the first goal, using clinical opioids such as methodone and suboxone. Highly regulated doses of these substances allow the brain to begin a detoxification process without triggering the very powerful withdrawal symptoms that people addicted to opioids suffer from when they quit cold turkey.
Over the course of five to 10 years, people with serious opioid addictions who are in recovery without medicated assisted treatment have about a 1 in 100 chance of successful sobriety, Hulvershorn said.
“There are certainly people in the world who have recovered from opioid use disorders without medication,” she said. “However, it’s so rare that it happens. I wish that wasn’t true. I wish we could say, ‘Go to therapy, and that will take care of the problem.’ But it just doesn’t work out that way.”
Relapse also occurs because of the support system, or lack there of, around someone who is using opioids. As their addiction becomes more involved, people tend to spend more time with others who use opioids. All of the places they would hang out are associated with use, and the friends and other people central to their lives are using drugs, Hulvershorn said.
Starting recovery and trying to stop using opioids also means leaving behind the social circle they rely on.
“They’re surrounded by the use,” she said. “You have to get the treatment, and extract themselves from all of the social problems that have resulted from their use. Honestly, I don’t know why more people are using. It’s takes over in a way that’s really hard for people to get away from.”
With the biological response to addiction managed, the longer, more complicated process involves counseling and support groups to restructure their social lives, Hulvershorn said.
“They’re not constantly surrounded by all of these other forces that make it easy to use,” she said. “That process is not fast.”
At the root, a person in recovery needs to start feeling good about themselves again, Hulvershorn said. Getting a job, spending time with your family and exercising are all building blocks to increasing self-esteem. They start to realize that life can be normal without drugs.
Unfortunately, that requires a level of support that many people don’t have, Hulvershorn said.
“You need to have enough money to do those things, you need a house to live in, you need food,” she said. “That’s not going to come from one place, it’s going to come from a diverse array of places.”
The United States is in the midst of the worst drug epidemic in history.
Opioids, including prescription painkillers, heroin and fentanyl, are killing Americans.
The Daily Journal is taking a yearlong look into the public health crisis that touches nearly every segment of our community and crosses all socioeconomic lines, from families who lost loved ones to health and law enforcement workers on the front lines.
Addicted & Dying also will explore solutions and a path forward.
On Monday, we explore what families can do when a loved one of any age is addicted. On Tuesday and Wednesday, we share the stories of two men who died from their addiction disease.
Have an idea for our project? Contact us as 317-736-2770.
Addiction: Addiction is considered a brain disease and a chronic, relapsing condition. Opioid drugs change the brain.
Stigma: Families affected by cancer, Alzheimer’s Disease or Parkinson’s Disease get help and support from the community. Families affected by addiction often struggle in silence due to the stigma attached to addiction, which is an obstacle to recovery.
Number of deaths: 32 in Johnson County in 2017, not including people who die at an Indianapolis hospital.
Hospital visits: 105 people in Johnson County went to emergency rooms for treatment of an overdose in 2015, which is similar to numbers reported from other, larger counties, such as Allen or Hamilton counties.
Prescription rate: For every 100 residents in Johnson County, 84 opioid prescriptions were written in 2016.
Sustained recovery: When a person in recovery from an addiction has been in remission from use for at least one year.