Lack of Knowledge, Lack Of Understanding

“…Poor management & security. No patients are held accountable for their misuse & the doctor allows patients to use other drugs over & over when getting treatment.”

I was tooling around on the internet. Somewhere between looking at recycled textile art on Etsy and viewing lists of the best audiobooks for 2021, I looked at job satisfaction reports on Indeed and found the above comment. It was written by a nurse who had worked at my facility. She was talking about me!

Before COVID, this nation faced significant nursing and other healthcare personnel shortages. COVD made this worse. Our opioid treatment program has had problems hiring and retaining nurses (and other personnel) just as other healthcare facilities have had. Most OTPs have early hours and lower pay than hospitals and other facilities, making it more difficult.

I wanted to get on Indeed to read about what nurses are saying about their job situations, hoping to find comments from nurses working at OTPs. I never dreamed I’d read a comment from a nurse who had worked at the same facility as me.

I felt angry and hurt when I read the comment, but then I felt sad. I didn’t do a good enough job educating her about the nature of addiction and the purpose of treatment programs. I missed an opportunity.

I can’t emphasize this enough: I can’t keep anyone from using drugs if that’s what they want to do. I don’t have that kind of power. No one does. Even placing people in prison doesn’t always stop people from using drugs.

Since I don’t “allow” or “disallow” anyone’s drug use, what good am I?

First, I can prescribe medication that keeps most opioid users off illicit opioids and on much safer and longer-acting medications. This allows them freedom from chasing opioids several times per day, and freedom from committing crimes to get money to get these illicit opioids. It usually improves their quality of life and here’s the big thing: It reduces their risk of dying. Since they are alive, they have a chance of participating in counseling.

Second, the chronic nature of opioid use disorder and other substance use disorders means we rarely see patients enter treatment and never use another drug. This disease doesn’t work like that. However, we can use evidence-based counseling techniques to assess patients’ willingness to change drug use behavior. We can use those techniques to help them decide what kind of action they’d like to take to change drug use habits.

Behavioral changes don’t happen quickly. Anyone who has tried to lose weight, exercise more, stop smoking or other things can probably relate to the difficulties of changing behavioral patterns. Sometimes we try things that don’t work, but we gain information about what may work for us in the future.

In the old days, I did taper people off their treatment medication (methadone or buprenorphine) if they continued to use illicit drugs. I’ve changed my approach, after learning more about how to support patients and help them in their recovery. These days, especially with fentanyl prowling around the drug scene, patients die when out of treatment. Accepted best practices show patients have best outcomes when we retain them in treatment and keep talking to them.

Obviously, the nurse who wrote the complaint wasn’t educated about this fact. I am one of several people who should have educated her about this.

I do lower doses if there’s another medical condition that makes methadone or buprenorphine dangerous, or if patients’ use of sedative drugs make dosing methadone or buprenorphine too dangerous. Even with these conditions, we try to talk the patient into going to an inpatient program for more intense counseling and help.

In fact, continued use of opioids is an indication to increase methadone/buprenorphine, not to decrease it.

Perhaps the writer of the complaint felt we should have stopped giving any take home doses to patients using illicit drugs. The comment was written after COVID started and we’ve been more liberal with take homes. State and federal regulations around take-home doses were relaxed so patients could dose at home and avoid crowds. We agreed this seemed appropriate to do. For the most part, our patients did well with these extra home doses.

Since I read the comment, I’m more careful to remind nurses and counselors during case staffing that we always must think about the risk/reward of treatment. In very few situations does excluding patients from treatment make sense. On the other hand, we don’t ignore drug use; every positive urine drug screen result must be addressed in counseling. But addressing drug use does NOT mean dismissing patients from treatment.

We recently had a nurse who worked only one day before she decided the job wasn’t for her. I hope she’s the one who wrote the comment. She didn’t have enough time to learn about what we do at the OTP. She didn’t work long enough to see all the miracles we see at OTPs.

I’ve said this many times before: I see more positive changes in people enrolled in opioid treatment programs than I ever saw back when I worked in primary care.

That’s the main reason why I love working at the OTP.  I’m sorry our nurse didn’t get a chance to see this for herself.

15 responses to this post.

  1. Posted by npcz83 on September 14, 2021 at 12:52 am

    You’re doing the right thing! I was on methadone for a couple years before I stopped using. For one thing, I didn’t know what being at a stable dose meant. I just stopped increase at 90 because I thought that should be enough. Then I (thankfully) learned that’s not how it works. Being stable is withdrawals and cravings being eliminated. So I got up to 125mg and haven’t used or even craved an opioid since (that was 4.5 years ago!). So if I was tapered off and terminated I would probably still be using heroin today.


  2. Posted by Tony Keen on September 14, 2021 at 1:05 am

    I spent years on suboxone, bouncing from oxycodone and back to the suboxone. I had several physicians during treatment, and was kicked out of a couple for failed urine screens. I stayed with it and finally found a doctor that was in it to help. He didn’t kick me out for a failure, but did hold me accountable. This struck a note with me, and the fact that he did let me stay in the program made me determined to do it right. I talked him into putting me on the Sublocade injection and now I am over 3 years clean, sober and happy, living my best life with the wife and people that stood by me. It takes that doc that’s willing to keep working with you, not the hard line doc that doesn’t allow missteps. You impress me with your knowledge of the problems your patients have and I have stayed up on your blog for years now. Thanks for what you do.


  3. Best blog. I was sometimes on the fence about some of your understanding of this brain disease of addiction SUD but today’s blog let me understand that I had nothing to worry about you in fact get it 100%. I want to thank you for your blog it has a big audience and you are doing a great job educating so many people on SUD and your being so honest and vulnerable has made you one of my new favorite providers. Are you a AMERSA member? If not you should be because there are many of us their changing the narrative.


    Paul B


  4. Posted by Kristan Hilchey on September 14, 2021 at 3:24 am

    Perhaps we should take diabetics who eat too much sugar off their metformin or insulin? Discharge the obese patient who continues to eat? How about taking the patient with OCD off the medication that lowered his counting to 10x a day instead of 200 because he hasn’t stopped completely? Why do we expect complete remission and total compliance with addiction, but no other disease with a behavioral component? Even more important, in what humane society would it be acceptable to discharge any of these patients and remove the medications that are not only improving but SAVING their lives? Why do we only accept addiction treatment that includes punishment as a tool?


  5. I am a pain specialist and have followed your blog for several years.
    You are outstanding and I hope you know that I am grateful for your insightful posts.
    I wish you peace.


  6. Posted by Sparky on September 14, 2021 at 12:07 pm

    Excellent blog,if all the oud drs were like yourself we would be in a much better place in this disease of addiction


  7. Posted by Charles Erickson on September 14, 2021 at 12:14 pm

    Hi, Dr. Burson. I recently had a jarring experience. I had been a long-time (10+) years of buprenorphine, finally getting on Sublocade. The Sublocade was a miracle drug for me. It took away the incentive for me to chase the relatively mild euphoria induced by the bupe film strips. I had gotten down to one injection per 7 weeks, and I figured I would take myself off. My doc wasn’t involved in my decision, but he had told me previously that, if I could get by with one 100mg shot every two months, I would be ready to stop. So I did. But I made another decision that was less healthy: I obtained an illegal supply of benzodiazepines over the internet. It was just intended to get me through the detox off of Sublocade (yes, I know they are different drugs, as different as night and day, go figure). I was ashamed. I tried to stop after about 5 weeks of Ativan use. I experienced a lot of discomfort. Most worrisome was my blood pressure, since I have Afib. It was Memorial Day weekend. Somehow I made it through until Tuesday. My doc couldn’t see me until Wed. We had always gotten along well. He had told me to see my primary doc before seeing him, and I did. The primary doc’s young NP (primary unavailable) told me it was Sublocade withdrawal. Welp, turns out it was benzo w/d. Okay, my Sub doc correctly prescribed me a Valium supply to withdraw, and it worked like a charm. He is also a psychiatrist, BTW. But we had always been friends, or so I thought. He turned on me like a wildcat. He demanded proof that I had seen my primary doc. He threatened to throw me out of his office if I was lying (I wasn’t and never have lied to him nor to his staff). He helped me medically, but he abused me mentally. I cannot forget the feeling of losing a friend and a wild, abusive attack on me and my integrity. I was already feeling terrible. What the hell is he doing in that field? He said that he no longer trusted me. Well, the feeling is mutual. WTF, I am an effing addict. If I was right upstairs, I never would have done what I had done to become addicted to opioids. I wrote him a thoughtful letter, praising his staff, and asserting myself non-confrontationally. He showed his staff my letter praising them, and his staff called back 3 days later to see if I was okay (I was). What am I supposed to think? Would you have treated a patient of yours like that? If you can get through this long post, please give me your opinion about what happened, because it was 3 months ago and I am still having bad dreams.


    • Hi Charles, I’m sorry that happened to you. I’m not sure why he got so angry either. Was it because you bought illicit benzos from the internet? As you say, not the best decision you’ve ever made, but why would that make him so angry? Why did he say he can’t trust you? If it’s possible, could you ask him to talk about what happened, such as how you felt, ask him why he was affected so intensely, try to understand what happened? It’s a risk, since things could heat up again, but on the other hand this has really bothered you.


  8. I am a LPC who currently provided clinical quality improvement services to OTP’s in Pennsylvania. Could you point me in the direction of any articles that indicate keeping clients in treatment is best practice? I have at least one site I work with that continuously discharges individuals for stimulant use despite not providing services needed to address the use and often destabilizes their opioid use disorder by decreasing dose due to qtc interval concerns. If I had best practices to reference, I may be able to work on changing this.


    • Yes I can! The American Society of Addiction MEdicine published a helpful guide titled, “Appropriate Use of Drug Testing in Clinical Addiction Medicine,” which describes the state-of-the art approach to dealing with drug screens as a tool of recovery, not a weapon to be used against the patient. IF you Google that title you will find it, or you can go to and find it on their site. Thanks for advocating for patients!


      • The company I work for actually contributed to this document. It was before my time of employment, but I did read it when I was starting a MAR program in a primary care office and utilized it then. Thank you for reminding me of its relevance and importance!

  9. Posted by vivivianita on September 17, 2021 at 3:46 am

    You are amazing! I would like a consultation with you on zoom on on the phone. Is that possible? How do I go about booking it. Please advise. Many thanks,


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