Studies and Blame

Posted on by
Reply

A study was published in the Archives of General Psychiatry this week with the aim of determining the effects of counseling on addiction treatment with and without maintenance medications like buprenorphine. The results and the response to the study were, for me, completely unsurprising. The abstract linked above reported that counseling had no significant effect on patient recovery at any stage of research, and that treatment with buprenorphine and naxolone produced a tenfold increase in the number of patients with “successful outcomes”. Once medication was tapered off, success rates returned almost to baseline (8.6% successful outcome, compared to 6.6% successful before beginning medication). The study concludes that “[p]rescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment: if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling [...].”

The results of this study are unambiguous. It is concrete evidence for what I have been saying to my colleagues and patients for years: counseling, while it has its place in patient care, is not a sufficient or even particularly effective  treatment for the medical condition of opioid dependence. This is not revolutionary or counter-intuitive. There is no chronic medical condition on Earth that can be cured by counseling alone. Neither high blood pressure nor diabetes would show a counseling effect if tested in a similar study. Yet officials in the field of addiction continuously demand counseling as the sign of a valid treatment strategy.

What really surprises and upsets me about this study is the reaction to it, as expressed in this article from Addiction Professional. The very first paragraph of the article cautions that because the results for counseling were “disappointing”, the study required a “careful read” and in fact “should not be interpreted as diminishing any role for talk therapy”. Never mind the fact that counseling has been empirically shown to be ineffective when not combined with a well-informed medical treatment strategy; never mind that, even before this study, counseling-based addiction treatment programs have had abysmal success rates for decades. None of that is any reason to think there might be a diminished role for talk therapy!

I do happen to think that talk therapy should take diminished role in addiction treatment, but that isn’t even the most upsetting part of the article. It goes on for several paragraphs to express surprise at the fact that, once the medication was taken away from the patients, many stopped doing well; this culminates in one of the final sentences, in which a quote from Roger D. Weiss of Harvard Medical School blames the patients for the failure of counseling to make a good showing in this study.

Weiss’ quote implies that the counseling failed to make a difference because “[Patients] wanted the medication — that’s what they were there for.”

This trend, of blaming patients for not wanting to improve, is a despicable and predatory practice that goes back to the earliest days of addiction treatment, and would never be tolerated in any other field. It’s one I have written about a great deal, so I won’t go into again here, except to say that a more medication-based approach to addiction treatment would do a great deal to weed this idea of sickness as a moral failing.

The study published this week did a great deal to advance the study of addiction treatment, and it is my fervent hope that as time goes on this data, like all empirical data, will be used to create a more effective and comprehensive system of treatment in this field.

A New War on Drugs

Posted on by
Reply

 

A great deal is made of the ‘War on Drugs’ in this country, and while it’s important to try and keep illegal drugs from falling into the wrong hands where they can be used for harm, there’s a much easier and possibly even more important battle over drugs that we simply aren’t fighting.

I’ve mentioned the epidemic of pain pill abuse a few times before on this blog. Prescription narcotics rank among some of the most addictive substances, activating exactly the same systems as heroin and cocaine. While they do have legitimate uses, they also have a huge potential for abuse — one that very few doctors, legislators, or even patients seem to be aware of. And while I’m always in favor of educating people about the nature of addiction, the epidemic of pain pill abuse has passed the point where education alone will be enough to stem the tide. It has been reported that 3% of the nation’s physicians supply more than 67% of the pain pills, a vast number of which get diverted, or are taken because of addiction rather than chronic pain. Those 3% of physicians must be aware that at least some of their patients are inappropriately dependent on the medication, and yet no attempt is made to limit it. No, education alone is no longer the answer in this battle against rampant abuse of drugs.

Thankfully, this battle isn’t one that requires actual violence, like the devastating fighting that can occur when police try to seize quantities of dangerous illegal substances. Fighting pain pill abuse won’t require us to police the nation’s borders against well-armed cartels of smugglers and profiteers. We know exactly where the the massive supply of inappropriate pain pills comes from; the prescription pads of physicians. Every prescriber of these pills is registered as a physician, and is a well-known figure in their community. All it would take to fight this epidemic is a few sentences written into the law restricting overprescription of painkillers, and a few DEA agents with a computer. That’s all it would take to essentially shut off the supply of prescription pain pills that are being diverted or taken inappropriately. Physicians who prescribe buprenorphine for addiction are limited to 100 patients each; if we exceed that limit, the DEA comes calling. How is it, then, that while we are kept strictly to our limit, other physicians can write for thousands of patients to get an unlimited number of painkillers, without any monitoring of progress or tracking of prescriptions? Take Michael Jackson’s death as an example. How was it possible for a single physician to order that many medications without a single red flag going up anywhere in the records of some pharmacy or pharmaceutical company? How is that no one every questioned him? If all the medications were for a legitimate course of treatment, they needn’t have been stopped, but it should at least have been looked into. The lack of oversight when it comes to prescription painkillers is appalling.

I understand that government intervention is often inefficient and can easily go wrong, but in this case it is vitally necessary. I have had more than one patient who was caught scamming my office, taking buprenorphine prescriptions while also going to another doctor for narcotic pain pills, either to take them in conjunction with buprenorphine or sell them on the street. These patients are usually discovered via the pharmacy, the point where their two prescriptions interact. The thing we need to do, then, is get the pharmacies on board and begin tracking some of these prescriptions from the point of sale. Obviously we need to protect the availability of narcotic medications for all those who need them for legitimate purposes, but there also needs to be some effort to control what is, in fact, a dangerous family of substances with therapeutic potential. Our current strategy — completely unrestricted flooding of the market — is resulting in nothing but widespread addiction, overdose, and massive diversion of prescribed medications.

Good Drugs and Bad

Posted on by
Reply

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

Posted on by
Reply

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

Posted on by
Reply

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

Posted on by
Reply

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.

Addictive Personalities

Posted on by
2

We used to think of addiction as a moral sin — something that happened to people who were weak, or sinful, or broken in some way. Over time, this view grew into the perception of addiction as a moral failing, or some type of personal deficit that made some people become addicts and others not. The first few haphazard attempts to medically describe the disease of addiction still held onto this viewpoint, that addiction was caused by an inborn character weakness; eventually this gave rise to the idea of an “addictive personality”, a vague series of personality traits thought to cause addiction.

The concept of an “addictive personality” as a cause of addiction has been discredited for years, ever since physicians have begun to think of addiction as a physical disease and not an inbred moral issue. It became clear that certain chemicals had the potential to addict anyone, regardless of personality, and before long most serious medical  discussions had abandoned the concept of an addictive personality altogether.

Now, as we struggle with the concept of addiction as disease of the brain, those who work with addicts still have to deal with the many “bad” behaviors that those with addiction display. We have also started to realize that to some extent many people with addiction display many of the same characteristics — poor judgement, poor evaluation of risk/benefit analysis, impulsevenss, easy boredom, craving for excitement, difficulty learning new
behaviors, lying, and others.  These clusters of behaviors seem to be common to many suffering with addiction; in other words, they appear to form a pattern of behavioral symptoms that are linked to the physical disease.

Do these behaviors arise because of the addiction and the neural damage it can cause, which would make them a set of acquired cognitive deficits secondary to the development of addiction?  Or are they a set of dormant, inborn characteristics that exist in our patients that are pre-disposed to developing addictions (which we know have a genetic component)?  We don’t know the answers to these questions, and they will be very difficult to study, partly due to the complexity and misunderstood nature of addiction, and partly because it develops at a very early period of life when a person’s full personality is not yet formed. If, at some point, it can be proven that these behavioral traits come before addiction and contribute to its development, then perhaps there is a definition for an addictive personality disorder after all.

The discussion of a possible “addictive personality disorder” is not about developing a new way to label addicts, or trying to go back to the concept of addiction being some type of inbred defect. If there were a cluster of personality traits that we could recognize as being suggestive of the development of an addictive disorder, then perhaps it would lead to early
recognition of a “pre-addiction” condition that might be amenable to early recognition, intervention, and prevention. Even if we can prove that an “addictive personality” exists, it should still not be seen as a defect or a moral failing; like other potential personality disorders, it is due to factors beyond a person’s control and merits treatment, not punishment.

The brain is such a complex system that there are certainly undiscovered connections between chemicals and behavior still waiting to be uncovered. I am looking forward to physicians and patients moving forward together to advance treatment and prevention of this disease.

The Physician’s Position

Posted on by
Reply

Working in the field of addiction has the tendency to put M.D.s and other health care professionals in a very unusual and often disorienting position; we are expected to give in to the instructions and demands of ‘counselors’ and other self-proclaimed addiction experts who are not professionally  or medically trained. This is often very frustrating to us when we attempt to make our voices heard. We are used to being respected for our education, the number of years that we have put into training, our professionalism, the standards we try to uphold, and our expertise regarding issues of human health and disease. Yet, in this particular field, we are often viewed by others as knowing less than the patients we treat. And it’s all because most doctors and highly-trained professionals don’t have a personal history of addiction.

I have experienced this strange anti-non-addict prejudice many times in my online discussions with representatives of 12-step programs. (In one memorable argument, I was ridiculed for having letters after my name — as though the ‘M.D.’ was a pair of mystic runes that prevented me from seeing the truth.) Trained doctors are relative newcomers in addiction-related fields. Our profession has not, historically, been the one leading the treatment of this disease. In fact, many blame us for ignoring addiction, not understanding it, offering false hopes, enabling it, or in fact being a major cause of it through our prescription pads. And while it’s true that mismanagement by uninformed doctors has been a contributing cause of addiction — particularly addiction to prescription painkillers — that is reason for more doctors to come into the field and get the education to understand this disease and its causes. Efforts to keep physicians out of addiction certainly won’t help us understand and deal with addiction as a disease.

I’ve seen it said often that “nobody understands but another addict”. This attitude does not exist anywhere else in medicine, and I am not sure where it comes from. While it can certainly be helpful and emotionally supportive to speak to someone who’s shared the same problems you have, there is a limit to this idea. Cancer patients don’t refuse to be treated by doctors who have not themselves had cancer. A patient with chronic headaches won’t storm out of a doctor’s office because the doctor doesn’t have chronic headaches and “wouldn’t understand”. Physicians are trained to be able to offer help, understanding, and compassion to patients in many different situations. In fact, a physician who has specialized in treating a particular disease may “understand” better than the patient what the disease is doing to their body, and how to fix it. Most people who have a problem are anxious to explain their problems to others, to make them understand what it is like from their viewpoint, and to seek their understanding and help. Only in this field does there seem to be this rejection of assistance from those who have not had addiction problems.

I believe that the tide is changing, and that physicians do have both a stake in this disease and some very valuable ideas to offer, which is why I write this blog. There are certainly going to be some bumps in the road, and physicians will have to prove that they are compassionate and competent in treating addiction, but there is only so much proof that can be offered. I am afraid that no amount of successful care from trained professionals will convince some of those who cling to ineffective treatment methods and are not interested in learning anything new.

Medication Metaphors

Posted on by
Reply

I have many patients who have been stable on Suboxone for a long time, sometimes for years, who come to me and ask to taper off their dose in the hope that they can get off the medication altogether. I have used blood pressured medication and insulin as examples to explain why Suboxone is a maintenance medication that needs to be taken continuously, but these patients never seem convinced. They feel that they are not ‘succeeding’ or are not ‘sober’ while they are taking the medication, even if they are living full, healthy, happy lives. I’ve talked a lot on this blog about why I believe people come to feel this way, and why I disagree with their reasoning. I haven’t spent as much time talking about the reason why I try to dissuade my patients from trying to taper off. The reason is very simple: it doesn’t work.

With some medicines, tapering off is a valid strategy. Antibiotics work like catapults or bombs; they are a way to kill a large number of invading enemy organisms very quickly. Once most of the invaders are dead, the problem is over, and more antibiotics won’t do any good. There’s no point in firing weapons at an empty field with no enemy soldiers on it. After following the prescribed course, the patient can stop taking the antibiotics and return to their normal lives, feeling perfectly healthy. Other medicines, like non-narcotic painkillers, are given only for a short time because the human body can heal itself without their help. Something you would need to take painkillers for — say, a cut from a surgical procedure, or a broken bone –  will repair itself whether or not you take medication; the painkillers are only to help you feel more comfortable along the way. Once the body’s healing process is finished, there’s no need for you to feel more comfortable, so the painkillers can (and should) be stopped with no ill effects.

Buprenorphine works very differently from either of these examples. Addiction isn’t caused by any invading organism, so taking one massive dose and then stopping the medication won’t do any good. Many people seem to think that buprenorphine will work like other painkillers, and that the brain will repair itself while they take it, but for the vast majority of people this simply isn’t the case. The damage caused by addiction affects a very delicate part of the brain, which won’t heal on its own the way a broken bone will. Our current understanding of the disease of addiction is that  the damage caused by addiction is permanent, so the symptoms will also be permanent, unless they are treated by a maintenance medication like buprenorphine. 12-step and counseling programs sometimes tell their clients that the brain can repair itself after a certain amount of time and counseling, but there is absolutely no solid science to back up such a claim. As soon as a patient stops taking buprenorphine, the underlying damage asserts itself again and the symptoms return, which very often leads to relapse.

A good way to think about this is to imagine the damage caused by addiction as a leaking crack in a dam, and imagine that the dam is holding back a reservoir from flooding the town where you live. It’s fairly easy, and VERY important, to put a patch over the crack to keep it closed; if you don’t, then the water pressure will make it wider, and it will be harder and more difficult to seal up later. As long as the patch holds, life can go on as normal in the town, but the patch isn’t fixing the underlying crack or causing it to “heal” itself magically. All the patch is doing is keeping the damage from getting worse, and keeping the people in the town from suffering the consequences of a break. If the patch is ever removed, the water will immediately start leaking through again, pushing the crack wider and causing a flood.

Using this image, we can think of buprenorphine as a patch over the damaged parts of the brain, holding back the flood of symptoms, cravings, and damaging behaviors that addiction will cause if left untreated. It doesn’t fix any of the underlying damage. It only keeps it from getting worse and keeps it from negatively affecting a patient’s life. In my experience, patients who taper off their medicine because they feel that they aren’t fully ‘clean’ will suffer a relapse in almost all cases.

Providing patients with the complete truth is very important when they have questions or concerns. I always tell my patients that while it is possible for a very few people to taper off Suboxone successfully, for most people it is harmful and counter-productive, and I rarely recommend it. Understanding how buprenorphine works and what it does and does not do is essential to a comprehensive and effective treatment program, and I would hope that all prescribers of buprenorphine take the education of their patients and their loved ones very seriously.

Anecdotes and Data

Posted on by
Reply

Of all the people offering addiction treatment, those who are not trained professionals tend to be laypeople who have struggled with addiction problems in their own past. They may describe themselves as “ex-addicts” or still in recovery, but they offer a common reassurance: that they have experienced all the troubles that addiction brings, and they understand what their clients are going through. Often, they market their particular
treatment program as something that worked for them personally, which they
want to share with others.

The desire to share something that helped you, so that it can also help others in your situation, is a good and noble impulse. But it often happens that the results of that impulse do more harm than good. Brain chemistry and behavior are complex, finicky things, so much so that even our oldest and best-tested methods of treatment often have wide margins of error. In this field, moreso than any other, what works for one person may do no good, or even harm, to someone else. In this field more than any other, we need large
studies and statistics to collect data on huge amounts of people and categorize it so that we can filter out individual eccentricities and find strategies that will help almost everyone.

Anecdotes, personal stories, and testimonials can sometimes be helpful, but they are not medical data. They are often incomplete, exaggerated, or inaccurate, disregarding the people who have strong financial motives to outright lie. People suffering from addiction are often desperate, frightened, and may be functioning at less than their full mental capacity, which makes them perfect prey for unscrupulous con-men selling a program
that they claimed worked for them. Even programs run by honest people who truly were helped by them are often grossly unsuited to help others. Stories and anecdotes tend to be more compelling than statistics, because it is easy to relate to someone telling their story, and the emotional impact of a person standing in front of you telling you about their life is very hard to ignore. But for those same reasons, anecdotes are incredibly unreliable as
the basis for seeking medical treatment. Many people distrust statistics, thinking that they might be fabricated or biased, but the fact is that medical statistics from credible sources (such as the CDC or ASAM) go through a much more rigorous fact-checking process than the founding myth of any nonmedical treatment program ever will. It is the stories of such
programs that are more likely to mislead their clients or put them in harm’s way.

This is only one more way in which we need to bring the field of addiction up to the same scientific standard as other fields, such as dentistry and cardiology. Very few people would, say, switch to an all-banana diet because they heard a story from a neighbor’s friend who said it had cured his cavities. Yet people routinely pay tens of thousands of dollars for the promise of a nebulous “spiritual transformation”, or for a bizarre program
of vitamins, horses, sauna treatments, and other provisions that have nothing to do with addiction, all because they have been fed bad information through “patient testimonials” and other stories.

Healthcare and medicine are based on truth; on what, in reality, actually can be proven to help people. I have seen many peoples’ lives improve after they come through my program, but I won’t ask that people come to my office just because I say that. I prescribe opioid maintenance treatment because its use has been continuously and irrefutably supported by the scientific study of brain chemistry and how it can be altered to improve the lives of people suffering from this disease.