My Hopeless Patient




(Details have been changed to protect patient identity)

I have a patient in my office-based practice whom I see only every two months. If you had told me ten years ago, when I first met him, that he would become a stable and productive member of society, I would have scoffed. If you told me he would someday have over three years of freedom from active addiction, I would have rolled my eyes in disbelief.

I think of this person when I’m tempted to write off any patient as hopeless.

He was one of the worst. I first met him when I worked at an opioid treatment program (OTP) over ten years ago. He was often impaired and belligerent. At least once he had to be transferred to another OTP, due to aggressive behavior towards the staff and other patients. He was belligerent with me too, and I dreaded my appointments with him. He had a terrible cocaine addiction, and almost all his drug screens were positive for cocaine and benzodiazepines. On several occasions I referred him to a local inpatient program, but he left against medical advice or was asked to leave.

A few years after I left that OTP, he called my office-based practice to ask if he could switch to buprenorphine. The woman making appointments scheduled him with me.

The next week, looking at my schedule, I remember saying, “Oh HELL no. I’m not seeing this guy. He’s not going to stabilize in an office-base practice.” But he had already paid to hold his appointment slot, so I felt obligated to see him. My plan was to tell him he wasn’t appropriate for an office-based program, and to recommend inpatient treatment, as I had so many times in the past.

At the first visit, he was less belligerent than I recalled, and had been free from cocaine for several months. He appeared to have a little more insight into his behavior and his addiction. I sensed he had a strong desire for change. Skeptically, I agreed to start him on buprenorphine, secretly assuming he would drop out of treatment after a few weeks.

From the start, his use of illicit opioids dropped impressively. From that point of view, he made immediate progress.

However, during his first year in treatment in my office-based practice, he had periodic relapses to cocaine. He’d come into my office, fling himself into a chair, and say, “Don’t bother giving me a drug screen. I messed up. I got high on cocaine and then took benzos to come down.” I was impressed with his honesty and I was impressed by how much his relapses bothered him. I was also impressed when he made – and kept – appointments with a psychologist for addiction counseling. He was dismayed and frustrated, because he said he didn’t really enjoy using drugs anymore, but still couldn’t stop using them. This angered and baffled him.

He’d get so frustrated with his own behavior that he would start crying. The first time it happened, I was uncomfortable and worried. He was the ultimate tough guy, more likely to yell than cry. I worried the tears meant a severe mental illness. As time went on, we both got more comfortable with his tears. I saw he was experiencing the pain of his powerlessness over addiction.

He’d been in and out of 12-step recovery for years, and didn’t feel like the meetings helped him much, but he’d go once in a while. He kept going to counseling, though he was only able to afford sessions once or twice per month. He kept his frequent appointments with me. Above all else, he kept his appointments.

I had moments of grave concern, worried he really wasn’t stable enough for me to be treating him in an office-based setting, and on several occasions mentioned my concerns to him.

In my own mind, I also worried about how someone reviewing his chart would view me as a doctor. If someone from the DEA or Department of Health and Human Services wanted to review his chart, they would think I was careless with this patient, and that I should have referred him back to the methadone clinic. During his relapse years, I worried that I was giving this patient inadequate treatment, yet knowing him as I did, I didn’t think he would ever go back to an OTP or inpatient treatment. I also really believed he was going to make progress in recovery, though I didn’t have much to justify my belief.

I also leaned on him to consider an inpatient program. He was set against both an opioid treatment program and an inpatient program, saying he was sick of being treated like a child, and that he didn’t do very well when people told him what to do.

I saw what he meant.

In opioid treatment programs, sometimes a milieu of “us versus them” can be pervasive. Despite using kind and collaborative counseling approaches, patients often feel they are unfairly told what they can and can’t do.

They are right, of course. Opioid treatment programs have to follow an amazing number of state, federal, and local regulations in order to stay open. These rules rankle patients, who feel like they’re being treated like children by irrational parents.

I do get that. Even at the best OTPs, byzantine rules frustrate patients.

In an office-based setting, there’s more freedom to individualize treatment. By that I don’t mean patients can or should get by with less care. But I have more flexibility, and more opportunities to build rapport with patients in my office than in the OTP.

Addiction treatment literature describes a type of counseling known as motivational interviewing (MI), or motivational enhancement. I’ve read books about this practice, and though I’m a beginner compared to experienced therapists, I do try to use MI methods where I can.

MI encourages treatment providers to listen closely to the patient, clarify what the patient is saying, and ask the patient to participate in solving problems. MI is a collaborative type of counseling, believing patients know more about how to help themselves than more traditional counseling techniques give them credit for knowing. MI also teaches that confrontations with patients aren’t usually helpful.

At the OTP, this patient had a hard time controlling his temper when an authority figure (me) confronted him about drug use and bad behavior. In my office setting, I didn’t confront him but asked him to describe how his relapse happened, and asked him what he thought triggered the overwhelming desire to use the drugs. I asked him what he thought could be helpful for next time, and he had some good answers.

This approach worked well. The time between relapses grew longer, and he appeared to have more and more insight into what caused him to relapse and how he could avoid those situations.

For example, in the past, he got into physical fights at his work place, would get fired, and go use cocaine. At one session, he told me how he’d love to punch his boss in the face. He said it would feel good, but only for a few minutes, and then he would lose another job. He didn’t like his job, but wanted to leave it on his own terms.

Eventually, that’s what he did – he gave a 2 week notice, and left with another job already lined up. Sadly, he couldn’t afford health insurance at his new work. I told him to petitioned Reckitt-Benckiser’s program of free medication for one year for patients in dire financial conditions, and he met their requirements. I also agreed reduced my office fee temporarily, until he got back on his feet.

Then his mother was diagnosed with end-stage cancer. He worked at night so he could help take care of her during the day. He was less angry but more depressed, and he finally agreed to start taking an antidepressant medication. During her prolonged illness, he still struggled with occasional illicit drug use, but he was able to work full time and also help care for his mother. He was very distraught when she died, but happy he’d been able to spend time taking care of her at the end of her life. Ironically, the rest of his family, who had once written him off as the black sheep, came to depend on him during this difficult time for them all.

Since then, he’s been diagnosed with several chronic medical problems, but he has a good job that he likes, and he has good insurance coverage. This allows him to see his primary care doctor regularly. He helps his father around the house and helps financially when he can.

He gradually transformed into a productive member of society.

I have come to enjoy his visits. He’s actually very funny, with a droll sense of humor. His last positive urine drug screen was more than three years ago, and this was his last illicit drug use.

His life isn’t perfect. He has problems with relatives, and has some unmet goals in his life that he’s working on, but looking at him now, you wouldn’t guess he once had serious and life-threatening issues with addiction.

A couple of times a year, we discuss whether he wants to taper off buprenorphine. So far, he said he doesn’t want to risk it, and prefers staying on buprenorphine. I agree with him; he’s doing so well now, I don’t want to risk making changes that could harm him.

What helped this patient? Was it relief from an overly authoritarian opioid treatment program system? Did he age out of his addiction and youthful antics, as so many people do? Did he benefit from the motivational enhancement counseling I tried to provide? Or was he sick of the addiction, and just needed a little help while he got better on his own? I don’t know, but it’s been a delight to be even a small part of his recovery.

When I’m tempted to write off a patient as hopeless, I think of him.

10 responses to this post.

  1. Posted by TrudyDuffy on November 7, 2016 at 1:05 pm

    Compassionate, evidence based, long term care is hard to find. I have learned to meet my son where he is at in his recovery. Far too many programs abandon patients, merely prescribe and are absent sufficient counseling. Reading your posts gives me hope my son may find his way to a practice like yours. My son inspires me beyond words, facing stigma, family rejection, bed bug infested treatment facilities, abstinence only recovery homes that reject MAT. Yet he picks himself up and keeps trying. It began with OxyContin.


  2. Posted by Elizabeth Stanton MD on November 7, 2016 at 7:32 pm

    Really great post! It is a great one that I will keep in my files to look at when I am getting a little frustrated with a patient. I think what you gave him was Hope. You were able to see something in him that he could not see and would not have believed was there. Your patience in letting him slowly come to see was healing for him. Your are quite the therapist, Dr Burson. Not a novice at all!!


  3. This was wonderful. two things we always say in the MAT group I am in. Progress not perfection, and change takes time. This story was a great illustration of both.


  4. great article thanks for the read. I was a chronic heroin addict and relapsing all the time. Struggling through a detox became harder and harder. I started using kratom tea and that helped me out a lot. Its not the end all be all answers but it definately helped.


    • As a reminder to my readers, kratom is not an evidence-based treatment for opioid addiction, and it does have opioid effects. However, I’d like to see some studies of the active ingredients of kratom to find out if it has properties useful for addiction treatment.


  5. Posted by DONNA on November 14, 2016 at 8:06 am

    I have 15 yrs in recovery. This came after 10 yrs of relapse …..over and over and over again. I went through 3 inpatient programs, 2 intensive outpatient programs, drug court through the legal system, NA groups, 12 step groups, abstinence based therapy, 90 day program, tapering using opiates less in strength, enough cold turkeys that I still remember the horror like it was yesterday, and still ….I relapsed over and over and over again. Not once was I told about methadone or suboxone. Even when I became suicidal and was admitted to a mental health facility was methadone or suboxone mentioned. I found out about MAT through my sisters employer, a primary care Dr who I am sure has heard my story through my baby sister, who was her RN. She reached out and called me one day, and mentioned methadone. So I called a clinic, and within 1 week was on methadone. Since day one, May 21 2001, I have never relapsed again. Here I am , all these years later, finally a success. I went back to college, became a mental health therapist and Certified Peer Support Specialist. I have been working in the field for 6 yrs now. I can finally make something positive out of all those years of hell by helping others. I feel it should be required that ALL options are given to patients so they can make an informed decision. What if I had know about MAT the first time I tried to get help? How many years would have bed saved from addiction? How many relationships saved, or money saved, or legal repercussions that I still have to deal with? However, I am so thankful that I was finally pointed to salvation!


  6. Donna, I often have asked myself the exact same question… What if I had been given accurate or ANY information about medically assisted treatment in detox or hospitals? How much pain and suffering would my family, friends, and myself been spared?


  7. Your blog makes me both want to cry and rejoice at the same time. Cry because I have yet to find a provider like you that looks at opiate addicted patients as PATIENTs with individual needs and not just another “junkie”. I am currently on MAT and at my second clinic after transferring due to the medical director instituting 100mg dosing caps for all patients, insisting 60mg is enough to hold any patient and if you ask for more its because you just want more “dope”. I endured being laughed at, called a dumb junkie and told I was going to die at my last dose increase at this clinic before I transferred to one that did not have made up caps based on stigma and stigma alone. Your blog touches on so many issues that I have had in treatment and validates all of the concerns I have had all along, despite being looked at as just another addict. I am clean, employed full time and just received a promotion, thriving and yet the clinic refuses to see me as an individual with needs that are different than their standard protocols. Despite the fact that providers are allowed to submit requests to the state for exceptions to the rules, my clinic refuses to do so. I pay $400/month for medication that in reality costs $1/day and 10-30 minutes of subpar counseling that is then forged to look like they met the 2 and a half hour/month requirements.

    I feel so helpless when it comes to standing up for myself because I have yet to meet a provider that doesn’t just assume that every patient is trying to pull one over on them. I have no idea where to start to find help with patient advocacy.

    I would love the chance to talk to you about a few issues that I desperately need sound advice on. If you could spare some time, it would mean the world to me.


    • I am sorry that I don’t have time to respond to people individually, but I agree that it sounds like your OTP isn’t using best practices. One characteristic of a well-run OTP is that there should be no dose caps. Patients are different and each person’s best dose must be determined clinically.
      You do have some options; you can file a grievance at your program, and you can contact advocacy groups like NAMA in your state.
      You can also contact your state’s SOTA (state opioid treatment authority) and report the OTP’s policy of dose cap. Sometimes they can help educate that physician about best practices and help all the patients under his/her care.
      It sounds like you are doing great in your recovery. Your OTP should praise and support you, and help you continue your momentum in recovery. It’s awful that they don’t do this. Sometimes we have to give ourselves the praise that we wish could come from others


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