Monthly Archives: October 2011

Good Drugs and Bad

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I’ve talked before on this blog about the fear patients and physicians often have that treating addiction with buprenorphine is “only trading one addiction for another”. While this might technically be true, it’s a phrase that ignores the huge material and medical improvements to patients’ lives that buprenorphine gives by eliminating the high-withdrawal cycle of active drug abuse. (Not to mention putting a stop to the destruction of the brain and other organs by toxic substances.)

The problem here is that there are a lot of fine distinctions between the normal course of the disease of addiction and the controlled, symptomless “addiction” of buprenorphine, but people who don’t know a lot about the field of addiction medicine aren’t likely to see that. And it’s mostly people who don’t know about addiction medicine — voters, lobbyists, abstinence care providers — who control the way it is seen by the public and dealt with by the law.

There is a similar confusion I often hear about “prescription drugs”. Lots of people know that misuse and overdose on prescription narcotics cause a huge number of deaths every year. There’s a general sense that we have to reduce the number of drugs being prescribed, because more drugs leads to more death. So when physicians like me who realize the need for medication treatment of addiction try to push for the power to prescribe more medication, we are met with resistance from the belief that prescription drugs kill people, and are bad.

While this is an understandable response to the amount of drug deaths we see yearly in the U.S., it is also an overgeneralization that actually does a great deal of harm to everyone involved. It’s true that many kinds of prescription medication, especially narcotics, can be and are abused. It’s true that patients often scam multiple doctors to get prescriptions for these kinds of medications, and that the best way to cut down on their abuse would be to keep a stricter watch on prescriptions and reduce the number of prescriptions given out. So how can I advocate for wider prescription?

There are several very important distinctions that “prescription drugs” fails to acknowledge. The first, and maybe most important, is that it’s virtually impossible for a patient who is already addicted to opiates to lethally overdose on buprenorphine. Once the opiate receptors are fully saturated, taking more buprenorphine will have no appreciable effect. So while it can certainly be diverted to the street and shouldn’t be given out indiscriminately, buprenorphine is infinitely less dangerous than ordinary prescription narcotics and benzodiazepenes. It also carries fewer health risks in and of itself than many stronger opiates.

Secondly, buprenorphine by definition is a medication used to treat addiction, and therefore would only be prescribed by physicians who are knowledgeable about treating the disease of addiction. It’s my opinion that the root of our prescription painkiller problem today is physicians who don’t know or don’t understand the addictive effects of the medications they prescribe, and aren’t willing to deal with the addictions of their patients. Over-prescribing of opiates and narcotics has led to a rise in the incidence of the disease of addiction, and now new, different medications are required to treat this disease that we created.

A good way to think about this problem is by analogy to viruses and vaccines. It seems non-intuitive at first that exposure to a virus could help you avoid the problems caused by that virus, but that’s exactly how vaccines work. It’s also how buprenorphine works; by introducing a safer, more predictable, more controllable version of the problematic prescription drugs, we can prevent and alleviate the problems they cause, from crime rate spikes to the deaths of celebrities.

There is no such thing as a “good drug” or a “bad drug” — all drugs can be good when they’re given and taken in the right circumstances, and all drugs can be bad when they’re abused. Saying that all prescription drugs are bad is a shortsighted assumption that can do long-lasting damage to patients and physicians alike.

Moral Lessons

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Last week on this blog I shared the story of one of my patients, and how her situation illustrates that the truth is never simple, especially not when it comes to healthcare and the management of debilitating diseases. This week I want to talk about the same complexity from the treatment side of the problem.

12-step programs are often concerned with addiction as a “spiritual and moral” disease, instead of (or in addition to) a physical condition. Most 12-step programs incorporate moral lessons into their treatment plans. Possibly the most common moral lesson, and one of the most important, is the idea of “letting go”, of turning control over to a Higher Power, which is almost always synonymous with God. The point of this step is to “teach” humility and help patients to “let go of their pride”.

Humility is one of the core values that 12-step programs try to impart to their patients. Yet, looking to the people and organizations who run the programs, humility doesn’t seem to be among their core values. Each and every 12-step program insists that it is the only possibly path to recovery, that it is the only one capable of giving patients the wisdom they need to overcome their “spiritual” shortcomings. The plain truth of the matter is that no particular model or program can show recovery numbers that stand out; nearly all have a very low overall recovery rate. Those that can boast more impressive recovery rates can usually only do so to the extent that they include treatment of addiction’s physical causes in with their “spiritual” treatments. This is because teaching moral values, even good moral values, won’t help cure someone of a physical disease. To people who are sick and suffering, the message often won’t even get through.

It’s easy to see why each of these programs needs to paint itself as the only one that works; in a market where no one product is distinguished by superior quality, all programs depend on marketing to convince potential customers to choose them. It’s a ploy, one that can play on a customer’s need to feel that they are getting exclusive or secretive treatment, that not everyone has access to. In the worst cases, it’s little more than a snake oil pitch.

But again, we have to remember that the truth is never that simple. Many people who run and participate in 12-step programs honestly believe that their program is the best, perhaps because they went through it successfully, or knew someone who did. There are any number of ways that passionately convinced people can dismiss or argue against numbers that indicate a pretty standard failure rate across programs. It can be difficult to see the faults of a system while you’re in the middle of it.

I don’t support the methods 12-step programs use to treat their patients, or the hypocrisy that the 12-step business model seems to make necessary. AA and NA, since they are non-profit and therefore aren’t competing for customers, are much less dependent on this sort of “marketing”; they function more as amateur community support groups. There is certainly a place in the field of addiction for such support groups, although they should never be the primary form of treatment.

12-step programs make money by selling a system of morality to their customers — a system which their own business model often makes impossible for them. It’s always difficult to negotiate a relationship between medicine — the relief of human suffering — and money; the American government is seeing the fallout from a poor medicine-money relationship right now. But a business model that encourages lying to customers in order to convince them to choose one service over another is predatory and should not be allowed to continue.

Simple Truths

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The truth is never simple.

This week, I discovered that one of the patients in my office is a drug dealer. While she is seeing me for her opioid addiction and getting buprenorphine prescriptions, she continues to see her regular doctor to get prescriptions for her narcotic pain pills. She then sells the narcotics on the street. She is defrauding her insurance company, lying to multiple doctors, and enabling other addicts by illegally making prescription narcotics available to them.

She is also a 76-year-old grandmother, widowed, and barely able to walk due to scoliosis — the reason she was taking addictive prescription narcotics in the first place. She lives with her son, who helps to take care of her. Both this woman and her son are on Medicare and disability, and her profits from selling narcotics are a significant part of their income and is absolutely essential for them to make ends meet.

Selling drugs is criminal and morally wrong; in addition to harming those who buy the drugs, it has long-lasting consequences on the entire healthcare system. “Diversion” — when prescription drugs are sold on the street rather than being taken as prescribed — is a major issue in pain management and addiction right now, and it’s one of the reasons that many physicians are so reluctant to treat addicted patients.

The selling of drugs illegally also reinforces the connection between substance addiction and crime; it familiarizes younger addicts with criminal behaviors, but also casts undeserved shame on people who have never committed a crime but are addicted to prescription narcotics due to illness and injury, like this woman herself.

Clearly what my patient is doing is wrong — but saying she is “weak”, or a bad person, becomes difficult. Here we have a woman who is desperate and disabled, just trying to survive. The Occupy Wall Street movement which has recently spread throughout the country is teaching us just how much desperation and anger exists among people trapped in poverty and unemployment, and how desperate situations can lead to desperate acts. The Occupy movement has been ridiculed for not having a clear agenda or offering solutions to America’s financial problems, but this is foolish, and it’s a distraction from the really important thing; that it doesn’t matter whether Occupy Wall Street has a clear agenda. What matters is that it is happening. People are spontaneously gathering all over the country to express their frustration with the economy. That this is happening at all is a clear sign that this country’s social, economic, and medical systems are massively, disastrously broken.

My patient is not connected to the Occupy Wall Street movement, except for the fact that her situation is a symptom of a massively broken system. Just the fact that she is forced to sell her pain pills in order to make ends meet is a sign that something has gone terribly wrong in the Social Security systems meant to keep her out of poverty, and the medical systems that are meant to effectively manage her treatment.

Her terrible situation does not excuse her from the responsibility of the harm she’s caused by selling illegal drugs. All talking about it can do is help others understand the root of the problem, which is the only way we as a society might have a hope of solving it. And if nothing else, this goes to show just one more way in which the public, “commonsense” perception of drugs, drug addicts, and even drug dealers is far too simple, divided, and prejudiced to approach the deeply complicated truth.

Self-esteem and Treatment

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Addiction treatment is often a very turbulent and even painful period in a patient’s life, for reasons that may or may not be directly connected to their treatment. Often patients are driven to seek treatment by a traumatic event in their lives — the death of a loved one, the “intervention” of friends and family, or legal troubles that require them to get “clean”. This
is one reason why my office will recommend counseling to those who want it, since pure medical treatment of the disease sometimes leaves behind emotional and interpersonal issues in a patient’s life that should be addressed.

Every patient’s life is different, but one problem that I see many of my patients wrestling with a lack of self-esteem. If it seems odd that self-esteem should be an issue in addiction treatment, keep in mind that, no matter what kind of treatment is used, overcoming addiction is often a long and arduous process. Even with medication — the kind of treatment that causes the least physical suffering — an addiction patient often has to
adjust their life in major ways; whether it’s finding a new drug-free social circle or dealing with the effects their illness and treatment are having on friends and family, the challenges of addiction treatment can be ongoing and severe. Without some belief in their own strength and ability to cope, some patients can find it next to impossible.

Unlike removing their cravings for addictive drugs, this isn’t a problem I can easily solve for my patients. But it’s clear to me that something needs to be done to help give addiction patients more faith in their own ability to manage their health and cope with the hardships of treatment, they need to be empowered — the same sort of general encouragement that is often available for people recovering from other diseases, like cancer, or from major surgery. It is recognized in these areas of medicine that optimism and self-esteem are valuable tools in recovery, and they are encouraged by medical personnel and by friends and family. In addiction this, like so many other aspects of care, is largely ignored, and many treatment providers still try to shame patients out of their desire to use, which only makes things worse. A person suffering from addiction will most likely try to eliminate feelings of shame and guilt by relapsing to their drug of choice, not by pulling themselves up by their bootstraps to do a better job.
Building self-esteem and self-empowerment in this patient population is a complicated and delicate process. It is best accomplished after patient’s cravings and withdrawal  symptoms have been treated with medications as the relief of these symptoms will at least give patient the ability to refrain from using. Expecting patients to refrain from using in the face of intolerable withdrawal symptoms will only expose them to another potential
failed attempt at changing their lives and will continue to pile on the shame, guilt, and feelings of helplessness and worthlessness. The current most commonly relayed message to those suffering from the disease of addiction by most treatment programs based on 12 step phiolosphy is still shame, guilt, and helplessness. These messages to those who are addicted must stop before we can make significant progress in treatment. As I’ve said a thousand times before, addicts are sick, not evil; and sick people deserve
treatment, not punishment.
As a physician, I sometimes find it difficult to walk the thin line between encouraging my patients to think positively about the future and giving them false hopes about what addiction treatment is currently capable of. I am also mostly powerless to help them with the consequences of bad decisions in their lives, and the patterns of bad decision-making that may have accumulated over the years of their addiction. Nonetheless, as people with a serious medical condition, addiction patients deserve the same encouragement that  cancer patients routinely receive; that they are stronger than their illness, that they can beat their condition and return to their normal, healthy lives.