Expanding Access to Buprenorphine

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My last blog post stimulated some lively debate, and I thought this topic deserved further discussion. However, I would like to ask commenters to talk about the issue and please refrain from mentioning specific names of previous commenters. Please and make your points in a thoughtful and respectful manner. Thanks for your cooperation.

Given our present epidemic of opioid addiction and opioid overdose deaths, authorities are considering lifting the 100-patient limit for physicians who prescribe buprenorphine from office-based settings. Some people in the addiction treatment field oppose expanding access to buprenorphine in the office setting, saying some of these patients don’t get the counseling that they need, but only medication. They say there aren’t enough regulations to prevent shady physicians from opening buprenorphine mills.

Experts on both sides of the debate make good points. It’s a tough topic, but let’s explore the issues further.

1. “You don’t provide enough counseling.”

Weirdly, this used to be a main complaint against OTPs, but now OTP personnel are directing the same complaint toward office-based buprenorphine physicians.

Is there any data to help us decide how much counseling is enough for opioid-addicted patients who are started on medication, either buprenorphine or methadone?

The POATS trial gives some information on this topic. (Weiss et al, 2010, http://ctndisseminationlibrary.org/protocols/ctn0030.htm )

POATS showed that opioid-addicted patients maintained on buprenorphine/naloxone were likely to reduce illicit opioid use during treatment with the medication, but most relapsed after being tapered off the medication at twelve weeks. So this part of the study supported keeping patients on medication longer, just like the older data with methadone for heroin users. No surprises so far.

Now comes the interesting part: POATS showed similar outcomes for patients getting standard medical management versus standard medical management plus fairly intense counseling. The group with added counseling didn’t do any better than the standard medical management group.

However, the standard medical management consisted of an hour-long first visit with the doctor, and a fifteen- to twenty- minute visit per week for the first four weeks, then every two weeks.
This may be more than an average buprenorphine doctor provides in real life. It’s a little more than I do for my office-based patients. My first visit with new patients is one hour, and usually I see them back in one week for a twenty-minute visit. But then, if they are doing well, I see them every two weeks, until the patient is established in counseling. After that, if all is going well, I cut down to monthly visits. I conclude that the average buprenorphine doctor may have to increase visit frequency to get the results seen in the POAT study.

The group with enhanced counseling treatment got 45 minutes with a counselor twice per week for the first four weeks, then twice per month. At present, patients of OTPs must have two counseling sessions per month, even at the beginning of treatment. Opioid clinic opponents say twice per month isn’t even close to enough counselling, and use this point as a reason to say opioid treatment programs deliver bad care.

The POAT study was relatively short. Twelve weeks may not be long enough to detect an improvement in patients getting enhanced counseling. We know life changes usually don’t happen quickly. Maybe it is unfair to say the counseling didn’t help, because the patients weren’t followed long enough.

Now let’s look at interim methadone. Interim methadone was proposed as an alternative to long waiting lists for patients to enter an opioid treatment program. People were concerned about the welfare of opioid addicts who wanted help, but had to wait for a treatment slot to open. Interim methadone is a short-term, simplified treatment where methadone medication is started for the opioid addict, until the patient can be admitted to an OTP. With interim methadone, some counseling given, but only for emergency situations. Drug screening is still done, but is more limited than for OTP patients. These interim patients can transition to a traditional opioid treatment program when a slot opens for them.

It appears that starting just methadone, with limited other services, still helps the patients. Studies show these patients are less likely to continue to use heroin, are less likely to commit crimes, and more likely to enter a full-service OTP when admission is offered. [1]

Would “interim buprenorphine” work as well? I don’t think there are any studies to give us data, but it seems logical that it would.

2. “Just apply to be an OTP”

Government officials have said that if office-based physicians wish to see more than one hundred buprenorphine patients, the physician should apply to become an opioid treatment center.

When I first read this suggestion, I laughed, because it sounded so silly to me. Well-intentioned though this statement might be, it starkly exposed a lack of knowledge of the average physician’s economic circumstances.

I don’t know many doctors like me who have the necessary capital to do this. Some professionals in the field estimate it takes starting capital of around a quarter of a million dollars. I’ve seen one OTP fold due to inadequate financial support and management, and another escape closure by a narrow margin. These days, it takes deep pockets to afford the eighteen to twenty-four month process to establish an OTP. Getting the certificate of need alone can take years. (Just look at Crossroad’s struggles to get a CON in Eastern Tennessee, an area with arguably more opioid addiction per capita than most other states!)

OTP sites must be approved by multiple agencies: the DEA, CSAT, SOTA, and local authorities to name a few. The pharmacy has to meet strict regulations, as do personnel. If you want to accept Medicaid, that’s another avalanche of regulation and paperwork.

I’m not saying it’s impossible for a physician to open an OTP, but I am saying that it would cost so much that most doctors who treat opioid addiction wouldn’t consider it. I could be wrong – maybe my colleagues are making a whole lot more than me…

3. “In it for the money.”

Experts in the field who work for opioid treatment programs oppose expansion of office-based treatment, saying doctors charge exorbitant fees for their patients. Sadly, in some cases, they are right. But many office-based doctors charge reasonable fees. If we allowed doctor to treat more than one hundred opioid-addicted patients at one time with buprenorphine, wouldn’t that reduce demand for services? And when demand decreases, shouldn’t cost of treatment drop too?

For example, let’s take a community where one buprenorphine doctor is price gouging, and charging $500 per month for only one doctor’s visit. The second buprenorphine doctor charges $250 per month for the same service plus addiction counseling. Both are at their one- hundred patient limit. If both were allowed to increase the number of their patients, wouldn’t the second, more reasonably-priced doctor get some of the more expensive doctor’s business?

Conversely, some advocates for office-based treatment say that opioid treatment programs are upset because they have lost money in recent years. They accuse organizations like AATOD of wanting to limit further expansion of office-based programs because it cuts into their business. With more access, more patients would abandon OTPs for these less restrictive programs

DATA 2000 changed the landscape of opioid addiction treatment. OTPs aren’t the only option for patients seeking treatment for their opioid addiction.

My point is, both OTPs and buprenorphine doctors can accuse the other group of being in it for the money. But as I pointed out in my last blog…no medical treatment in this country is free.

4. “My medication is better than your medication.”

Patients entering opioid addiction treatment often ask me, “Which is better, buprenorphine or methadone?” I say, “Both.” Each has its advantages, and I’ve discussed this in previous blog entries. Briefly, buprenorphine is safer, since there is a ceiling on its opioid effects, but it’s more expensive. Patients on buprenorphine also seem to leave treatment prematurely more often than methadone patients. This isn’t a good thing, since the majority of these patients relapse back to illicit opioid use.

Methadone, as a full opioid agonist, may be more difficult to taper off of, and maybe fewer patients leave treatment prematurely because of that feature. Methadone has been around for fifty years now, with a proven track record. It works, and it’s dirt cheap. Methadone does have more medication interactions, but those can usually be managed if all the patient’s doctors communicate with each other.

Buprenorphine isn’t strong enough for all opioid addicts. Because it’s a partial agonist, there’s a ceiling on its opioid effect. This property means it’s much safer than methadone, but it doesn’t work for everyone.

Buprenorphine is safer than methadone, which to me is its best quality. I’ve started hundreds of patients on buprenorphine and never had an induction death. Sadly, I cannot say the same of methadone. I am not saying overdose death is impossible with buprenorphine…I’m saying it’s much less likely, and that’s worth a lot to me.

Buprenorphine’s superior safety profile is one reason it was approved for use in an office setting. Methadone is riskier to prescribe from an office, because misuse and diversion is more likely to be fatal with this drug. That’s why buprenorphine has fewer restrictions on it. Neither medication is good or bad; the difference between the medications is pharmacologic, not moral.

Next week, I’ll describe my OTP, where we provide methadone, buprenorphine under the OTP license, and buprenorphine under my office-based license, all on the same premises. I think we’ve created a continuum of care that’s able to meet the needs of patients as their recovery evolves.

At our program, it’s not one program versus another. Difference patients need different things, and the same patient may need different things at different points in recovery.

1. Schwartz et al, “A Randomized Control Trial of Interim Methadone,” Archives of General Psychiatry, 2006

Office-based Opioid Addiction Treatment: Raising the One-hundred Patient Limit

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The hearts of addiction medicine doctors nationwide are aflutter at rumors that the limit on office-based buprenorphine patients may be raised or lifted. As it is now, the DATA 2000 law says each doctor who prescribes buprenorphine from an office setting for the treatment of opioid addiction can have no more than one hundred patients at any one time.

DATA 2000 was a big deal. Until it passed, it was illegal for any doctor to prescribe any opioid to treat opioid addiction, unless they worked at a specially licensed opioid treatment program. In other words, doctors in an office setting had to refer opioid-addicted patients to opioid treatment centers for medication-assisted treatment. And the only medication available was methadone.

Then DATA 2000 allowed Schedule 3 opioids to be prescribed from physicians’ offices for the purpose of treating opioid addiction, as long as these medications were FDA-approved for this purpose. Thus far, buprenorphine is the only medication that meets the DATA 2000 requirements.

But the law had other limitations. For example, each physician had to get a special DEA number to prescribe buprenorphine. And as above, no physician could have any more than one hundred patients on buprenorphine at any one time.

My office gets multiple calls each week from people seeking treatment for opioid addiction in an office setting. These callers say they’ve already been to the websites that list doctors. (http://buprenorphine.samhsa.gov and http://suboxone.com . They’ve made multiple calls and discovered these doctors aren’t taking new patients because they’re already at their one hundred patient limit. This is happening all over the country; patients want treatment but can’t get it. For many such people, opioid treatment centers are geographically impractical, so that’s not an option either.

Since addiction is a devastating and potentially fatal disease, government officials feel pressure to do something to help our nation’s opioid addiction problem. Lifting the one- hundred patient limit has been suggested as one option to improve the situation. This would seem to be the best, easiest, and quickest way to get more people into treatment. At least, most Addiction Medicine doctors like me think it makes sense.

Not everyone agrees.

Opposition has come from some unexpected sources. I went to an opioid addiction treatment conference in a neighboring state lately and heard the president of AATOD (American Association for the Treatment of Opioid Dependence), Mark Parrino, MPA, speak against lifting the limit.

First let me say I admire Mr. Parrino immensely. He has been and continues to be a huge advocate for this field. He’s done more good in the field of opioid addiction treatment than most people I can think of, and has been doing this good work long before I ever even entered the field.

But that doesn’t mean I agree with him on everything.

When he spoke at the conference, he said he was opposed to expanded buprenorphine treatment in the office-based setting because patients don’t get the counseling that they need, so it really isn’t medication-assisted treatment, it’s just medication assistance. He says opioid treatment programs provide on-site counseling, drug testing, and other services that can help patients, and that most office-based programs don’t offer such comprehensive services. He also said diversion of buprenorphine from office-based practices is a huge problem, and that much of the black market use is actually abuse of the medication. He raised the uncomfortable issue of price gouging by some unscrupulous buprenorphine doctors who charge large fees and deliver little care.

You can read a statement on the AATOD website that fully describes their opposition – or at least call for caution – regarding raising the one hundred patient office based treatment limit:

http://www.aatod.org/policies/policy-statements/increasing-access-to-medication-to-treat-opioid-addiction-increasing-access-for-the-treatment-of-opioid-addiction-with-medications/

I don’t completely disagree with the points Mr. Parrino made at the conference, but I do think the same arguments can be made against OTPs if one were inclined to do so.

What about opioid treatment programs that pay lip service to the counseling needs of the patients? What about OTPs that hire people to be counselors with little or no experience in the counseling field? Just as Mr. Parrino can point to the worst examples of office-based buprenorphine treatment, I can point to OTPs who aren’t doing a great job. How can an OTP counselor provide Motivational Interviewing as a therapeutic technique if that counselor has never even heard of MI? Yet I’ve seen these problems at opioid treatment programs.

Don’t paint all office-based practices with the same brush. Many of us want to provide good treatment with adequate counseling. For example, my office has a therapist who is a Licensed Professional Counselor with a Master’s in Addiction Counseling. He does a great job, and as an added bonus has great legs. (He’s my fiancé, before you assume I’m sexually harassing him at the workplace).

Alternatively, if the patient prefers to do only 12-step meetings, I’m OK with that, so long as they provide me with a list of meetings they’ve attended each month. Or if they’re already working with a therapist, it’s OK with me if they want to continue, as long as they agree to allow me to speak with their therapist about issues directly relating to the treatment of their addiction.

Diversion of buprenorphine to the black market is a big problem. Not all office-based buprenorphine doctors are as careful as we should be. We will never be able to get rid of all diversion of any controlled substance that we prescribe, but all buprenorphine doctors should be doing drug screens and have diversion controls in place to limit the problem.

Not as much methadone is diverted, but only because of the very strict regulations on methadone take- home doses at the OTP. Many patients – and OTP personnel – feel present regulations on methadone take- home doses are overly strict and limit flexibility of treatment for patients who are doing well. Is the answer then to regulate take -home doses of buprenorphine as closely as methadone?

What about the predatory doctors who prescribe buprenorphine just for a quick buck, sensing they can charge exorbitant fees from desperate opioid addicts? I can’t say anything in their favor. They embarrass me. As with many things in life, the actions of a few give the rest of us a bad reputation. But I do think these doctors are in the minority.

And don’t believe everything you are told about office-based practices; I’m sometimes told by patients that I’m in it “for the money” though I charge the same for an office visit for a buprenorphine patient as I would for any other medical ailment. Some patients feel like their treatment should be free, but the U.S system of medical care is not usually free for any disease.

In short, though I recognize there’s some truth in many of Mr. Parrino’s statements, I still think most buprenorphine doctors try very hard to do things right so that they provide good care for opioid addicts who can’t or won’t go to an opioid treatment program. Expanding access by raising the one-hundred patient limit will allow more people to get addiction treatment.

NSDUH Data Released

NSDUH Data on Heroin Use

NSDUH Data on Heroin Use

Each fall, the National Survey on Drug Use in Households releases data from their yearly survey, and data from 2013 is now being released. It’s a gradual process, with more information released as data is analyzed and compared to years past.

The NSDUH report compiles data collected about drug and alcohol use in the nation and in individual states. This annual survey of around 70,000 people in the U.S. over age 12 also collects data on mental health in the U.S. This research information is collected from phone calls to individual households and is the primary source of data on the abuse of drug including alcohol in the U.S. Data can be compared to past years to look at drug use trends, among other information.

Since this survey is conducted on household members, some scientists say the data underestimates drug use since its methods exclude populations living in institutions such as prisons, hospitals and mental institutions. Such populations are known to have the highest rates of drug use and addiction. But the annual NSDUH report is still one of the best sources of information we have at present. This data can be evaluated for new trends of drug use and abuse, and can help direct funding toward problem areas. Researchers use this data to assess and monitor drug use, as well as the consequences.

Data from 2013 shows that around 9.4% of U.S. citizens use illicit drugs at least monthly. This includes marijuana, cocaine, heroin, hallucinogens, and misused prescription medication. This rate of use hasn’t changed much over the past two years, but it’s a little higher than it was ten years ago.

Of the people who used illicit drugs at least monthly, two thirds used marijuana as their only illicit drug. Marijuana, not surprisingly, is still the most frequently used illicit drugs in the nation. This percentage of people using marijuana has been slowly but steadily increasing over the past ten years. Interestingly, the number of people surveyed who said they were daily or near-daily users of marijuana increased from 5.1 million in 2007 to 8.1 million in 2013.

I do not see this as a good thing, but my blog is dedicated to opioid addiction and its treatment, so I’ll let you make up your own minds about marijuana.

I was happy to see that non-medical use of all prescription medication continued to drop, though slowly, down to 2.5% of the population. Non-medical use of prescription opioids specifically has also shown a slight drop from 2009 to 2013. I hope this means people (and their doctors) are beginning to understand the dangers of illicit opioid use. Tranquilizer use also has shown a slow decline over the past three years, a trend I hope will continue.

Of the group of people who said they were non-medical users of opioids, over half still said they obtained their drug from friends or family, for free. Around 11% bought their drug from a friend or family member, and 21% got the drug from one doctor. Only 4.3% said they got their prescription opioid pills from a drug dealer or a stranger, and only .1% bought them off the internet.

This data tells us – again this year – that the main suppliers of illicit opioids aren’t drug dealers on the corner or dealers over the internet. Main suppliers are friends and family members of the user.

Why is this still a thing people do?? This has got to stop. Sharing medication, controlled substance or not, is dangerous – not to mention illegal. Sharing medication causes harm. You aren’t helping anyone by sharing.

The youngest age group surveyed, aged 12 to 17, showed a drop in the non-medical use of prescription opioids over the last decade, from 3.2% in 2003 to 1.7% in this 2013 survey. That’s reason to hope that youngsters now either have less opioids available to them or that they know how damaging opioid addiction can be. I hope this drop forecasts an overall drop in the number of people addicted to opioids in the coming years.

Now for the bad news: NSDUH shows that heroin use continues to rise, from around 373,000 people in 2007 to 681,000 people in 2013. That’s not quite a doubling over the past six years, but pretty close. That strongly correlates with what I see at my work; people addicted to opioid pain pills tell me it’s harder to find opioids, and also more expensive. Mexican drug cartels have seen this, and moved in to supply heroin as an alternative to opioid pain pills.

It’s an unintended and unfortunate consequence of efforts to limit illicit prescription opioid use.

This 2013 survey showed that there were an estimated 2.8 million new users of illicit drugs in people over age 12. Over 70% of these new illicit drug users started with marijuana. Only about 13% of new users started with non-medical use of opioid pain pills, and this is a lower percentage than in past NSDUH surveys.

This NSDUH data will be released in other reports as more analysis is done on this information.

Recovery Means…

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September is National Recovery Month, and it’s nearly over, so I wanted to make a special blog post to celebrate. I decided to write what recovery means to me, and I hope my readers will write in with their own definition of recovery.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover.

Neonatal Abstinence Syndrome: Genetically Influenced

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As you can see from my blog post of July 27th of this year, we know genetics influences the risk of developing opioid addiction. Now, according to a 2013 study, we know that certain genes are associated with less severe neonatal abstinence syndrome. [1]

Neonatal abstinence syndrome, called NAS, occurs in about 50% of babies born to mothers maintained on methadone or buprenorphine. Of course, NAS also occurs in babies born to mothers using other opioids, prescribed or illicit, but this study only included mothers in addiction treatment on methadone or buprenorphine.

The withdrawal signs seen in infants are gastrointestinal: diarrhea, poor feeding, and vomiting; central nervous system: tremor, increased muscle tone, increased startle response, and poor sleep; and other symptoms like sneezing, yawning, increased respiratory rate, fever, sweating, and nasal stuffiness. For infants, NAS is a serious medical problem that can cause seizures and even death if untreated, so it is important for doctors to know if an infant has been exposed to any opioids during the pregnancy. With longer-acting opioids like buprenorphine and methadone, the withdrawal can be delayed for up to a week. With short-acting opioids like heroin, withdrawal can occur quickly in the infant.

Thankfully, NAS is treatable, and most hospitals use a standardized protocol to check babies for serious withdrawal signs. If the baby has more than mild signs, an infant-sized dose of opioid is administered in tapering doses, to gradually reduce physical withdrawal.

Aside from treating the baby with tapering doses of opioid medication, we know other things can help reduce the severity of NAS. Reducing or even better quitting smoking before or during pregnancy reduces the chances of neonatal withdrawal, as can breastfeeding. Contrary to popular belief, it isn’t methadone or buprenorphine in the breast milk that helps withdrawal; it’s the warmth and comfort of being at the mother’s breast that soothes the baby. Similarly, babies are calmed when their environment is quiet and dark, and swaddling (wrapping the baby closely in a blanket) also helps.

Most people assume that the higher the mom’s dose of methadone or buprenorphine, the more likely it the infant will have withdrawal, but repeated studies show no clear relationship between maternal dose and the likelihood of NAS.

But now, this study shows we may become able to predict which babies will have more severe withdrawal based on genetic profile.

This prospective cohort study, conducted in Maine and Massachusetts from July 2011 to July 2012, looked at eighty-six pairs of mothers and infants. The study looked at length of hospital stay for the infants and the need for medical treatment for NAS in those infants. The study found that babies with certain genetic variants of the OPRM1 gene and the COMT gene had significantly shorter hospital stays and needed significantly less medication to treat withdrawal symptoms.

Of course, we can’t change genetic makeup, but we may be able to use this information someday to help predict which babies need longer hospital stays and more medication for their NAS. Ultimately, these studies may help us better understand NAS and how to treat it.

With the recent increase in incidence of opioid addiction, more women are getting pregnant while addicted to opioids. Most hospitals have seen an increase in the percentage of babies born with NAS, so this is an important area of research.

1. Wachman et al, “Association of OPRM1 and COMT Single-Nucleotide Polymorphisms With Hospital Length of Stay and Treatment of Neonatal Abstinence Syndrome.” Journal of the American Medical Association, May 1, 2013, Vol. 309(17).

We are More Than Our Disease

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Imagine you are a diabetic, complaining to your doctor’s office manager about poor treatment you’ve received by the doctor’s staff. How would you feel if the office manager said something like this?

“That’s just your disease talking. Your perceptions are wrong because your diabetes wants you to feel resentment and self-pity. Your diabetes wants to give you an excuse to go back out there and eat a bunch of sweets. Your diabetes has you confused. You really weren’t mistreated. Your thoughts and feelings aren’t real.”

Sounds kind of nutty, doesn’t it? Yet people with addiction are sometimes told similar things by their treatment programs.

While it is true that addiction can damage the structure and function of the brain, patients don’t lose all their higher brain functions and often have very accurate perceptions.

This week I encountered a patient who said workers at his opioid treatment program discounted his legitimate complaints about problems he saw at his program. He said he felt like personnel at this program thought because he was an addict, he didn’t know what he was talking about and had no right to complain.

I listened to him, and what he said resonated with me.

I outed myself a few months ago on this blog as a person in recovery. I’ve been abstinent from drugs and alcohol for over sixteen years, and my recovery is one of the most precious possessions I have. And yet, I do remember similar frustrations with my treatment program.

I went to an intensive outpatient treatment program many years ago. It was highly recommended by other doctors in recovery, so I hadn’t shopped around for treatment programs. Besides, who has any idea what to look for in a drug addiction treatment program? I just followed the recommendations of my state’s physicians’ health program.

I do admit that my brain had been damaged by drugs and by withdrawal. I knew my perceptions were not completely reliable, and yet, sometimes I heard my counselors say things that I knew were not OK, and that were offensive to me. I can’t remember exact words after so many years, but the essence of their remarks was I wasn’t able to think clearly, all my perceptions were wrong, and I had no right to be angry about anything, including disagreements with treatment staff.

Which is a rather convenient position to take if you are treatment staff. Essentially, you win any argument with patients, because you can say the patient’s brain is damaged, yours isn’t, so therefore you are right and the patient is wrong.

I remember when I was in aftercare, I overhead a comment made by my counselor to another counselor about another patient who frequently relapsed: “She can’t come to aftercare because she keeps getting drunk.”

His breach of her confidentiality was bad enough, but when I heard him I thought, “Aha! All this talk of disease, but he doesn’t really believe it or he wouldn’t blame her like this.”

Yes, maybe my brains were still scrambled, but I got that one right.

Now I’m on the other side of the treatment fence, and things look different. I think there is a temptation to take the easy way out when faced with a patient complaint, and dismiss the complaint as being irrelevant.

I’m not rising up on a self-righteous scold of all treatment staff; I’m writing this blog as much for me as other staff.

We must always be able to look honestly at our actions and attitudes as addiction treatment professionals. If a patient complains, we need seriously to evaluate our behavior.

For me, it helps to have a good treatment team around me, who are willing to tell me if I’m off the mark with my thinking. I also do my own mini-inventory at the end of each day (OK most days). Did I treat people the way I’d like to be treated? Did I try to do the best thing for them? Sometimes this means making a decision that angers patients or angers treatment staff.

Most importantly, when I’m with a patient, I want to remember he may have drug addiction, but that’s only one small part of who he is. He’s also other important things. For example, this person may also be a son, father, husband, artist, good provider for his family, have a great sense of humor, etc. Treating the addiction should help him get back to being himself. He is so much more than just an addict. Sadly, many of our patients have family who have written them off as “Just an addict,” and are no longer able to appreciate their wonderful qualities and talents.

Addiction treatment personnel: Let’s not make the same mistake.

Bibliotherapy: Women and Addiction

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I’m sorry to post another re-run this week, but i just moved, and my time and energy have been taken up with unpacking. I haven’t made time to write a fresh blog entry this week. Meanwhile, here’s an entry from a few years ago:

If you’ve looked at my blog before, you’ve likely seen that I like to recommend books. I prescribe books as medicine. Looking over my sagging bookshelves, I saw a number of my favorite titles that are specific for women and addiction. While some are a bit dated by now, even those contain information that’s helped me better understand how women, especially pregnant women, have unique needs in their recovery from addiction.

For example, in the past, when I talked to a pregnant patient who was still using drugs, I would tell her every awful thing her drug use could possibly be doing to the fetus. I thought I could scare her into sobriety.

Studies show this approach is associated with a worse outcome for baby and mother than a compassionate and hopeful approach. Pregnant addicts carry a tremendous burden of shame and guilt, as arguably the most stigmatized people in our society. Even other addicts look down on pregnant addicts. So when physicians add to their shame, they tend to run. They leave treatment (physically or mentally), and everyone suffers. With a gentler approach, these women tend to participate in their own treatment.

Duh. Don’t we all do better with gentler approaches?

Anyway, here’s a list of books about women and addiction. Some I have mentioned before, like Women Under the Influence, by the National Center on Addiction and Substance Abuse at Columbia. This is maybe the most comprehensive book, full of references, about addiction in women. Happy Hours by Devon Jersild is more conversational, with excerpt from interviews with women addicted to alcohol, but it also contains solid information. One of the most entertaining, because it is a well-written story told by a female alcoholic is Drinking: A Love Story, by the late Caroline Knapp.

Parched, by Heather King, is similar to Ms. Knapp’s writing, and also worth a read. This book is a well-written, entertaining documentation of an intelligent woman’s descent into alcohol addiction. Thankfully, she also describes her recovery. This is a better-than-average addiction memoir, and hasn’t gotten the recognition it deserves.

Using Women: Gender, Drug Policy, and Social Justice, by Nancy Campbell, written in 2000, is an unusual and fascinating book. It describes how society has viewed female addicts throughout history and how they are frequently judged more harshly than male addicts. Throughout the decades, addicted women don’t do what’s expected of them by their society, and society’s expectations often shaped U.S. drug policies. The author contends that female addicts cause more outrage because they stray so far from assumed female roles. The book is filled with cool black and white photos of sensationalized news stories from the girl addicts of the 1950’s to the crack moms of the 1990’s.

Women, Sex, and Addiction: A Search for Love and Power, by Charlotte Davis Kasl, PhD, 1989, focuses more on the way the inequities of power in relationships shape female behavior with sex and drug use and addiction. The author discusses all sorts of addiction, not just sex or drug addictions. For many female addicts, codependency and sex are strongly intertwined. The book also has sections of lesbian and bisexual lifestyle and addiction, and male codependency and addiction. Some sections were interesting and helpful, and others…not so much. The author uses older terminology, from the time when codependency was more in vogue.

Women on Heroin, by Marsha Rosenbaum, 1981. This book follows the careers of 100 female addicts in a street study. The author talked with a hundred women of many ages and various races to hear what their lives are like, being addicted to heroin. One theme of the book is that initially, drug use gives the illusion of empowering the women, but eventually the need to support their habit steals their power. Women resort to criminal means to support their habits, and this is more difficult for women caring for small children. Treatment programs often don’t consider children can be a strong motivating factor for a woman to get clean, but not if she loses her kids while she goes off to treatment. Lots of quotes from the women she interviews are scattered through the book.
All counselors working with female patients need to read this book to more fully understand how effectively to engage women into treatment. Besides containing useful information, it’s just a really interesting book.

Crack Mothers: Pregnancy, Drugs, and the Media, by Drew Humphries, 1999. Here’s a book bound to stir controversy. The book describes how the “crack baby” was a media invention, not a medical reality. While some children born to women addicted to cocaine had medical issues, we now know these kids didn’t grow up to be the permanently and hopelessly damaged human beings as conjured by the media. This book talks about the racist prosecution of pregnant minority addicts, and how they tended to be the ones to be jailed, while middle and upper class pregnant addicts were able to use their resources to avoid prosecution. In some cases, pregnant women had asked for treatment but were turned away because it wasn’t financially accessible, and they were jailed instead. I thought this book was very interesting and I read it in just a few days.

Substance and Shadow: Women and Addiction in the United States, by Stephen Kandall, The author is a renowned neonatologist, and this book is scholarly, filled with references. I’m reviewing the book from memory, since I loaned it to a friend and I can’t remember who has it. The author talks about the paternalistic methods of physicians in previous centuries, and how their attitudes increased the risk for female addiction to opioids. Then he traces the history of drug policy in the U.S., paying special attention to how women were treated – or not treated – differently. This book is a bit more intense, and not as light or quick reading as most of the others listed.

A Woman’s Way Through the Twelve Steps, and A Woman’s Way Through the Twelve Steps Workbook, by Stephanie Covington, 2000. Compared to the method of working the twelve steps outlined in either AA’s Big Book, or NA’s Step Working Guide, this workbook is a little “fluffy.” It’s a softer way of looking at the steps, and may be quite beneficial for women who have been traumatized by abuse in the past. For some women, harsh rhetoric occasionally heard in 12-step meetings can triggers memories of abuse, verbal or physical. For women who are turned off by more traditional steps guides, this book and workbook offer an alternative. I liked the book better than the workbook. For some people, this could be a great resource.

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